Friday, October 24, 2014

Knowing Your Benefits: Outpatient Injections

Understanding your health insurance benefits can feel like navigating your way through stormy seas without a compass.  It is important to find out your benefits ahead of time so there are no surprises when you receive an Explanation Of Benefits (or EOB) from your insurance or a billing statement from your health provider.  Here are some tips below to help the process go more smoothly!

To determine your insurance benefits prior to coming in for a procedure at the surgery center, you may contact your insurance provider directly and follow the steps below:

·         Call the Member Services number located on your insurance card; if needed our Tax ID is 45-4054764.
·       Ask the representative what the benefits are for the CPT Codes associated with your procedure (please see list below):

99144- Conscious Sedation
64483- Transforaminal Epidural/Nerve Block (Lumbar/Sacral) (1st level)
64484- Transforaminal Epidural/Nerve Block (Lumbar/Sacral) (2nd level)
64490- Paravertebral Facet (Cervical/Thoracic) (1st level)
64491- Paravertebral Facet (Cervical/Thoracic) (2nd level)
64492- Paravertebral Facet (Cervical/Thoracic) (3rd level)
64493- Facet or Medial Branch Block (Lumbar/Sacral) (1st level)
64494- Facet or Medial Branch Block (Lumbar/Sacral) (2nd level)
64495- Facet or Medial Branch Block (Lumbar/Sacral) (3rd level)
62310- Interlaminar Epidural (Cervical/Thoracic)
62311- Interlaminar Epidural (Lumbar/Sacral/Caudal)

Remember, there are going to be 2 separate sets of charges associated with your procedure; one set for the physician (Dr. Hyman or Dr. Chimes) and one set for the Ambulatory Surgery Center (Overlake or Evergreen).  To determine what the charges are for the surgery center, please contact them directly at the phone number provided on your injection forms.  I hope this information can assist you in obtaining your insurance benefits and continuing on the path to staying active!

Wednesday, October 22, 2014

Cervicogenic Headache

The following excellent article is from my friends and former colleagues Eric Helm and Robert Donlan on the topic of cervicogenic headache

Cervicogenic headache means "Headaches caused by the neck."  I think Drs Helm and Donlan outline a good overview of how diagnosis and management

Helping physicians be better listeners- through patient responsibility

One piece of feedback that patients give all clinicians is that they want to "feel really listened to."  They don't want clinicians to spend time questioning whether they are being honest or mis-representing themselves.

Imagine yourself in the scary situation of a new onset of pain in your neck, and beyond just the horrible pain, you are worried that the pain is just the tip of the iceberg and may indicate evidence of a more serious condition.  Because of your concern, you go to the Emergency Room.  Tell me which of these situations you'd prefer:

Situation A: You are immediately evaluated by Clinician A, who assumes that everything you are saying is true, and assumes your only motivations are to be assessed by a skilled clinician and get steered efficiently toward an appropriate treatment

Situation B: Clinician B, who has the same basic skill set, but before they can speak to you, they saw 2 patients with similar symptoms, but who had a long history of drug abuse, and have histories of using the ER to obtain opiates.  Clinician B needs to take seriously that these patients may actually have real pathology that needs to be treated, but is appropriately concerned that they are abusing the ER to obtain drugs.

I'd obviously be seen by Clinician A.

Thinking about this, what is the difference between the two clinicians?  There is nothing intrinsic to the physician that is different- the difference is all things outside of their control.

So, if you are are the patient, it would be ideal to create a social environment that allows people stuck in the situation of Situation B, and allow them to practice in an environment more similar to Situation A.  This would allow the clinician to be a better listener.

Unfortunately, that is NOT the current healthcare environment we have created.  The excellent blog had a wonderful post this week called The ER Demonstrates the Inverted Priorities of American Society.  In this blog post, Dr. Edwin Leap details how our current healthcare structure creates a Moral Hazard, where patients no longer have societal checks in place to prioritize their own health.

My experience with blog posts like these is that people react to this as follows:
- Clinicians- read it, and feel "At last!  Someone is getting the word out about what we have to deal with!"
- Some patients - read it, and feel "I get what they are talking about, but this doesn't explain ALL patients, and I'm a little bit uncomfortable with the 'blame the patient' mentality."
- Other patients- read it, and feel "This jerk hates patients!  Proof that doctors are evil!"

Clearly, there is a disconnect.  I think the main disconnect is related to how many unreasonable patients there are.  If the unreasonable patients described in Dr. Leap's post accounts for 1 in 5000 patients, then I'd agree that he may not be sufficiently prioritizing empathy.

But what if the % of unreasonable patients is much higher?  Speaking with colleagues who work in Emergency Room settings, the % of unreasonable patients can be very high, often over 50%.  I feel for the patients, but also feel for the physicians treating them.

Ideally, I like to work in one mode, which is "get patients better" mode.  I don't like having a second gear of "let me figure out if this patient is telling me the truth" mode

Therefore, creating systems where patients have some "skin in the game" is a necessary measure to make sure that patient's spend effort prioritizing their own health.

Tuesday, October 21, 2014

The Key to Age Defiance? Exercise!

