A major battle ensued in Congress last week over proposed legislation to halt a statutory 10.6% cut in Medicare payments to physicians.* The democratic-sponsored bill (HR 6331) breezed through the House, but it fell a single vote short of the 60 needed to clear the Senate. HR 6331 also eliminates the 5.6% decrease in physician fees slated for January 2009 and institutes a 1.1% increase.

To cover the additional expense, HR 6331 would siphon billions over the next several years from the Medicare Advantage budget, and President Bush says that he will veto any legislation with such a provision. Medicare Advantage subsidizes private health insurance for Medicare-eligible recipients. Democrats set their sights on the program after the Congressional Budget Office reported that healthcare services provided through Medicare Advantage health plans cost the Centers for Medicare and Medicaid Services (CMS) 12% to 19% more in 2007 than equivalent services provided through traditional Medicare.

On one side of the battlefield are the private health insurers, the Bush administration, and Congressional republicans; physicians, backed by the 

 and Congressional democrats, stand resolutely on the other side. Senior citizens, individuals categorized as disabled, and many military veterans find themselves caught in the crossfire, with combatants on both sides insisting that should the other side win, healthcare options for Medicare enrollees will shrink.

AMA predicts that decreased reimbursements will force many physicians to lay off employees, refrain from implementing new technologies, or cease practicing medicine altogether. In a 2008 AMA poll, 60% of AMA physicians said they would "limit the number of new Medicare patients they treat" if physician fee reimbursements were cut. Closing any more doors to Medicare patients could prove especially problematic in rural areas, where physician shortages are endemic.

Private health insurers counter that forcing them to hold service fees in line with traditional Medicare prices&#8212;as HR 6331 mandates&#8212;would induce them to withdraw from Medicare Advantage, curtailing healthcare choices for Medicare enrollees. The insurers posit that this could greatly hamper care in those regions where few physicians treat Medicare patients. According to the Medical Group Management Association, 24% of physicians nationwide will no longer accept new Medicare patients.

Budget slashing may not be insurers' only problem with HR 6331. The legislation curtails their direct marketing activities, increases government oversight, limits the out-of-pocket burden they can impose on subscribers, prohibits certain penalties and premium increases for Part D coverage, expands the list of drugs they must cover, and requires them to pay interest on Part D drug charges reimbursed more than 30 days after submission. It also requires the plans to practice mental health parity, treating mental conditions the same as any other medical condition.

Many private health plans offered under Medicare Advantage provide lower levels of coverage than traditional fee-for-service Medicare. The insurance companies then sell their enrollees "supplemental" health insurance to cover the excluded services. HR 6331 would end this practice.

HR 6331 also funds the Medicare Part B assistance program for beneficiaries with the lowest incomes, which expired July 1. Absent new legislation, the $96.40 monthly premiums for Part B coverage will be deducted from subscribers' Social Security checks beginning in August. 

Although reductions in physician fee reimbursements took effect July 1, CMS says it will not process any new claims until July 15, giving Congress time to reach a compromise acceptable to the White House. CMS already holds claims for 2 weeks, as required by law, and physicians worry that the 10-day hold will delay reimbursements even further. CMS insists this is not the case and makes the following recommendations:

Physicians who submit Medicare claims for services on or after July 1 should use the physician fees in place prior to July 1.

Copayments and deductibles collected from Medicare beneficiaries must be based on the reduced Medicare rate, regardless of the rate the physician charges to Medicare.

To minimize confusion, consider holding Medicare claims until new legislation has been passed, if financially feasible.

Physicians who use the reduced rates on new claims submitted to CMS after July 1 will have to submit a revised claim if Congress rescinds the cuts, retroactive to July 1. 

Political strategists predict that because it is a major election year, legislators will not allow these drastic cuts to remain in place. Indeed, physicians' groups have already started putting the squeeze on those political candidates up for re-election this year who voted against HR 6331, withdrawing endorsements and canceling donations. A blitz of advertising has hit the airwaves and television, and news show audiences are being bombarded by pundits from both sides. To find out how this will play out, stay tuned for Medicare Wars, Round II, expected to resume July 7, when congress reconvenes after the July 4 holiday.

