Adding Levels of Ineffeciency to reduce the cost of care

It was one of those meetings where logic just seemed to fly out the window and minutia took control and strangled what little common sense was left in the room. It is bad enough that the nurses don't have the time to take care of patients because they are so busy having to chart everything, and that the real care is being done by lpns. Well, here come the next level of making sure the paperwork is better cared for than the patient. The hospital is having to hire even more nurse practitioners. The reason? Since there is so much more time spent doing paperwork, well entering everything into the Federally Mandated EMR, the docs who used to see the patients and manage their care don't have time to actually see the patients. So, you have to hire a bunch of nurse practitioners to do yet a whole second level of paperwork, to free up the docs to be able to actually see the patients.

So, it used to be a nurse took care of the patients and a doctor managed their care. Now it is lpn who actually sees the patients, a nurse and a arnp who spend all the time documenting on the patient, and a doc who tries to see the patient and has to manage all the others paperwork.

I had to open my mouth. I asked if the nurse practitioners where going to actually see patients and write orders. I got the of course from the nursing supervisor. I asked what training do they have. She gave me a look like she wanted to kill me. She said, "well, they are BSRNs and then have their nurse practitioner's degree". I asked again, what again is their training. Before she could answer, I said, "if a patient is admitted by infectious disease, does the anrp have an infectious disease fellowship?, what about cardiology?" She said that some of the nurse practitioner's have been cardiac nurses. I said, "so she does cardiac patients only?" Of course the answer was no. I looked at the applicants for the nurse practitioner position. All of them had gone straight through school, there was no clinical experience at all. I told her. If your mother is admitted to the hospital with a pe and right heart failure, how do you want her care managed? You can have an experienced nurse watching her and taking care of her, or you can have a lpn and a arnp who doesn't have a singe ounce of clinical experience charting away to make sure JACHO and CMS are happy while the doc is getting pummeled by all the other anrps that are in way over their head.

About that time the hospital head administrator said something that made me like him a lot, he said "look, our job is to try to find out how to take care of patients and stay in business while the government tries to do the opposite."

Frank's Blood

I familiar with A, B, O and even the rh blood types, but Frank's blood is in a league all by itself. It seems to only come from foleys, ng tubes, et tubes or chest tubes late at night. Its volume can not be quantified, it can not be typed, it can only be reported. It is always bright red but turns immediately brownish black whenever a MD inspects it. It will always saturate a dressing which can never be located to see just how much it was. The untrained often think it is Gross's bleeding which is quite hard to miss.

Vet Med

One of my patients is a veterinarian who recently had surgery. She showed me her itemized bills from the hospital, surgeon, anesthesia and lab. She then showed how much her insurance paid and how much she had out of pocket. Lastly, she showed me the total cost. I wondered why she was showing me all this, since she was here for another reason. Then she grinned and handed me another bill. It was for the exact same surgery that she had performed on a dog. It was more and she got paid in cash!

Medicare Fraud(fraud)

In the office we are always seeing patients who are on full Medicare and Social Security Disability who as near as we can tell are very employable. They are able to drive, play sports, shop and file endless complaints about everything. It came to a real head the other day when we had one of our cancer patients who has bone mets, pathologic spine fractures, intractable pain and partial hemiparalysis get his disability declined. All this while one of the "fibro" patients is mad because she might miss her golf luncheon.

Our ever wise, observant, master of all things receptionist, biller, scheduler decided to call that Medicare Fraud line that has been so common on the TV. (these are part of the multimillion dollar ad campaign launched by the government about reporting Medicare fraud). She tried to report suspected Medicare and disability fraud. Turns out, there is no where to really report it. There is really no one to talk to. In fact, they don't care. So, she called the Social Security Administration. Guess what? She got the same thing.

Just goes to show you, reporting Medicare Fraud is a fraud!

Pathognomic Wisdom

Saw Earl (not his real name) in the office this week. Earl is one of those people whose wisdom knows no bounds. He has shrapnel in his arms and his legs from a torpedo attack in the North Sea and scars from working the farm all his life. As I was sewing him up from an office procedure, Earl decided to impart some of his wisdom. Everyone who was free in the office came in because, when he talks, everyone listens.

Earl said that it seemed to him that the problem with politics and government is that people want other people to pay for things that they want. He said, here is how to fix it. There is your base tax. This is to pay for what the Constitution says the government is to do. No more, no less. There is nothing to pay for anything else that the government has tacked on. Then you put on your tax form a bunch of boxes that say, would you like to pay extra for any or all of these, and how much? That way, those that feel strongly about something that they want the government to pay for can chip in and the people who don't want to pay for it wont. "I call it ala carte taxes." You want an earmark, put it in the form. People and politicians will find out real quick what people really want to pay for. Also, this way, the people set the budget, not the politicians. Also on the form you can have boxes that say, the government has no business paying for. Seems to me, we fix things real fast if we do it this way.

Procrustean's Bed

One of my biggest gripes about what has happened to health care is that there is more taking care of paperwork than taking care of patients. Anyway I was between cases and going though the patients chart looking at all the stuff that has to be entered. (You know electronic records are supposed to save time!) and of course all of the record requirements are JACHO and CMS mandated. On the patient intake there is a whole section on psychiatric symptoms including where the patient is to be asked if they had any suicidal of self destructive ideation. Of course, this has to be documented. The only issue was that the patient was from the NNICU and was 4 days old. A RN had to enter all this. Even though it was N/A all through it, the nurse still had to do it instead of watching and taking care of their patients!

The Null Card

Its rare that we ever get drug samples these days. The feds have basically chased them all away. I really thought the sample meds helped as I personally hate it when you had someone go get a prescription only to find out it didn't work. The samples were also a good thing to help out our indigent patients.

Anyway, I saw an elderly lady in the office yesterday. Like many Seniors she has Social Security and Medicare and is barely making it. She needed a medication that she just could not afford. For that matter she could barely afford food. We called around, searched and begged and finally got a sample card that gives you the first month of the medication free to try. We were so excited! Then we read the card, it was not valid for anyone with Medicare or Medicaid! We looked at all the other vouchers and discount cards that we could find. Guess what, they all said the same thing!

Obamazeebub

This is what you get when you make a deal with Obama and his minions.

http://blogs.wsj.com/metropolis/2010/11/20/union-drops-health-coverage-for-workers-children/

ACLU Healthcare screeining

I was watching all the talking heads on TV discuss the TSA screening issue and how people are chosen at random to be checked as well as those who refuse the scanner. One of the commentators seemed to hit it on the head when he said "look, we cant just screen and pat down Islamic travelers who are traveling by themselves with one way tickets that are paid for in cash. That would be profiling! That is what the ACLU has filed suit about!"

I though about it and wondered how that would affect the practice of medicine if we followed the ACLU anti-profiling school of thought. We would be ordering PSA levels, pregnancy tests and sickle cell smears on every 80 y/o Caucasian female. Of course every male would need to have a pregnancy test before surgery not to mention a mammogram. We wouldn't want to profile of course, that might be discrimination.

