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Just wanted to see how many of us are starting to be forced to enter into MIPS...

So far it seems like the measures are contrary to best practice, IE must get a throat culture or rapid strep in a pharyngitis before antibiotics, even if the centor criteria score is high, etc...

I work for 2 groups and a 3rd per diem, Only one group has so far made us start undergoing MIPS, I am being told however that this information is publicly available for each doc, concerned on future job opportunities searching this information.
 

GeneralVeers

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Just wanted to see how many of us are starting to be forced to enter into MIPS...

So far it seems like the measures are contrary to best practice, IE must get a throat culture or rapid strep in a pharyngitis before antibiotics, even if the centor criteria score is high, etc...

I work for 2 groups and a 3rd per diem, Only one group has so far made us start undergoing MIPS, I am being told however that this information is publicly available for each doc, concerned on future job opportunities searching this information.
I actually thinks the MIPS recommendations are NOT unreasonable (for now) things like:

1. Don't get a head CT for a minor bump on the head
2. Don't give antibiotics for sinusitis
3. Don't give antibiotics for bronchitis
4. Get an US for pregnant patients with abdominal pain

Etc.

If only I could get my midlevels to practice with MIPS criteria we could vastly cut down on BS ct scans and antibiotics ordered.
 
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I actually thinks the MIPS recommendations are unreasonable (for now) things like:

1. Don't get a head CT for a minor bump on the head
2. Don't give antibiotics for sinusitis
3. Don't give antibiotics for bronchitis
4. Get an US for pregnant patients with abdominal pain

Etc.

If only I could get my midlevels to practice with MIPS criteria we could vastly cut down on BS ct scans and antibiotics ordered.

I agree with you on that, The rest are reasonable, I only have an issue with the pharyngitis one. I just feel like tracking us on this is petty, also why am I taking MIPS hits for a midlevel
 

GeneralVeers

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I agree with you on that, The rest are reasonable, I only have an issue with the pharyngitis one. I just feel like tracking us on this is petty, also why am I taking MIPS hits for a midlevel
Just don't give antibiotics for pharyngitis. There is no evidence that it makes them better faster, and the the reduction in rheumatic heart disease is minimal.
 

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I agree with you on that, The rest are reasonable, I only have an issue with the pharyngitis one. I just feel like tracking us on this is petty, also why am I taking MIPS hits for a midlevel
Oh yeah I love taking a MIPS hit for the mouth breathing mid-level who orders systemic abx for otitis externa.
 
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hundreddaysoff

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Yup, we have mandatory MIPS. As a relatively minimalist doc, the current rules don't bother me so much.

My medical director tells me the actions of my midlevels, however dumb, don't count toward my MIPS scores. Is he wrong?
 

thegenius

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We kill more people with penicillin (or augmentin, or omnicef, or whatever antibiotic people give for strep) than we prevent RHD.
Please present a source for that!
 

thegenius

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I too don't actually mind the MIPS stuff. The pharyngitis thing can be a problem and I have used a diagnosis of "neck pain" or "odynophagia" and given antibiotics.

Just diagnose Tonsillitis not pharyngitis.
That will also result in a fallout in the MIPS criteria.

From MIPS for Pharynigitis
if your ICD-10 diagnosis is any of the following:
Diagnosis for pharyngitis (ICD-10-CM): J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

I looked up all those ICD-10 codes and several of them include tonsillitis.

So you have to be more generic and use a diagnosis like "neck pain", "odynophagia", maybe even "reactive adenopathy", or basically anything but those codes above.



I do something similar for bronchitis and abx. If I want to give someone antibiotics and they might have bronchitis, I just change the diagnosis to "productive cough" or "shortness of breath", or I'll just tell them they have CAP and diagnose that even if the CXR and vitals don't support it.
 

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Weird, @southerndoc hasn't done a big MIPS spiel in here yet? Slacker!

C'mon man, you know you wanna... Let's hear it! :D
Ha! Just a fact of CMS trying to reduce payments.