*For a summary of how CMS calculates reimbursements for physician fees, see "

Congress Temporarily Turns the Tide on Scheduled 10.1% Cut to Medicare Physician Fees

Articles

Resident and Staff

War Over Medicare's Physician Fees

, PGY 5, Chief Surgical Resident, Department of Surgery, Medical Center of Central Georgia, Macon; 

, PGY 2, Surgical Resident, Department of Surgery, Medical Center of Central Georgia, Macon; and 

, General Surgery Private Practice, Macon, GA

A 58-year-old man presented to the hospital because of a 6-hour history of sharp, nonradiating abdominal pain that worsened upon movement. He had never experienced such pain before and had no significant medical history. The patient reported no fever, chills, nausea, vomiting, or diarrhea. His vital signs were normal, but his abdomen was tender to palpation. Laboratory examinations were normal. Abdominal and pelvic computed tomography scans using intravenous and oral contrast were obtained (Figures below). The patient developed peritonitis and a surgical consultation was obtained.

DIAGNOSIS: Perforated jejunal diverticulitis

Abnormal peristalsis and elevated intraluminal pressures are thought to cause multiple false diverticula on the mesenteric side of the bowel; this condition is known as jejunal diverticulosis.

 Autopsy series indicate an incidence of approximately 0.5%.

 Perforation and diverticulitis are the most common complications of jejunal diverticula.

 Other complications include obstruction, hemorrhage, and bacterial overgrowth.

-Axial CT scans at 5-mm sections showing mesenteric inflammation (white arrows; A and B), intermesenteric air (arrowhead; A), and an outpocketing (blue arrow; A).

Perforated jejunal diverticulitis is difficult to diagnose because perforations are contained between the leaves of the mesentery. Patients often present with a history of sudden and focal abdominal pain that occasionally progresses to diffuse constant pain associated with nausea, vomiting, and fever or chills. Physical examination is significant for localized abdominal tenderness to palpation and decreased bowel sounds on auscultation. Diffuse abdominal rigidity is a late manifestation of a contained perforation and mandates immediate surgical exploration. The patient's white blood cell count is sometimes elevated and demonstrates a left shift. Abdominal radiographs rarely show free air. Abdominal and pelvic computed tomography (CT) scanning is the best diagnostic modality, demonstrating focal areas of thickening, mesenteric inflammation, and outpocketings.

 Our patient's CT scans at 5-mm sections in the axial plane demonstrated mesenteric inflammation, intermesenteric air, and an outpocketing (Figures). No free fluid or air was visible in the peritoneal cavity, excluding other sites of a perforated viscus. A diagnosis of perforated jejunal diverticulitis was made, which was confirmed during exploratory laparotomy. Segmental small bowel resection with primary anastomosis was performed; this is the preferred surgical treatment for small bowel perforation, except for colonic diseases that require an ostomy. A laparoscopic approach is an alternative for experienced surgeons.

In contrast to jejunal diverticulitis, symptoms of small bowel neoplasms develop gradually and are usually obstructive, but perforation is possible. Physical examination and CT scan findings, especially of lymphomas and focal Crohn's disease, are difficult to differentiate, but are usually segmental and not diffuse like small bowel diverticulitis.

Meckel's diverticulum results from incomplete obliteration of the vitelline duct during fetal development. Its presentation is similar to that of jejunal diverticula, but the diverticulum arises from the antimesenteric side of the small bowel. Like perforated colonic diverticulitis, a perforated Meckel's diverticulum perforates into the intraperitoneal space. Diverticulosis of the small bowel is usually diffuse and easily seen on CT scanning. In most cases, only one diverticulum is perforated. Surgical resection and anastomosis is the treatment of choice for the inflamed and perforated segment of small bowel, and any normal appearing diverticula should be left alone. The proximal location of small bowel diverticula precludes use of an ostomy, which could prove detrimental and result in malnutrition, especially in the elderly.

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

Rankin FW, Martin WJ Jr. Diverticula of the small bowel. 

Vantrappen G, Janssens J, Hellemans J, et al. The interdigestive motor complex of normal subjects and patients with bacterial overgrowth of the small intestine. 

Sibille A, Willcox R. Jejunal diverticulitis. 

Donald JW. Major complications of small bowel diverticula. 