HIPPA Tax

As usual I spent I spent part of the night waiting on the OR for yet another urgent case that would not be urgent if the patient went to see their primary care doc earlier. Well, that is if they could. They had Medicaid which is worse than having no insurance as no doc can afford to take it but that is for another post. Anyway, I was looking at their paper chart. Yes, even though we are on electronic medical records, there is still a paper chart. Guess what it is filled with? HIPPA forms. Over 22 pages of them. Some are the faxes that we have to send to get electronic records, others are all the medical information waiver forms. A lot of trees died for HIPPA. This got me to wonder. When the government passed HIPPA did they have a CBA estimate that said, hey this is going to cost the economy billions, and this cost is going to be taken away from taking care of patients? Lets see, we have all the manhours of staffing that it takes to make sure all of the paperwork for HIPPA is done. We have the HIPPA compliance consultants, we have all the increased costs of the EMRs to make them HIPPA compliant. There is all of the paper and the extra faxs. Then there is the government HIPPA auditors, not to mention the increased liability for a HIPPA breach. I'll bet it is in the billions.

I started to think about how much JACHO costs and how all that money could be used to actually take care of patients, but I stopped myself because it is not good to go into surgery p****ooo****!

Even God cant afford ObamaCare

We just had one of our hospital staff meetings. I was surprised because the place was packed. This is a good sign that something big was going on and I was out of the loop as usual. The medical center was announcing its latest cuts in services. To justify the cuts it showed the financials of each department. OB was a bottomless pit, anchor babies parents tend to not pay thier bills. The only things that made a proffit in the EDs was the parking garage. Then they went into Obamacare. Because of the higher copays coming up this year they expect a huge drop in the elective procedures. Not one of the private insurance companies is offering a contract that will offset the increased costs of Obamacare and the number of uninsured is skyrocketing. The good news was that we are still in business. We looked at some of the other medical systems. Catholic Health Partners which is one of the biggest truly nonproffit, send us your poor is selling off hospitals, equipment, everything. In many areas they are the only rescue net there is for the needy. You know something is bad when even God cant afford it.

Judicial Review

A few years ago one of my partners was raked over the coals in a medmal lawsuit. He won the case but it tore him up emotionally. It was one of those cases where bad things happened and he just happened to be there. Early in the case the plaintiffs attorney kept calling to settle, dragging it out as much as possible in the hopes to just get some cash. My partner and his defense team just said it was up to the court. When it finally went to trial, my partner won, but at a huge cost. He is one of the most caring people I have ever met.

Anyway, I was in clinic and it was chaos. I was on call so I had my patients and then all the ER calls. Right in the middle of it my partner comes around the hall and shuts the door. He says "Remember my lawsuit? The Judge is here. He has a big " " mass that was found and remembered me from the case. He wants me to do the surgery. I asked him why me, and he said it was because all the experts witnessess on both sides seemed to agree that you were one of the best."

Obama and Newtons Third Law

I have noticed that Obama seems to be a physics major as everthing he does seems to follow Newtons third law. This came very true last night when we had a big board meeting where all the health insurance providers for our staff presented their contract offers. The cheapest that would let our folks keep their same coverage had a 27% increase. BlueCross was 43%, United Health 37%, Cigna 54% and Aetna 51%. Perhaps, instead of having him push a bill to decrease our healthcare costs, we could get him to push and pass one to raise them?

It is what it is

I was listening to several of the news talkers the other day. They were having a big argument about being conservative and liberal. I decided that I think the big argument is about those who are "it is what it is" and those who are "it shouldnt be that way". I think that both are ok because the former deals with the situation and the other tries to change things and somewhere in the middle is a good thing. The problem I see the most though, is when those that are in the "it shouldnt be that way" camp refuse to accept the situation that is present.

I had that thing happen just the other day. I had a patient in the office who is a local liberal radio personality. On his show there was an argument about "dont ask, dont tell" which he really hates. A caller asked the host if it was ok for men to shower with his daughters. He said no. The caller then asked if men shouldnt shower with his daughters, why should gay men be allowed to shower with other men? The host got flustered. He then said, "people dont always get sexually excited in the shower". The caller said, why then can men not shower with your daughters? The host got slustered and then fell back on "it shouldnt be that way".

I had to give the host some medical news. It didnt go so well, all I got was it "shouldnt be that way". The problem was, it was what it was.

Action Auto Medicine

I just saw a potential way to fix our medical system by watching a young 20 year old man at Action Auto. He was amazing and far ahead in wisdom and insight. I was there trying to get a idle air control valve. When I went to the counter and told him what I thought I needed, he looked at me and asked why I thought I needed it. I explained what the car was doing and when it was doing it. It would stall at idle so I had to drive with one foot on the brake and one on the gas. He said, we can put it on the computer and run all the tests and then check the mass airflow sensor, the down stream O2 sensor and change the fuel filter, or we can go with the most likely and blame the idle air valve. He then said, there are a bunch of ways to fix a problem. If you want it fixed permanently, you can pay $80 bucks for a new valve. If you want it fixed for awhile, you can just go hit the one in your car with a hammer as it is most likely just stuck. If you want you can try to clean it out, but just keep a small hammer in the car so every six months or so you can just whack it. I thought about it, walked outside to the car. I didnt have a hammer but I did have the baseball bat that cracked at the last game. I whopped the valve and the car ran just fine.

I bet if I had insurance and did not have to pay out of pocket I would have said run all the tests and then I want a new gold plated top of the line valve. Since everything was out of my pocket, I went with the cheapest, fasted way. Of course the Action Auto guy was not responsible if I did something stupid or if my car died and I got into or caused an accident.

Grim Reap what you Sow

We knew that it would happen, but how do you explain business to people who have never been in or ran a business. In healthcare, the private insurance elective procedures generate the revenue that covers the expenses of all the other care. We told our Blue Dog that if the healthcare bill goes through, private insurance will cost more, patients will have higher deductables and will therefore not have the procedures that pay the bills to keep the hospitals open. They didnt listen. People cant afford to have thier total joints, knee scopes and such and as a result hospitals are going broke and cutting services. So, they "expanded healthcare" by making sure that there was nobody who could afford to give it.

They also said that people who are high risk could buy insurance in "co-ops", these dont exist, so these people dont have insurance and still need medical care. The hospital in the Blue Dogs home town is now closing at the end of the year.

1-900 Healthcare

I decided earlier in the week to see how much of my clinic I could accomplish over the phone if I had too. It was astounding. I figured out that at least 45% of the patients that I saw in the office could have been diagnosed and managed with a brief phone call. Many of the pateints were consultations from other doctors who just wanted a specialists opinion, others were just follow up.

I then started to wonder. We see the pateints in the office because that is how we get paid. What if we got paid for the phone calls? What if the standart of care included telephone consultations? I could see a lot more patients so the shortage of specialists in rural areas might be decreased. The cost of these consultations would be cheaper.

