Friday, July 31, 2009

Attorneys' Laws 1-9

I have often heard that the fist law of Attorneys is that the attorney always gets paid. Well I saw today that Nancy Pelosi and Harry Reid are hiding in the health care bill provisions that allow attorneys to deduct all expenses in contingency cases as soon as they are incurred. Their idea is that this tax break will help improve access to trial lawyers and encourage attorneys to take cases that they would otherwise turndown. Not to mention that it would make the trial lawyers wealthier. Since the second through ninth laws of being an attorney are also, "attorneys always get paid," I guess the tenth is that they dont have to pay taxes.

Well I thought of our situation in medicine. We by law can not deduct from taxes our expenses for taking care of the indigent. For the most part neither can the hospitals or other health care providers. It seems that we are the only business that can not deduct bad debt. Would allowing medical providers to deduct their expenses help with access? Tax incentives seem to have worked in other areas, why not medicine? Right now, hospitals off set the cost of taking care of the indigent and the under insured by trying to get the most from the private insured. As a result, the private insured are paying more and more. Reducing the tax load reduces the hospital overhead, the lower the overhead, the less is needed from the private insured to make the hospital run. This lets the hospital negotiate lower contracts and thus more funds are available for care.

Oh, nevermind. I just saw that they want to add tax to private insurance and to increase the tax on hospitals. Just take what I said and reverse it.

Tuesday, July 28, 2009

Obama's Sign (The Devil is in Charge of the Details)

Forwarded by a physician who was able to make it through the first 500 pages of Obamas Healthcare Bill: HR 3200

Page 22: Mandates audits of all employers that self-insure!
Page 29: Admission: your health care will be rationed!
Page 30: A government committee will decide what treatments and benefits you get (and, unlike an insurer, there will be no appeals process)
Page 42: The "Health Choices Commissioner" will decide health benefits for you. You will have no choice. None.
Page 50: All non-US citizens, illegal or not, will be provided with free healthcare services.
Page 58: Every person will be issued a National ID Healthcard.
Page 59: The federal government will have direct, real-time access to all individual bank accounts for=2 0electronic funds transfer.
Page 65: Taxpayers will subsidize all union retiree and community organizer health plans (read: SEIU, UAW and ACORN)
Page 72: All private healthcare plans must conform to government rules to participate in a Healthcare Exchange
Page 84: All private healthcare plans must participate in the Healthcare Exchange (i.e., total government control of private plans)
Page 91: Government mandates linguistic infrastructure for services; translation: illegal aliens• Page 95: The Government will pay ACORN and Americorps to sign up individuals for Government-run Health Care plan.
Page 102: Those eligible for Medicaid will be automatically enrolled: you have no choice in the matter.
Page 124: No company can sue the government for price-fixing. No "judicial review" is per mitted against the government monopoly. Put simply, private insurers will be crushed.
Page 127: The AMA sold doctors out: the government will set wages.
Page 145: An employer MUST auto-enroll employees into the government-run public plan. No alternatives.
Page 126: Employers MUST pay healthcare bills for part-time employees AND their families.• Page 149: Any employer with a payroll of $400K or more, who does not offer the public option, pays an 8% tax on payroll
Page 150: Any employer with a payroll of $250K-400K or more, who does not offer the public option, pays a 2 to 6% tax on payroll
Page 167: Any individual who doesn't' have acceptable healthcare (according to the government) will be taxed 2.5% of income
Page 170: Any NON-RESIDENT alien is exempt from individual taxes (Americans will pay for them).
Page 195: Officers and employees of Government Healthcare Bureaucracy will have access to ALL American financial and personal records.
Page 203: "The tax imposed under this section s hall not be treated as tax." Yes, it really says that.
Page 239: Bill will reduce physician services for Medicaid. Seniors and the poor most affected." Page 241: Doctors: no matter what specialty you have, you'll all be paid the same (thanks, AMA!)
Page 253: Government sets value of doctors' time, their professional judgment, etc.
Page 265: Government mandates and controls productivity for private healthcare industries.
Page 268: Government regulates rental and purchase of power-driven wheelchairs.
Page 272: Cancer patients: welcome to the wonderful world of rationing!
Page 280: Hospitals will be penalized for what the government deems preventable re-admissions.
Page 298: Doctors: if you treat a patient during an initial admission that results in a readmission, you will be penalized by the government.
Page 317: Doctors: you are now prohibited for owning and investing in healthcare companies! Page 318: Prohibition on hospital expansion. Hospitals cannot expand without government approval.
Page 321: Hospital expansion hinges on "community" input: in other words, yet another payoff for ACORN.
Page 335: Government mandates establishment of outcome-based measures: i.e., rationing.
Page 341: Government has authority to disqualify Medicare Advantage Plans, HMOs, etc.
Page 354: Government will restrict enrollment of SPECIAL NEEDS individuals.
Page 379: More bur eaucracy: Telehealth Advisory Committee (healthcare by phone).
Page 425: More bureaucracy: Advance Care Planning Consult: Senior Citizens, assisted suicide, euthanasia?
Page 425: Government will instruct and consult regarding living wills, durable powers of attorney, etc. Mandatory. Appears to lock in estate taxes ahead of time.
Page 425: Government provides approved list of end-of-life resources, guiding you in death. Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.
Page 429: Advance Care Planning Consult will be used to dictate treatment as patient's health deteriorates. This can include an ORDER for end-of-life plans. An ORDER from the GOVERNMENT.
Page 430: Government will decide what level of treatments you may have at end-of-life.
Page 469: Community-based Home Medical Services: more payoffs for ACORN.
Page 472: Payments to Community-based organizations: more payoffs for ACORN.
Page 489: Government will cover marriage and family therapy. Government intervenes in your marriage.
Page 494: Government will cover mental health services: defining, creating and rationing those services.