Remember in your younger years when a cold might wipe you out for a few days, but then you were quickly back to running and jumping on the playground?  Well, as people age, their ability to bounce back from disease and injury takes longer and a bigger toll on the body.  These changes are MOST noticeable during the transition out of middle age and into the senior years, when even the flu can be detrimental to your health. In order to delay aging, there is in fact a “Fountain of Youth”:EXERCISE!

The American College of Sports Medicine (ACSM) has designed exercise guidelines both for adults under and over the age of 65.  The guidelines include a mixture of aerobic and strength training recommendations that, when combined, can help a person reach and maintain optimum fitness and delay aging.


The following exercise guidelines are recommended by the American College of Sports Medicine:

  •  Do moderately intense cardio 30 minutes a day, five days per week (intense enough that you cannot sing, but can hold a conversation)


  • Do vigorously intense cardio 20 minutes a day, 3 days per week (intense enough that you cannot sing)

  •  Do eight to 10 strength-training exercises, eight to 12 repetitions of each exercise twice a week.

Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.

 It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of daily physical activity may be necessary.  For most adults over 25, this is NOT a sustainable level of exercise, both because most professional adults frankly do not have that time of time available every day, and because most adults who exercise for that duration usually break down from injury.  This has several consequences:
      We emphasize the importance of FREQUENCY rather than DURATION.  Some people are inclined to circumvent the 30 minutes per day, 5 days per week by trying to catch up and do one super-long workout over the weekend.  That is NOT equivalent.  Just as it is important to divide your food intake into 3-4 meals per day rather than one big meal, it is important to divide exercise so that is a DAILY activity.

2       For overall health, exercise is the most important intervention.  However, for the specific goal of losing weight, diet matters significantly more than exercise.  We will discuss this more in a future blog post, but no one is capable of sustainably overcoming poor dietary habits with exercise.

**With busy work schedules, family obligations, and packed weekends, it can often be difficult to get the recommended amount of physical activity. Try these tips for incorporating exercise into your life:
- Do it in short bouts. Research shows that moderate-intensity physical activity can be accumulated throughout the day in 10-minute bouts, which can be just as effective as exercising for 30 minutes straight. This can be useful when trying to fit physical activity into a busy schedule.
- Mix it up. Combinations of moderate- and vigorous-intensity physical activity can be used to meet the guidelines. For example, you can walk briskly for 30 minutes twice per week and jog at a higher intensity on two other days.
- Set your schedule. Maybe it's easier for you to walk during your lunch hour, or perhaps hitting the pavement right after dinner is best for you. The key is to set aside specific days and times for exercise, making it just as much a regular part of your schedule as everything else.
- The gym isn't a necessity. It doesn't take an expensive gym membership to get the daily recommended amount of physical activity. A pair of athletic shoes and a little motivation are all you need to live a more active, healthier life.
- Make it a family affair. Take your spouse, your children, or a friend with you during exercise to add some fun to your routine. This is also a good way to encourage your kids to be physically active and get them committed early to a lifetime of health.


The following exercise guidelines are recommended by the American College of Sports Medicine:

  • Do moderately intense aerobic exercise 30 minutes a day, five days a week (intense enough that you cannot sing, but can hold a conversation)


  • Do vigorously intense aerobic exercise 20 minutes a day, 3 days a week (intense enough that you cannot hold a conversation)


  • Do eight to 10 strength-training exercises, 10-15 repetitions of each exercise twice to three times per week

·        ** If you are at risk of falling, perform balance exercises **

Both aerobic and muscle-strengthening activity is critical for healthy aging. Moderate-intensity aerobic exercise means working hard at about a level-six intensity on a scale of 10. You should still be able to carry on a conversation during exercise.

Older adults or adults with chronic conditions should develop an activity plan with a health professional to manage risks and take therapeutic needs into account. This will maximize the benefits of physical activity and ensure your safety.

Starting an exercise program can sound like a daunting task, but just remember that your main goal is to meet the basic physical activity recommendations: 30 minutes of moderate-intensity physical activity at least five days per week, or vigorous-intensity activity at least three days per week, and strength training two to three times per week.

Choose activities that appeal to you and will make exercise fun. Walking is a great, easy way to do moderate-intensity physical activity.


  • Start, and get help if you need it.  The general recommendation is that older adults should meet or exceed 30 minutes of moderate physical activity on most days of the week; however, it is also recognized that goals below this threshold may be necessary for older adults who have physical impairments or functional limitations.
  • Functional health is an important benefit of physical activity for older adults. Physical activity contributes to the ease of doing everyday activities, such as gardening, walking or cleaning the house.
  • Strength training is extremely important. Strength training is important for all adults, but especially so for older adults, as it prevents loss of muscle mass and bone, and is beneficial for functional health.
  • If you can exceed the minimum recommendations, do it! The minimum recommendations are just that: the minimum needed to maintain health and see fitness benefits. If you can exceed the minimum, you can improve your personal fitness, improve management of an existing disease or condition, and reduce your risk for health conditions and mortality.
  • Flexibility is also important. Each day you perform aerobic or strength-training activities, take an extra 10 minutes to stretch the major muscle and tendon groups, with 10-30 seconds for each stretch. Repeat each stretch three to four times. Flexibility training will promote the ease of performing everyday activities.