Oh, wait a minute. The last thing Medicare would ever do is something that would allow more patients to be cared for in a cheaper way. Afterall, they set what is and what is not paid for.

Magical Thinking

Late last night several of us were in the little office in the ER while we waited for the OR to get ready for the second of the emergent cases of the night. One of the ER docs was there watching the news that was showing some of the Presidents speeches of the day. The ER doc went on a kept muttering, "Magical Thinking". I asked what he meant by that and he said, "he says things like he thinks that just by saying them they will come true, you know like jobs, economy, the whole bit. Just look at him, he is about to have a major psychotic break!" Before I could ask further, we had to go to the OR but I couldnt help but wonder. If the president does have a psychotic break, who makes the call? I mean, is there someone whose job is to keep track of the sanity of the commander in chief and Baker Act him if he goes supratentorially dysfunctional? If he does get Baker acted, is there some plan set up to have a competency hearing? Who is part of that hearing? For that matter, does a presidental canidate ever have to pass a psychological evaluation?

Not the Patient!

There are many times when a patient comes in with either a family member or friend who tries to hog the whole patient visit by talking about their own medical problems. I had one today who didnt even let the patient get a word in edgewise. The patient's friend wanted to talk about her own bypass and how she had all these test. I finally had to explain that it was her friend medical issues that the visit was for. No sooner had I said this then she started talking about how she had belly pain. Eventually, I interupted and asked the patient if I could talk to her in private and asked the patients friend to step out. With the friend out of the way, I was able to talk to the patient and get her the treatment she needed. The patient's friend used the time out of the room to fill out a survey that said I was rude and inconsiderate. I wanted to tell her that it was a patient satisfaction survery and she was Not the Patient!

MBA Medicine

It was one of those meetings. I was the only physician or medical person for that matter at the governance meeting of the medical center. Everyone else was either a businessmen, accountant or lawyer from the administration. One by one they presented data on the finances of the medical center. Which DRGs we made money on, which we lost on. Then came in the team for marketing. they showed us the demographics of are area, age, income. They explained that we needed to be focusing on certain patients with our advertising and our services so they would want to come to our medical center. With each presentation, the term patient was lost and customer was substituted.

When the presentations ended there were all kinds of questions about how to market to the "customers" and why certain ones do not come to the downtown hospital. Finally, it was my turn. I asked "Where do our patients come from?" I got the look of looks, and then with exacerbation, the MBA of marketing pulled up the slide of the demographics of the referral area. I just look at him and stared. Finally, I said. "Look, patients have primary care docs. You chased them all out of the hospital. They want nothing to do with you. When Mrs. Smith calls her doctor because she is not feeling well, he is going to tell her where to go. Hospitalists are great, when they work with or for the internists and family docs, not when they work for and only for the hospital. When is the last time you have seen or talked to any of the primary care docs in your pretty demographic slide?"

"If you want to market, work with the primary care docs in the referral area. Show them that you are going to give their patients' the best care. Streamline admissions, testing and follow up care. The referring docs are your customers." "If you want to market you are the best heart center, convince the PCPS and the outside cardiologists." "Ms. Smith is going to go where her doctor tells her she will get the best care."

The rest of the people at the meeting just started at me like I was an alien and then began to discuss their confustion why the biggest Ortho group was moving its cases to the other medical center.

Puttin it Bluntly

It was the usual type of case in the OR. As I went to sew up the fascia, the needle wouldnt go through the tissue, in fact it broke right in half. We then spend the next five minutes trying to free the piece of the needle that was stuck in the tissue. When I looked at the package, it was the usual 3-0 vicryl SH but then it said "blunt"!

It turns out that a while back there was a study that showed there may be a decrease in accidental needle sticks in OR personnel if blunt needles were used because they were less likely to penetrate a surgical glove. At one point it was even recommended that they be used in some closures. On more careful examination, it turns out that the real reason there were less needle sticks was that the blunt needles were useless and pushed to the side.

So, some government suit decided to mandate blunt needles (OSHA and JACHO), so all the needles were replaced without letting the surgeon know! I had to to fill out 3 forms for each needle that I use now that I want sharp to satisfy these new mandates!

I wonder what will happen next, will they take away scalpels and make us use plastic sporks?

Yellow Omega Sign

(on the inside bottom corner of the patient chart) One of our internist was really upset today. He is one of the most caring physicians I have met. He was beside himself. It turns out that a patient had demanded narcotics and he said no. As a result the patient went onto a physician rating site at slammed him so that if you Google his name, that rating turns up. That made me wonder. If patients can anonomously rate docs, why cant docs do the same for patients?

When I was a resident, we would put a yellow Omega sign on the inside bottom corner of patients charts who were crazy or obnoxious. That way the poor sod who had to take care of them next would be prepared. I wonder how we can do that now in the digital age? Think of it, we could identify those that are faking disability, those who are hypochondriacs, those who are noncompliant, drug seekers, the whole bit.

Jackpot ala ATLA

This pretty much sums it all up!

http://vimeo.com/15137268

Redirect ala-Michelle O

It is bad enough to have hospitals dump patients on you but now with all the healthcare changes, they are following Michelle Obama's plan as well as her husbands. Becuase everyone's health care costs are going up and this Medicaid expansion means no one can afford to take care of those with it, hospitals are following Michelle Obama's South Side (of Chicago) Healthcare Care Initiative. Before the patient even has a chance to enter the hospital, they are met by a person who encourages them that it would be better for them to go somewhere else and they will even pay for the cab or bus ride to get there. This is exactly what she devisedd when she was a VP of U of C in Chicago and even had David Axelrod promote it.

So, we are now having patients arrive not by ambulance but by cab and airport limo!

Candyman, Candyman,Candyman

I had a patient say to me " wow, your the Chief of Surgery, you must be good". I wanted to puff up and say "of course", but told the truth. I explained that I missed too many meetings so the ones who were actually at the meetings mad that they were there voted me in when they went down the list to see who hadn't already done it.

Anyway, part of my duties as "Chief" is to be the physician who oversees the risk management committee. It is amazing at what it tracked, everything from patient complaints, to infections, to food quality. On my desk last week was a thumb drive full of data from the ED. Outcomes and encounters are all tracked. They are broken down by diagnosis, provider, and shift. In all these data streams, we look for trends.

One of the things that jumped out was that there was a big difference in the number of patients seen by different physicians, this was independent of shifts. It also showed that the physicians were seeing the same number of true emergencies but that the difference was in patients there for back pain or "acute fibro". To find out what was going on, I called over to our head patient registar for the EDs. As a side note she is amazing. When people ask her how long she has been there she tells them that she was always there, they just built the ED around here). Anyway, she explained it all. She went down the list of docs and said, Candyman, Candyman, Candyman, HardA***, HardA***, B*****, Candyman and so one.

Sure enough, she matched the list. The word gets out quickly which docs are in the ED. In fact, people call the EDs to see which doc is where. The Candyman docs will write for a little pain meds to get you through until you can follow up with your own doctor for your long standing pain. After all, your "pain is a vital sign". When there is a Candyman, everybody runs to the ED to claim that their pain is "horrible" to get their fix. When there is a HardA***, the ED is quiet. She even explained to me that they alter their staffing depending on which providers are where.