Monday, July 27, 2009


The House of Representatives have proposed a tax on cosmetic surgery to cover the cost of healthcare. How much do you think we can get out of Nancy Pelosi?

25 units of Botox ($400 every 4 months), endoscopic browlift ($3200-5000), Upper lids, lower transcong blephs ($1200), C02 facial ($3500), Medium flap face lift with playtsmaplasty ($7500). All prices based on Federal Congressional Insurance Maximum Allowables.

The Buck Stops Here (not!)

I just did one of my pet peeves! I consulted someone for something that I could take care of, but didn't wan the liabilty.

We call it Fleaing a patient. It is based on the fact that the dying dog gets covered by fleas as it departs the world. The hospitalist who can manage the patients blood sugar consults endocrine, because the patient has a pacer cardiology is called, the patient cant fart so Gi is called. Each time the doctor does not want to be the last standing when the patient dies and the family looks for someone to blame and finds a way to consult another doctor (flea). Attorneys always ask, did they consult a specialist? So every specialist gets called. When there isn't a local specialist, they can transfer the patient to somewhere where there is one because of EMTALA and the fleaing starts again. The buck gets passed. And so it goes. (By the way, attorneys will argue that defensive medicine does not exist). It is amazing when the local specialists will suddenly decide that although they are trained in the procedures that the patient needs, they have restricted their practice and no longer perform that procedure. (limits liability) So the patient gets transfered.

Well, here is the problem. After transfer after transfer you get to the end of the line. The problem was that it was me. I have done the procedure that the patient needs in my training and once since. I know how to do it but the outcome will not be good. I told this to my patient and his familty. They have been to 4 other hospitals so far and everyone has passed the buck. They asked me what I would do if it were me or one of my family. I told them that I would try to find someone that has done the most and has the most experience. That is what they wanted. I called in every favor and pleaded and the surgeon who trained me accepted the case. He is at another center where they are self insured and make the patients sign arbitration agreements.

Thursday, July 23, 2009

Political Nihilistic Delusions

Been spending my free time emailing, faxing and snail mailing my resignation of my AMA membership as have most of the other doctors that I know who still were members. I shouldn't have but I watched the Presidents news conference last night. There was more confabulation that I get when a gang banger is trying to explain how he got shot while minding his own business. I dont know how Congress and other politicians can say with a straight face that they are going to get down to the problems and fix health care without coming full circle and discovering that they caused all the problems! Healthcare used to be a true free market, you went to the doctor and the hospital and negotiated your price. Then in WW2 Congress set wage limits, to help get better workers, companies could not pay their people more so they started adding healthcare as a benefit. As these people got benefits and could afford more care, other got jealous and soon Congress came up with Medicare which was at first and emergency back up but soon became an entitlement. Since it looked bad for private insurance to pay for what Medicare would not, it had to compete and of course grew and grew to the monster that it is. Every year Congressmen would add new perks and new groups that are entitled to it, not to mention more and more administrators and federal employees. Congress then worked to decrease all the possible ways that services could be performed cheaper by not letting physicians collectively negotiate with insurance companies for fees and approved diagnosis and treatments. The created Stark laws that prevent single office care so you cant have a Wallmart where in one office visit you can get your xrays, labs and meds. The politicians kept the door open for every possible frivolous lawsuits which boomed defensive medicine. Congress then made sure that you cant go to an insurance company and get a huge discount because you dont smoke and are not overweight because that would be discrimatory. They made sure that if are an illeagal immigrant you can go to any hospital and get the best care possible so that the cost is passed on to those who actually have private insurance.