Gotian A, Katz S. Jejunal diverticulitis with localized perforation and intramesenteric abscess. 

Macari M, Faust M, Liang H, et al. CT of jejunal diverticulitis: imaging findings, differential diagnosis, and clinical management. 

Emergency Medicine Quiz: Can you diagnose the cause of this patient's abdominal pain?

Intestinal parasites cause significant morbidity and mortality worldwide, and they are particularly prevalent in underdeveloped countries. Those routinely encountered in the United States include 

Enterobius vermicularis, Ancylostoma duodenale, Necator americanus, Giardia lamblia

 But as exotic international locales become more accessible and American palates acquire a taste for more unusual fare, physicians may find themselves treating patients infected with organisms that are acquired abroad or rarely seen in the United States, such as 

Anisakid nematodes (family Anisakidae) are classified into the superfamily Ascaridoidea, which contains the well-known human pathogen 

. All anisakids are transmitted in water and use aquatic invertebrates and fish as intermediate or paratenic (transport) hosts. These parasites mature in fish, birds, and marine mammals. Species of medical importance include the whaleworms (

 spp.), both of which comprise a complex of morphologically similar species that can be differentiated by electrophoretic or molecular methods.

 spp. typically use seals and sea lions as their definitive hosts. Because the larvae of these parasites are large and readily visible in the flesh of many commercial fish and are typically not pathogenic in humans, sealworm infections are rare. Larvae of 

 spp. have been found in more than 40 species of fish in the North Atlantic and tend to occur primarily in benthic or demersal fish.

 spp. are generally encapsulated on the viscera of fish, but they can occur in the flesh, where they are difficult to see because of their small size and translucency. According to the Centers for Disease Control and Prevention, fewer than 10 cases of 

 spp. infection are diagnosed annually in the United States, a surprisingly low number when you consider the prevalence of this parasite in numerous fish species that inhabit the Atlantic and Pacific oceans. Whaleworm larvae typically mature in both toothed and baleen cetaceans. To date, nine species of 

 have been identified, and these may vary in their final cetacean hosts and geographical distribution. The larvae of 

 spp. have been found in more than 50 species in North Atlantic and infect both pelagic and demersal fish.

Once anisakid larvae are ingested, they immediately begin to penetrate the gastric and intestinal mucosa, causing the first symptoms of anisakiasis, often within 24 hours. According to the Food and Drug Administration, 

 spp. infection is frequently diagnosed when the affected individual feels a tingling or tickling sensation in the throat and coughs up or manually extracts a nematode.

 In more severe cases, patients may experience nausea and abdominal pain that is reminiscent of acute appendicitis. These symptoms can manifest from 1 hour to 2 weeks after infection. The 

 includes the case of a female patient who developed abdominal pain, nausea, and emesis shortly after eating a sushi dinner. Although her symptoms resolved the following morning, they recurred 1 week later and persisted for 5 days, which prompted the patient to seek emergency care. A computed tomography scan of the patient's abdomen revealed a proximal small bowel obstruction.

 spp. infection, fish must be thoroughly cooked or frozen to ensure that any larvae are killed. 

 spp. infections are more prevalent in Japan, Spain, and Scandinavia, where raw or undercooked seafood dishes frequently appear on the menu, but Americans are increasing their consumption of sushi and other raw or undercooked seafood. As a result, US physicians may encounter a growing number of patients who have parasitic infections or suffer from their associated complications, such as 

For more information on the life-cycle of 

 spp. and the diagnosis and treatment of anisakiasis, see "

Is it safe to eat sushi? Bowel obstruction related to anisakiasis

," published by Dr. Roland and colleagues in the March 2008 issue of 

*David J. Marcogliese, PhD, is a research scientist for the Aquatic Ecosystem Protection Research Division of the Science and Technology Branch of Environment Canada in Montreal.

Common Intestinal Parasites. Available at: 

Anisakis simplex and related worms. Available at: 

As exotic international locales become more accessible and American palates acquire a taste for more unusual fare, physicians may find themselves treating patients infected with organisms that are rarely seen in the United States, such as Anisakis spp.

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War Over Medicare's Physician Fees

Emergency Medicine Quiz: Can you diagnose the cause of this patient's abdominal pain?

Anisakis spp. in humans