As I was leaving she took a piece of paper off the stack of Memos next to here. It was from the med center administration. It was about a decrease in the Press Gainey scores for the ED during certain shifts. It recommended that they try to find the problem and then report back. I looked at the memo and then went to the office. There on the flash drive was the Press Gainey data. You guessed it, the scores were higher for the Candymen!

Chicken Little Syndrome

One of the problems we have in the ED is people lying about their symptoms to be seen sooner, or to be seen by a MD instead of a ARNP or PA. With the ED filled with people who really dont need to be there, some people who also dont need to be there think that they can lie about their symptoms and get in faster. Mind you our triage nurses are pretty adept at determining who is and is not reatl. This weekend though one got through the cracks. He was in the ED trying to get an excuse for missing a meeting with his parole officer. He thought he would tell the nurse that he had chest pain, then when he got back explain that it was his ulcer that was bothering him and get a script and go home. Anyway, before he could say anything they hooked him up to an ekg and he got his wish, he was right back. In fact he was right back through the ED and straight to the CCU and then to cardiac cath. He kept trying to explain that it was his ulcer and all he needed was an excuse. The third degree block on the EKG said different. Turns out he never really had an ulcer, he has a new bypass though and by the way he got an excuse for missing his next parole officer meeting.

Acute ORS

I was the "man in the barrell" over the Labor Day Weekend. It was like being the only duck in the shooting gallery. Patients were being dumped from four states as fast as the ambulances could carry them. The outlying hospitals were doing all they could to get rid of the nonpay medical liabilities. Six were children who had health insurance but the parents had got rid of it "cause they were getting it free from Obama". I guess nobody told them that SCHIP was broke in their state. One was a former Teamsters local president who had worked for a trucking company that went bankrupt. He was a local guy who even appeared in an Obama commercial. Several were elderly patients who couldnt get in to see a doctor and had let their problems get so out of hand that they were immediately turfed.

It seems that acute ORS (Obama Regret Syndrome) is spreading like an epidemic. Unfortunately, it has already destroyed the medical system that could have treated it.

Red dab of health!

I was sitting in the lounge when somebody brought up MRSA infections and saw that WhiteCoat did a geat article on it in his blog. I wondered.

Did anybody notice that the superbugs began to emerge at the same time the FDA banned mercurochrome? It is extremely active against all strains of staph and gram negs. In fact, it is one of the most effective topical agents.

The FDA banned it because of the mercury which was never shown to be absorbed to any degree or to lead to any problems. Just like the thermosol scare, mercurochrome became the enemy. Even though it is now proven to be very safe, no one will produce or sell it because of fear of lawsuits.

Like many sureons, I add a bit of bleach to the bath water every now and then to help decrease staph colonizations but I think I am also going to bring back some mercurochrome from our next mission trip! (That it, with the way things are going with healthcare, the next medical mission trip may be to Washington DC!)

Whoop, there it is!

California so far has had over 1700 reported cases of pertusis with 7 infant deaths so far. This does not count those that have died that there was no post on. 2700 confirmed cases so far. Since it is very hard to test for the number is probably far more. This is the worst epidemic in at least 50 years. So where is Jenny McCarthy and the dont vaccinate your kids groups? Where are all the attorneys that tried to sue claiming that vaccines caused autism? There are at least three schools in California (according to NPR) where 80% of the have not been vaccinated. Just wait until those schools have an 80% rate of polio.

If Doctors were paid like attorneys

I think it is interesting to hear attorneys argue about how doctors should get paid. I wondered what it would be like if we were paid like attorneys. First, you would call the office to see if the doctor would consider your case. After talking for a bit with a paramedical you might get an appointment to discuss your possible case with the doctor. After consideration, he might agree to take your case for a retainer and then a cost structure of so much per hour (hours that only he can determine and not verify) plus expenses. You would also have to sign an arbitration contract. Any calls to him would cost at least $200 and then $200 for each 15 minutes. There would be additional charges for documentation, travel, etc. The retainer would have to be paid up front of course.

In the event of a serious problem or one in which the patient client does not have the cash, the doctor could take the case on a contingency agreement where if the patient survives, the doctor gets 1/3 of all future earnings, plus expenses, time etc.

Better yet, lets pay attorneys like doctors. If you show up at the court house, they have to take care of you regardless of your ability to pay and you can sue them at any step.

No-can

Got a call that one of my partners patients was a bit somnolent and hard to arouse after the family decided he was hurting in his sleep and got a bit agressive with his PCA. When I got he was holding his sats with a facemask but I wasnt sure how much was the morphine vs something else going on. To help determine this I asked for some Narcan. Turns out there is a shortage. Two of the companies that made it have stopped. It was going to cost them too much to jump through all the FDA hoops. Another company did not say why they stopped making it. The last said it wasnt sure if it was going to increase production or even continue to make it.

We stole some and got the pateint better. Good thing the FDA has stepped in to make it so hard now to produce generic drugs and to make it so easy to sue!

Camión Basculante

Our county hospitals are going bankrupt. One of the main reasons is the number of illegals flooding their EDs. To stay afloat they have had to resort to new techniques. The technique is EMTALA. It is so hard to prove an COBRA violation that the small hospitals will immediately create some reason that they can not provide the care for the patient. All illegals who are pregnant get transfered becuase of lack of prenatal care and probable high risk. Of course all traumas, and everything else they can make up gets sent on the camion busculate to the university. Somebody has to pay the bills, so pass the buck!

Tomcat Social Economics

Our accountants moved into an old historic building (for tax reasons, but that is another rant). One of the first things they noticed was for an old building, there was not a mouse to be found. They soon discovered that a small Tomcat was living just behind the building in a small crawl space. Some of the people decided it would be nice so they started feeding the Tomcat. Before they knew it, they had mice everywhere. You couldn't leave your lunch uncovered while you went to the restroom because a mouse would be there. The Tomcat got fatter and fatter. Infact, if you didnt feed it, it would go from window to window crying until it got something. Then it wanted to be fed more and more. Soon, there was not only the one tomcat, but a whole bunch of cats. They were everywhere! All whining for food. The original tomcat was so fat, he couldnt catch a mouse if he tried! Becuase there were so many cats the cat poop was everywhere! The accounting group had to have a called staff meeting about the cats. The cost of the exterminators to take care of the mice was astronomical. Clients were offended by the cats and the odor. In the meeting the people who were the ones who started it all complained that they just couldnt stop feeding the cats, somebody had to take care of them! When all was said and done, the group decided that no one was to feed the cats, if someone felt strong enough that the cats needed support, they could take them home!

Interesting thing. The cats mewed at everyone and screamed through the windows for what seemed like weeks, and then went away. The exterminators caught up with the mice. A few weeks later there were couple of cats living in the crawl space. They could be seen in the morning hunting mice. No one saw any mice in the building.