The key thing with MIPS is that (1) your data will follow you, and (2) there are proposals to replace it already.

Your reimbursement data will be tied to MIPS. If you move and change employers, your employer may ask about your MIPS performance. If you are a low performer, they will lose money which makes you less marketable. Most physicians don't realize this. I'm aware of one company already doing this (not mine).

There are ways around it (acute complicated bronchitis and specify complication in your note). Also, if you document acute bacterial bronchitis, then it's excluded. MIPS also considers a "severe headache" after trauma to need a CT head. You can still game the system just like hospitals that put Zithromax tabs in their waiting room to get by the 6-hour antibiotic rule.
 
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GeneralVeers

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Also just looked at the official MIPS website and can verify my participation but can't see my stats. Does anyone know how to obtain a copy?
 

Groove

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Yeah, get used to MIPS, embrace it...and learn to game the system. It's here to stay, at least for now. Any CMG and/or SDG will be tracking performance. The unfair thing, at least at my shop, is that MLP fallouts get applied to whatever attending they sent their chart to for signature. So, my personal MIPS might be 100% but I end up getting 85% because of MLP fallouts.
 

thegenius

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The article in the link above says "Severe allergic reactions occur in 0.24% of patients"
obviously not true. That is a gross overestimate.

Then he goes on to say (paraphrasing) "for 10,000,000 million cases we treat, we are killing or almost killing 24,000 people"
a ridiculous stretch from the above - written for

Then the article goes on to say that the NNT for steroids is 4, yet if it's so good why does the IDSA recommend against them?
IDSA Guidelines for Strep Throat



While I believe that antibiotics are not the amazing cure for strep throat....that article above is written in a cocky, biased way. Kind of disappointing actually. The author wants to be a trend-setting maverick in our field (my opinion...)


His conclusion that we should, basically, never give people antibiotics for GAS-P goes against the recommends from the IDSA, which is the leading authority on this issue.

One would have to prove that the IDSA is not recommending in good faith (get kickbacks from drug companies, placating the public) to argue that the IDSA is not looking at the evidence correctly
 
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thegenius

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From the IDSA

III. What Are the Treatment Recommendations for Patients With a Diagnosis of GAS Pharyngitis?
Recommendations


  • 8. Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents (strong, high).
  • 9. Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days (strong, moderate).
 

Dr.McNinja

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The article in the link above says "Severe allergic reactions occur in 0.24% of patients"
obviously not true. That is a gross overestimate.
Do you have different references? He didn't make it up.


Then the article goes on to say that the NNT for steroids is 4, yet if it's so good why does the IDSA recommend against them?
IDSA Guidelines for Strep Throat
I mean, The NNT says it's 3.



While I believe that antibiotics are not the amazing cure for strep throat....that article above is written in a cocky, biased way. Kind of disappointing actually. The author wants to be a trend-setting maverick in our field (my opinion...)
You're not wrong, but at the same time some of these deeply held beliefs are similar to those of certain other people who really need to be beaten over the head with the data.


His conclusion that we should, basically, never give people antibiotics for GAS-P goes against the recommends from the IDSA, which is the leading authority on this issue.

One would have to prove that the IDSA is not recommending in good faith (get kickbacks from drug companies, placating the public) to argue that the IDSA is not looking at the evidence correctly
That's the thing. There is evidence that placebo vs antibiotics is no different. IDSA needs to prove why they simply want to keep inertia.
Of note, the IDSA wants us to start Tamiflu on literally everyone too, so there's that.
 

thegenius

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Do you have different references? He didn't make it up.
Just read all the comments in the original link you provided. Someone wrote

Other issues – IMO the rate of severe allergic reactions from oral antibiotics (0.24%) is an overestimate. In a recent publication the rate is much lower 1 out of several million. (Journal of Antimicrobial Chemotherapy, Volume 60, Issue 5, November 2007, Pages 1172–1173, Choose Your Affiliation - NYU Health Sciences Library).