If Congress wants to get to the bottom of the healthcare mess, they need to be able to look in the mirror unfortunately their Nihilstic delusions wont let them see their reflections. Just like reflectionless vampires, they will go on and suck the blood out of their victims.

Monday, July 13, 2009

I dont have to think so I cant be accountable!

Beeper keeps going off. There is a new JACHO policy about pain medications, you cant write in the post op orders, Morphine Sulfate 1 to 4 mg IV q 2 hours prn pain. You must write, if pain on pain scale is 0-1 give no morphine. If pain is 1-3 give 1 mg morphine 1v. If 3-4 give 2, and so on. Gone are the days when the nurse was able to watch the patient and keep them comfortable by asking them about their pain and watching their vitals using their experience and wisdom to guide them. Now the attitude is dont let the nurse think, just let them do paperwork. If they dont have to use judgement then they dont have to be accountable.

Oh, I forgot, before the pain medication can be given, the nurse must document what pain was on the pain scale. I know that most of my patient who are waking up from surgery are in pain but can only raise one finger to show their pain scale. It is of course the middle finger which is raised when they are shook violently to wake them up so you can ask them about their pain scale.

Sunday, July 12, 2009

Cachexic Healthcare

The timing was perfect. On the way to a meeting I was listening on the radio to an Obama Administration spokesman saying that that the Administration has saved millions of jobs and made new ones and she pointed to healthcare as an example. The meeting was for the Executive Committee of the hospital which is where the clinical staff and the adminsistration try to mesh the two to provide the best care possible given the monetary situation. At the meeting, the administration dropped the bombshell. The hospital loses money on self pay, Medicare and Medicaid and makes up the difference with the private insured. Well, the number of the private insured patients has plummeted. Since the main money is made on elective procedures like total hips and knees, and people are holding off on these, the medical center is going broke. This is despite the fact that hospital is 85 to 95% full on average. A huge cut in Medicare is also coming and the Obama Administration and Congress is getting rid of the tax breaks that hospitals got to take care of the indigent. Since by law the hospital has to provide its services and it can not turn anyone away who comes to the ER the only place it can cut costs is staffing. So, as of this Monday 25% of the medical center's staff will be laid off. Four of 12 associated community hospitals will be closed and all outpatient physical therapy/occupational therapy and infustion centers will be closed.

I guess I should look on the bright side. The other medical center is cutting 30%! I guess Obama's spokesperson hasn't been to a hospital lately.

Friday, July 10, 2009

Using Restraint

One of my biggest peeves is the ever increasing paperwork load that keeps nurses from actually taking care of patients. Well, JACHO and CMS are at it again. Somebody without a clue complained that there are nursing home patients with dementia are restrained and therefore we need to completely regulate the use of restraints with tons of new paperwork. No one bothered to explain to the regulators that the nursing home patients have dementia which means that they dont remember that they cant walk so they try to stand and fall and hurt themselves. Anyway, JACHO and CMS came up with all these new regulations for the use of restraints. So, here we are in the ICU where a patients who has ODed on xanax is waking from his coma and tring to pull out his IV, endotracheal tube and ng. Since he has to be restrained for this, the nurse must document every thirty minutes the need for and the degree of restraints. To comply with JACHO and CMS this is a three page form that must be filled out either on paper or in the electronic chart. Since the nurse is the one who has to do the documentation, you either need to get another nurse to watch the combative patient and take them away from their patient or you leave someone less qualified to take care of the patient.

I wonder how many pateints will self extubate themselves and die because of these new regulations? At least they will leave behind a nice chart.

Wednesday, July 1, 2009

Least Common Denominator

I know that many people feel that defensive medicine does not exist but I did a little controlled study to see just what happens. Here is how it works. When a patient comes to the ER, they often get admitted by one of the hospitalist services. These doctors see the patient and are the general managers of their care. Because of liability reasons, if the patient has chest pain rather than work it up themselves and assume the risk, it is an immediate cardiology consult. Headaches, neurology. Diabetes, call endocrine. Pretty soon you have consultants jumping on the patient like fleas on a dog. Of course each of these consultations cost money. If the patient has insurance, each consultant charges their fee. Now here is the study. I looked at whether or not patient who were indigent had more of less consults. The answer was that they had more. The reason was simple. Indigent patients are less likely to follow up and more likely to sue. So, you consult more to make someone else responsible. As one of our ER docs put it, you are recruiting co-defendants. So, it seems that the least common denominator is not money, but liability.