A Sith Lord

I received this in my email this morning.

What, that cant be you say. Or can it? Consider the following.

Barack Obama became the leader of the free world after a brief career as a virtually unknown and unimportant US Senator. Chancellor Palpatine became Emperor after a brief career as a virtually unknown and unimportant Senator from Naboo.

In 2008, Barack Obama campaigned on a platform of "Hope and Change", (after a carefully orchestrated crisis). Similarly, Chancellor Palpatine, prior to seizing emergency powers and declaring himself Emperor, raised everyones hopes at the prospect of ending the Clone Wars. (after a carefully orchestrated crisis)

And take a look at this Obama speech here at http://www.youtube.com/watch?v=ItHtOqh2Yk0 . I could swear he sounds just like Palpatine.

Coincidence? Sure, That's what THEY want you to think....

DoctorBashir

(my little edits)

Driving Ms. Disabled

It was one of those days. I lost count of how many of the patients I saw were "disabled". I mean, full fledged, on Medicare and Social Security disabled. One was 28 and was disabled due to chronic pain from her obesity. Another was 30 and was disabled because of headaches. Of course, there were the buch with fibro. The one thing that got me was, all of these people drove themselves to the office. They are so disabled that they cant work and get free healthcare as well as checks from the govt, but they can drive! Why cant they get a job driving? For that matter, why cant they get a job putting gas in cars? They all are very good at talking on the phone and texting while at the visit, why cant they get a job doing that?

If the government wants to help decrease the fraud in Medicare and Social Security, I suggest that it revokes the drivers liscence of anybody who is on Social Security disability!

Add a D to the MD, Drop the M for an S

It is hard enough to get qualified applicants to go to medical school, much less into surgical specialties but now this one takes the cake. We had one of our interns leave the surgical program, to go to dentistry. Not to be an oral surgeon, to be a general dentist. I cant fault his decision making, he put it this way. He will be his own boss. There is far less regulation. Obama hasnt messed with it yet. It can be cash pay and you dont have to deal with insurance if you dont want. Dental emergencies are not covered by EMTALA. If you dont pay, you dont get squat.

He was our sharpest intern.

Obamatrophic parasites

Parasites are a problem, but they are a fact of life. They live by feeding on the host, taking not earning. Many organisms have atleast learned to use them, at at least get something from them. These organisms have made the parasites, biotrophic parasites, parasite that actually can help the host. They are not symbionts because the host can live well without them but at least the parasites are partially paying their way and the host might actually do better. Like all parasites, however, if there are too many, the host dies. There are also necrothrophic parasites that just eventually kill the host. Then there are Obamatrophic parasites. These are necrotrophic parasites that just live on the host and try to multiply to the point that the host dies, and biotrophic parasites that are organized to believe that they dont have to contribute to the host anymore and in fact that they are entitled to the hosts resources. These Obamatrophic parasites work only to support the condition that helps them not contribute.

I operated on a HR rep from a large company. They are looking for 300 people. The jobs start at $13/hr plus benefits. They cant get enough applicants (well there are enough but they are illeagals). Why would you want to go to work when you can get $300/week for free from the Feds and state, free healthcare, housing, food? Especially when it is just extened for another 4 months. Hey thats over two years of just sleeping in, watching TV and playing XBOX! Why would anyone want to work?

You Know, the blue one!

I should not have done this, but I could not resist it. I was picked to give one of the short welcome lectures to the new interns. (again, I blew off a meeting and look what happened!) Following my administrative motto of "do it good enough that you dont get in to trouble but not so good that they ask you to do it again," I titled my lecture, "Things that they didnt teach you in medical school." My first slide whas a pile of different colored pills. I explained that many times when you ask what medicines your ER patient takes, they will tell you that they take "one green one, one blue and two yellow". If you ask if any of them are blood thinners, they will look at you like your are stupid and say "you know, the BLUE ONE", but I only take it when I think my blood is thick. When you ask if they have any medical problems, they will say no and have no idea why they are on the blood thinner. They will deny that they have had any major surgery but you will notice the medial sternotomy scar and the off center midline abdominal incision.

The next slide was the "yellow pill". At least it was yellow from this pharmacy. It was hydrocodone. I explained that this pill makes everyone hurt. Because they take hydros all the time, they will tell you everything hurts becuase their pain receptors are messed up, so you cant tell what is what. (you will wish the previous doc left a little chip like dogs have in the wound so you could just scan the patient and find out what was done.) They will have no idea what their abdominal scar was from and will look puzzled at you because you asked. (the scar is supposed to tell you what surgery they had.) They will all be in so much pain that they cant do anything, except they can walk outside and smoke.

The next slide was a wooden shoe. I explained that their are many people at the hospital to help you, but dont rely on them or believe them. Double check everything becuase you cant tell the saboeteurs from the allies. Check your own xrays and verify your labs. When you look at xrays, first check to see if it is the right patient, secondly look at the xray to see if there is anything in the xray that might kill the patient, such as your shadow!

The next slide was a phone. I said it is always easier to call and ask for help then it is to call and ask for forgiveness. Lastly, I said, if you dont know spanish, start learning!

I think I will probably not be asked to do this again.

Throck Multi-tool

I was in my usual state of disbelief last night on rounds. Why is it so hard to get a pair of surture removal scissors or a staple remover? Why can you always find the hemocult cards but never the developer? It seems that to make it through rounds I end up hoarding all these things so that once I find them I can put them in my pocket so I dont have to hunt them down for the next patient. Then I got an idea. I love my little Leatherman multitool! It has got me through camping trips, military deployments, and car break downs. Why cant we come up with one for medicine? Kind of a swiss army knife for docs.

Then I started thinking about what it should have. It needs suture removal scissors and staple removers of course, but what else? Flashlight, stethascope, #3 mac blade, hemostat, 16 guage needle for those darned popped lungs, could add one of those portable US things, oh, something to remember all those darned EMR passwords that change every few days at all the hospitals we have to cover, nurse GPS locator, food finder, hemocult developer, gloves, culture swab, IV pump shut upper, bandage swabs, cast cutter and above all bad odor eliminator.

The device would have to be disposable of course and I would have to get it JACHO mandated. Oh, wait a minute. They would keep them locked up in the Suremed and you would still have to find a nurse and get the patients number to get the thing out anyway.

Not Treat but Street

Up til now, if you went to the ER they would see and treat you regardless of your ability to pay. Often, even if you did not have enough for a prescription, they would give you some medication or at least samples. For these non-emergency condition, the old term was treat and street. This is getting to be no more. First, we cant get sample meds. The Feds are taking care of that. Secondly, the hospital just cant afford it. Unfunded mandates have wiped them out. So, we are now seeing the new trend in EMTALA triage evaluation. If it aint an emergency, you are out of there. If you twisted your ankle and it has a good pulse, you are out of there. (unless you want to pay there and then) . Emergency means you are about to lose your life, limb, eye or baby. If it aint one of these, you get a copy of the phone book with numbers of doctors offices you can call.