J Allergy Clin Immunol. 2010 May;125(5):1098-1104.e1. doi: 10.1016/j.jaci.2010.02.009. Epub 2010 Apr 14. Anaphylaxis epidemiology in patients with and patients without asthma: a United Kingdom database review. 21 / 100,000 person years.

Plus (and this is me writing)....0.24% just seems too high. I see severe allergic reactions (which I presumably means requiring epinephrine, or they have definition of anaphylaxis which I guess means they should get epi) maybe 4x / year. Most of these are to peanuts, milk, stuff like that.

Anyway.....


There is evidence...
There is evidence...
There is evidence...

That's the preceding comment for so many issues on this forum from tons of posters, including myself. We often read a journal article (or a summary like the link above) quickly, perhaps don't read it entirely, or over time forget little nuances to the data here and there. The main thing is there is a TON of evidence and unless one is employed to go over all the evidence and become an expert in evidence, decide what evidence is good, what evidence is bad, most people (including me, you, and just about everybody else in health care) tend to give too much weight too few studies or over-generalize results from their cursory reading. Plus...I also think that if people want to believe "X", and they read a paper that supports "X", they tend to stick to their belief and never change. Or change comes a long time in the future.

It very well could be that antibiotics for strep throat provides modest benefit. But there is a benefit as far as those who I consider to know the most about this....and it's not the author of that article above.


I also find it interesting that the notion of getting better 16h sooner is not worth it. That is a judgement call yet some doctors want to impose that doctrine on all patients.



And yes, I agree that Tamiflu is lousy. But I don't NOT give it....I just tell people that there is a medicine that the CDC recommends, I think it's kind of lousy, this and that, blah blah blah, and let the patient make the decision.
 

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And yes, I agree that Tamiflu is lousy. But I don't NOT give it....I just tell people that there is a medicine that the CDC recommends, I think it's kind of lousy, this and that, blah blah blah, and let the patient make the decision.
I do the same. I tell them I don't swab my kids for sore throats, and I don't give them antibiotics for that condition. If they really feel strongly about it, they're welcome to do so. Just don't expect it to fix anything.
Same as I do for otitis media. And conjunctivitis. And all the other things we have scads of data about but cannot convince the public otherwise. The issue here is, the government is now cracking down on this, and so the phrasing needs to be "the government says I cannot give you antibiotics for this". Maybe it will work, maybe it won't. But at the rate we are going, everyone is going to continue getting the best antiviral out there*




*zpack
 
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Groove

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I too don't actually mind the MIPS stuff. The pharyngitis thing can be a problem and I have used a diagnosis of "neck pain" or "odynophagia" and given antibiotics.


I do something similar for bronchitis and abx. If I want to give someone antibiotics and they might have bronchitis, I just change the diagnosis to "productive cough" or "shortness of breath", or I'll just tell them they have CAP and diagnose that even if the CXR and vitals don't support it.
I just give them the diagnosis of "Bacterial pharyngitis" if I want to Rx them abx.

If they have bronchitis and I want to give them Rx (for whatever reason), I dx "Bacterial URI".

Supposedly, "complicated bronchitis" is an exception to the fallout but what I was finding is that even if I documented justification for the complicated bronchitis, the coders weren't catching it all and I would still receive a fallout. I haven't received any if I give them an alternate dx.

While I believe that antibiotics are not the amazing cure for strep throat....that article above is written in a cocky, biased way. Kind of disappointing actually. The author wants to be a trend-setting maverick in our field (my opinion...)
That's classic Swaminathan. Any time I read one of his articles, I always keep that in mind. He loves to cherry pick studies and put them together in such a way as to completely buck ingrained trends. His style is to put together "shock and awe" campaigns on ingrained medical trends. Don't get me wrong, I love some of his stuff, but he's definitely got a particular kind of style to his presentation. If you haven't noticed, that's the nouveau trend in academics these days...a la FOAMed style, where you seize on a new study that infers that classic approaches don't work and completely change practice based on limited data that fails to take into account contradictory studies, overall historical concerns, specialist guidelines and/or leading authority opinions on the subject. An example since I'm thinking about it would be lipase elevations and pancreatitis. I was doing a lit review last year on the topic and it was amazing to me to see our set of recommendations when compared to ACG guidelines (which are much more conservative btw).