One of the hospitals in the area has the same policy for all Medicaid patients. These patients dont get the list of phone numbers, they just get the number of the Medicaid service agent because there are no docs in the area that will take them.

Medicare not!

While on call I saw and treated a patient from another state who had just moved here. He asked me it I could set him up with a primary care physician. I said, sure no problem and referred him to our university medical centers department of internal medicine. I then got a letter back that stated that the university internal medicine department as well as family practice departments are no longer accepting new Medicare patients. The Geriatrics department is going non-participating and will only see Medicare patients if they have certian secondary insurances.

By the way, the University Medical Center is Federally funded as are its residency programs. I called the Chairman of Medicine and asked whats up. He said that they were getting creamed with so many patients because everyone in the community is fed up with Medicare and dropping it. They also are going broke trying to see Medicare and feel that the only way they can survive is to decrease the amount they see which means no more government insurance.

SGR $%$^&* for Patients

A great explanation of the whole SGR mess from a great sage!!!

www.theroadtoheallth.com

Opting out

There was a called board meeting of the medical staff of one of our big medical centers last night. The hospital is concerned about how many of the docs are opting out of Medicare and how it will affect the center. They knew most of the internists and FPs in the area were opting out but then the hammer hit. So were all the hospitalists! This basically meant that when you go the hospital you are responsible for payment and then you have to figure out how to get reimbursed from Medicare. Then the head of the Emergency Department Physicians group announced the same thing.

Over the course of the meeting it became clear, that the same thing was happening to the other medical centers in our area. I guess Obama was right that this healthcare bill was going to be great for the economic growth, In the collections industry.

This really SUCCinylcholines?

As I came in to the OR this morning it looked like a feeding frenzy at the pharmacy. Each CRNA and MDA were in line hoping to get some meds. There is a nationwide shortage of propofol, fentanyl, etomidate, succinylcholine and many of the other drugs that are used for anesthesia. These are all the generic cheap ones! I had to find out why so I called the main distrubution pharmacy. Since these drugs are generic, the profit margin in minimal and the liability risk is high, so there are not many companies making them in the US. In fact, most of the drugs are imported. The FDA has cracked down on inspecting the drugs but since the FDA is so slow, there is a huge delay getting them in to the country. On top of it, the FDA has decided that all older drugs must have the same testing that the new ones do, so to sell an older drug that has worked for years, someone has to pay the billions to run all the new tests on it. Of course no one wants to, so companies are just selling what they have and really not making any more.

So, when you have to have your emergency surgery just think, Attorneys and politicians have taken away your anesthesia!

Early bird get eaten by the worm

We take call a week at a time. This means that for a week I am zooming all over the city to different hospitals at different times. I've noticed something. When I am going in from 3am to about 9am, I will hardly ever see an Obama bumper sticker. When I am done at one of the hospitals and then driving to another later in the day, I see them. There seems to be a lot that can be inferred. This seems to be independent on traffic as the rush hour is over by the time you see the Obama stickers. The same is true later in the day. You never see them during the 430 to 700 rush.

Blue Phonorrhea

By law, we have to provide translation services out of our own pocket to any patient that does not speak engligh fluently. Since most of the patients who need the phones are also illegals we are paying for their care also out of our pocket. Anyway. Because you have to have a translator available at all times and there are so many illegals, the hospital went and got these blue phones. They have two handpieces. You pick up one handpiece and that patient picks up the other. It automatically calls an interpreter who then translates. This way you can comply with the governments unfunded mandate yet again. So, today on rounds I had to see eleven patients who had these phones. Of course all were illeagals. Each time you pick up the phone, there is a connection fee and then so much per minute. Of course the pateint's love them and use them to complain about everything. The average cost per patient per day is $212. Since the patients dont pay for it, the cost is of course passed on to others which eventually is the docs and the taxpayers.

As I made my way around the hospital, the blue phones there everywhere. They are only brought into the rooms of the patients who dont speak english. Suddenly, I was called stat to the ED. I had to explain to this MS-13 hombre that he needed to go to the OR asap. There was no translator, so I asked for one of those D+++ phones. I was told that we were out of them. I said "what do you mean, we have 160 of them!". The answer was that they were all in use, there were over 45 in use just in Labor and Delivery!

People wonder why healthcare is so exensive, somebody has to pay to take care of all the illegals and their mandated phones!

Fallout

In our medical center every patient who comes in on the surgical service has their chart reviewed as part of quality assurance. If there is a complication, it is recorded and categorized and entered into a data base. These complications can be wound infections, extended hospital stays, nosocomial infections, bleeds, etc. This database is constantly under analysis. Whenever there is a bump where the number of complications excedes the set levels that are determined nationally, it is said to fallout. Somethings such as an operative death or post operative death automatically fall out. So do all major complications. When something falls out, it is sent to be reviewed. Complications are kept per procedure, per patient, per unit etc.

This week was rough. One of our physicians "fellout". That is to say, he had more complications that his peers and those nationally. When this happens, all his complications are immediately sent for review. In this review, we inspect to check for clinical decision making, technical competence, wisdom and knowledge base. Many times the review finds that the particular surgeon just happened to be on call when bad things happen such as dead bowel from mesentaric ischemia or STEMIs with right main disease. This week the review brought out more questions than answers. So, I had to suspend the doc pending further investigation.

I have heard all these attorneys say the problem is that we physicans do not police ourselves. In fact we will stop a doctor from practicing while we investigate to be sure patients are not harmed. It is all part of the bylaws that you practice in the hospital. Do attorneys suspend each other from practicing while they investigate their competence?

Take your President to Work Week

Received in my email today:

This past week has been horrendous. I have had 5 of seven days on ER call with busy days including 30+ patient office days (half days actually) while instituting and impossible EMR, and doing 2-3 cases each night from the ER and 6 to 7 cases per day in the general OR. As I was driving back to the hospital last night at 11pm for the third time, I thought of a great idea. The American College of Surgeons or the AMA should suggest that President Obama and some of our Congressmen/women join us for TAKE YOUR PRESIDENT TO WORK WEEK! I'm not talking about some p****Mayo Clinic or Harvard surgical service. I'm talking about some grassroots bluecollar down home time on the surgical service of everyman's community hospital. Just follow a general surgeon around for one week, Monday to Monday. He'll see:

1) The EMR slow us down like those puncture strips that cops throw infront of criminal vechicles.

2) The amount of non-reimbursed time that we spend answering phone calls, doing charts, waiting, driving and caring for patients.

3) The complete joke the 80 hour work week is for residents.

4) The incredible effort put forth by the entire medical team at our hospitals and the ridiculous risk we take from from opportunistic attorneys.

5) Just how good our healthcare system is even in the far corners of this country, and how misleading the "experts" are when they see otherwise.

6) Most of all, he will see the good job our doctors are doing before they start to rapidly exit the profession that he is making more and more frustrating every day.

Mr. President, come along for one week and educate yourself before you destroy the good things in our system. As you finish your one week on Monday, I'll remind you that for us the next day is never a day off.

I have a few to add of my own:

7) See how many illeagals we are seeing and taking care of and how they deplete the resources that allow us to take care of our citizens.

8) See the amount of fraud that is our disability system.

9) See first hand the incredible heroism of our police, fire and EMTS who put their lives on the line for others.

10) See how government red tape and Stark Laws have made medicine so expensive.

11) Let the President order the diagnostic studies and be responsible for all the outcomes so he can decide what is defensive medicine or not.

Dr. Obama

It has been pointed out to me that your anterior communicating artery has been bleeding profusely and that every minute it bleeds you lose cerebral cortex. I will do my best to schedule time to look at it between meeting with basketball teams, golf dates and trips to help my friends. After a month or so, instead of decisive action, I will appoint a commission to look into the matter composed of political appointees and public relations people who will spend several months looking at the issue from a political safe point of view after which I hope the problem will just go away. The commission will have no power, it will just make recomendations which I will pass on so that the person on the scene will be held accountable instead of me. I wish you well and remember, I am in charge.

Googlechondriacs

I think that we need to somehow change how google lists medical conditions. It seems that it lists them by number of hits or who pays the most instead of what is the most common answer. When you type symptoms or a medical condition, often the thing that comes up first is WrongDiagnosis which is sponsored by attorneys. So, when you type headache, you get stories of missed tumors or bleeds and how to sue instead of descriptions of what is a tension headache. It is even worse when you look up belly pain, the first sites are for lawyers and the second sites are for herbal tonics.

So, with Google we get people who come to the ER convinced they have a tumor or bleed who dont believe us when we say it is a migraine and others who go home convinced we are idiots because we didnt prescribe the herbals that they saw on the internet.

I cant even go into medications because I am fed up with all the people who come in with seizures becuase they stopped their dilantin once they looked it up and saw all the attorney adds.

Letting the flight attendants fly the plane (again)

I got called into a special meeting. One of our outside hospitals had filled a complaint against one of our pulmonologists. The complaint was that an older gentleman had presented to their ED with pneumonia. When the NP tried to call and arrange transfer, the pulmonolgist at the medical center where she wanted to transfter the patient to told them that he would only take a call from a physician and would not accept any transfer from a NP. This caused the NP to get riled up and file the complaint. After all, she was a ARNP, PhD., The pulmonolgist explained that he was tired of being responsible for people who dont know what they are doing and then having patients show up with totally different things than what he was told. He used other language like idiots and imbeciles. Anyway, I tracked down the patient. When the NP had left after her shift, the patient was indeed transferred, but it was to CCU. He didnt have pneumonia, he was in cardiogenic shock, what she though she saw on the chest xray as pneumonia was CHF.

I made sure that she got a copy of my findings and a copy of our new policy that transfers will only be made between physicians. I made sure that her hospital medical director and CEO got copies as well.

NP does not equal NP

Another Patient Death - Patient Saw NP And Was Sent Home

Family settles lawsuit with Heartland

ST. JOSEPH NEWS-PRESS, MO. Sat, May 22, 4:41 AM

May 22--A family and Heartland Regional Medica... avoided a jury trial in a wrongful death lawsuit this week.

The parties settled on a $725,000 judgment Monday in Buchanan County Circuit Court. The lawsuit accused medical malpractice by Heartland's Urgent Care Clinic, Heartland Health and James Weaver, a nurse practitioner, in the death of Timothy Allen Weber.

Mr. Weber's wife, Michele Weber, his parents and his three children were plaintiffs in the suit, filed in March 2009. The case was set for a jury trial this week. The parties reached a settlement and the case was dismissed on May 17.

According to court documents, Mr. Weber went to the clinic at 1115 N. Belt Highway around 10:35 a.m. on April 14, 2008.

With valid complaints and ailments, he was discharged about two hours later without normal vital signs and no testing or treatment for gastrointestinal bleeding, which led to his death.

It is also reported that he was never examined by a physician while at the facility.

Mrs. Weber found her husband at their home approximately four or five hours after his discharge from the Urgent Care Clinic.

He was pronounced dead at 5:40 p.m. at Heartland's emergency room.

An autopsy determined the cause of death to be hemorrhagic gastritis

Cachexia

I was watching the news and saw some recent photos of Hillary Clinton. She looked like there had been a rapid weight loss and there is definately a redistribution of her facial fat that is not typical with dieting. Curious, I looked back over the last few months and there definately seems to be something going on. From the dates of the photos it is happening fast. She also has changed her posture and hardly ever shows energy. Something is going on, chemo perhaps?

People get p*****off when you fix their disabilty

We had a patient who came in with a multitrauma who had wrecked their car and injured those in another car. The patient had taken too much oxycontin for her fibro. (Patients will always be too disabled to work but they will always be able to drive). Anyway, she was blitzed on narcotics. It wasnt her oxycontin but that is another story. While she was in the hospital she had problems tolerating her tube feeds and after alot of testing it turns out she has a gluten sensitivity. When she was told that she didnt have fibro and all she had to do was follow a different diet all she said was "I still get my disabilty checks right?"

Fannie Mae Health Insurance

Sorry that I have been away. We are getting creamed at work. The effects of "Obama Care" is beginning to hit. The new quotes for health insurance that is hitting small businesses in our area and the surrounding states is scary. Because of the increased demands on the private insurance companies as well as the costs imposed on business, rates for health insurnce are going up between 27 and 37%. As a result, companies are dropping healthcare. Patients cant get Medcaid because it is out of money. So, there are now more people without insurance and those who have it have giant deductables and are waiting until it is very late to get care. Medical centers like our that have an open door to the indigent are getting creamed. The indigent is now increasing, the underinsured is skyrocketing. The cost of practicing medicine are increasing exponentially with the new bill. It is like medicine is being done by Fannie Mae. Give everyone "healthcare" that they cant afford, hide the cost and stick it to future generations. Then let it forclose and destroy the whole thing.

Best intentions, wrong actions

As I was drinving home on the interstate, traffic started slowing down and a police care shot past me. In a few minutes I came up to the accident. I saw that they were doing chect compressions so I pulled over to help. They were pumping chest so I announced that I was a doctor and apnd new CPR and ALS and leaned the patients head over to start mouth to mouth since they were not ventilating. One of the people there, I think a road ranger pushed me in the chest away from the victim and askem me who I was. I told him again that I was a doctor. He wanted to now where I worked. I told him again but said you need to ventilate him . Pumping the chest doesnt do anything if the patient is not ventilating. I showed the police officer my medical licence and he said that didnt mind if I helped but I cant take over. I explained to him that if they dont ventilate the victim he will die. About this time an ambulate came. The gut was feeling for a radial pulse. I reached over and checked the carotid, too late.

I know the guy was trying to do what was right and his intentions were the best. A good thing to do though is when you dont know what you are doing and someone does, it might be good to listen to them. I dont know if the victim could have been saved, I do know though that he had no chance when you dont ventilate.