For the record, I give tons of PCN for "strep" and I rarely swab for confirmation. (I also can never recall an anaphylactic reaction in someone that didn't list PCN on their allergy in 10 yrs of practice. If they did list it and were being treated for strep, they got an alternate (usually zithromax). I also give steroids unless they are a mild case. I offer tamiflu to anyone with the flu or suspected flu. Have any of you guys had Flu A? It sucks. I would have been willing to take ANYTHING that might have reduced the viral load, circulating cytokines, etc. and helped me feel better, regardless of duration of the illness.
 
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GeneralVeers

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For the record, I give tons of PCN for "strep" and I rarely swab for confirmation. (I also can never recall an anaphylactic reaction in someone that didn't list PCN on their allergy in 10 yrs of practice. If they did list it and were being treated for strep, they got an alternate (usually zithromax). I also give steroids unless they are a mild case. I offer tamiflu to anyone with the flu or suspected flu. Have any of you guys had Flu A? It sucks. I would have been willing to take ANYTHING that might have reduced the viral load, circulating cytokines, etc. and helped me feel better, regardless of duration of the illness.
Except that I've had several patients complain about the huge cost of the drug if their insurance doesn't cover it, or they have a significant co-pay. $200 is a lot for most people, and probably not worth it to them to feel a "little better, a little sooner".
 
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Groove

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Except that I've had several patients complain about the huge cost of the drug if their insurance doesn't cover it, or they have a significant co-pay. $200 is a lot for most people, and probably not worth it to them to feel a "little better, a little sooner".
I always tell them that it's not a miracle drug and that it might be cost prohibitive and if it is...I'd much rather them fill the rest of the medications I prescribed and skip this one.

I'm sure all of us have our little tamiflu "speech". I still offer it though.
 

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Except that I've had several patients complain about the huge cost of the drug if their insurance doesn't cover it, or they have a significant co-pay. $200 is a lot for most people, and probably not worth it to them to feel a "little better, a little sooner".
$50 with goodrx.
 
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Except that I've had several patients complain about the huge cost of the drug if their insurance doesn't cover it, or they have a significant co-pay. $200 is a lot for most people, and probably not worth it to them to feel a "little better, a little sooner".
Not to mention the patients who return the same or next day saying they now feel worse because of the GI side effects.
 
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It's totally unclear to me why we treat strep at all beyond patient satisfaction. There's very limited evidence to do so. IDSA needs to get it together. Agree with RebelEM on this one.

I think much of the issue is Peds- their patients won't vaccinate, and they need to prescribe useless antibiotics to stay in business.
 

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I think much of the issue is Peds- their patients won't vaccinate, and they need to prescribe useless antibiotics to stay in business.
I maen, they're part of the problem, but the real problem is urgent cares. Vaccinating is still pretty common in most places, but it doesn't make a bunch of money for the office at all.
 
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I maen, they're part of the problem, but the real problem is urgent cares. Vaccinating is still pretty common in most places, but it doesn't make a bunch of money for the office at all.

Ugh I hate when a patient comes in “these pills the urgent care gave me isn’t working”

Me: these antibiotics are not going to work, you have a virus.

Patient: what can you give me?

Me: water and time....
 

GeneralVeers

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It's totally unclear to me why we treat strep at all beyond patient satisfaction. There's very limited evidence to do so. IDSA needs to get it together. Agree with RebelEM on this one.

I think much of the issue is Peds- their patients won't vaccinate, and they need to prescribe useless antibiotics to stay in business.
You highlighted the one and only reason to do anything.
 

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You highlighted the one and only reason to do anything.
Bingo. Doctors? Umm, no. We’re glorified customer service reps...

The secret to job security these days is balancing "evidence based" medicine with whatever it takes to make patients "satisfied" with the care they receive. After all, that's what makes our overlords happy and our jobs secure.

Sad but true.