Press 2 if you have Medicare

Instead of fixing the SGR, Congress pushed off the fix for a few months. SGR is a formula that is designed to decrease doctors fees for Medicare. Doctors big issue with Medicare is that the rates are about the same as they were in 1983 without an adjustment for inflation. Unfunded government mandates have increased but the reimbursement has not. Admittedly, docs were probably paid too much in 1983 but now times are different. To make the numbers look good for the healthcare plan, they used the cut numbers which include a 20% or so cut in physician reimbursement. This pretty much reimburses less than what it costs to provide the care. Anyway, our biggest primary care group of over 200 doctors has just decided enough is enough and limited its Medicare slots to less than 1 per doc per day. (45% of thier docs decided just to drop Medicare). They already do not take Medicaid. The specialists have already limited Medicare to patients that the primary care docs personally calls for an appointment.

"Thank you for calling Greater Metro Cardiothorasic Consultants' appointment line. Keeping your heart healthy is our business. If you have private insurance such as Blue Cross, United, Etna or Cigna please press 1 and one of our schedulers will be right with you to schedule a timely and convenient appointment. If you have Medicare, Medicaid or other government funded insurnance press 2 and you will be directed how to submit an appointment request in writing. Please be aware you will need your primary care doc to personally call one of our physicians. We will then get back to you in writing in 9 to 12 weeks with an answer to your request. If you are granted an appointment, it will on a space available basis."

ASDS

It seems now even the New York Times has figured it out in this article where they show how they expect Obamacare to be like Romneycare. More cost, less care! "Healthy people, in effect, began to subsidize people who needed more healthcare. The healthier customers soon discovered that the higher premiums were not worth it and dropped out of the plans. The pool of insured people dropped to the point where many of them had high healthcare needs. Without healthier people to spread the risk, the premiums skyrocketed, a phenomenon known in the trade as the "adverse selection death spiral". (New York Times 4/18/2010)

Allergic to HIPPA and JACHO

After a case, I was writing post-op orders. I instinctively go to the front of the chart where the patients allergies would be in bright red letters. Instead, all it said with a JACHO HIPPA approved sticker is "patient has an allergy". So, now you have to pour through all the computer and emr generated junk to actually find the allergy. I couldn't help myself, so I had to ask. Aparently, this is some new HIPPA JACHO thing. Infact, the patients name is not even supposed to be on the chart.

I know that to stay in business, JACHO does its best to invent new ways to create paperwork and to decrease actual patient care, and that the government likes to make new regulations without thinking of the consequences, but this just seems stupid.

SP/GAK

Call this week has been busy. Each night has had its fill of the latest SP/GAK (status post getting a++ kicked). Evey patient seem s to say that they were hit with a tire iron. I dont know about you, but the tire thing in my car is this little flimsy thing that is hard as heck to get out and is only about 10 inches long. Even if I was mad, I dont think I could figure out how to get that thing out, much less figure out how to use it to hit someone. I stopped at Autozone to get some tranny fluid and asked if they had any tire irons. They didn't. In fact they weren't even sure where to go to get one and suggested Tractor Supply. So I guess you should watch out if you are at Tractor Supply.

What ever happened to axe handles and baseball bats. Well I know about baseball bats. A good wood baseball bat will set you back a bit. An aluminum just doesnt seem bad a+++, and a composite is both expensive and flashy. You cant buy lead pipes anymore, copper can be sold for top dollar and no one is afraid of PVC. I guess 2x4s are the only way to go. I wonder if my nexy SP/GAK will be a 2x4xface?

Better stop doing what works!

One of the things that has helped decrease costs was the rise of the ambulatory surgery centers. These are outpatient centers that can do many different types of surgeries. Because they do not have the overhead of the hospitals, they were able to do surgeries for far lest cost. Medicare and insurance companies recognized this and reimbursed them less, but since these were private enterprises, they flourised. A great example, is that a cholecystectomy costs is 2/3 cheaper to have in a surgery center. So, in their great healthcare bill, what did Congress and the President do? Medicare will no longer allow cases to be done in surgery centers. So, it wants to pay 2 times as much for the same thing! Good thing these guys are in charge of the economy!

You get what you dont pay for!

The State of Massachusetts passed an emergency regulation to keep health insurance companies from have a huge price hike in their rates to offset the mandated care imposed by the state. The issue, it is the non-proffit health insurance companies that are affected and are the ones fighting. Since the companies have to cover all the things that the states require but can not use actuarial data, the non-proffits are going broke. The only way they can stay afloat is to raise their rates. Hey, come to think of it. Isnt the government like a big non-proffit? (politicials and their friends excluded?) So, in Massachusetts, the state is telling what has to be insured, tells what rates the insurance companies have to charge and the result is insolvency. Good thing Obamacare is different. Oh, wait a minute. Nevermind, it is the same thing.

Its only $5!

I cant talk too much about it as all I can think is that the President and Congress have reinforced what makes medicine more expensive and charged it to us and our children. Although we in medicine are surrounded by examples of this it is apparent that none of our congressmen or senators bothered to investigate the issues themselves. Here is what I found out in five minutes. I needed an antibiotic so I called several pharmacies, I found out that my copay would be $5 and they assured me that that was all I had to pay. I then called back later and asked how much it would be if I paid cash. It was a generic antibiotic. It was $31 at Wallgreens, $29 at CVS, $17 at Kroger, $3 at both Kmart and Wallmart.

Yeah, I guess Congress and the President are right, it is the drug companies and the insurnace companies that are screwing us!

Federal healthcare sandwich: Hold the Mayo and the greens

With all talk of the government taking over healthcare, we are already seeing how good the government care is. Earlier, the Mayo Clinic is Scotsdale stopped taking Medicare and now Walgreens is no longer accepting any new Medicaid patients in the state of Washington. In both cases, the reason is simple, poor reimbursement and excessive unfunded mandates.

I looked at what we could do in our practice to cut costs and at the same time continue to provide the best care we could. The big thing would be to move more testing and treatments in house. This way we could package care plans for a cheaper price. Well, it turns out, the reimbursement is set by the government and the Federal Stark Law prevents us from consolidating.

So, we cant lower the prices of our care because they are set by the government, and we cant cut costs because of the government. Now, they think the solution is more government. Its like they want to make a sandwitch to feed the nation that has no bread and nothing between the slices.

Good for Goose? how bout Gander?

I just saw yet another congressman claim that what we need in the US is a single payor system for healthcare. I guess my ADD kicked in and I thought, well this Congressman is a trial attorney. I wonder what he would think if we applied the same concept to tort law? I mean you can make all the same arguments. "Give everyone access", "Its a right" etc. So, I started looking up to see if anyone else had the same idea.

Someone did!

www.singlepayerlegal.org

I wonder if Congress could pass the healthcare bill if they just erased the words healthcare in the whole thing with legal care?

"Obama Care"

Got this in the Email.

Obama had a physical recently.Hes 48yo.His physical included a virtual colonoscopy and a cardic CT scan.Do any of you think you would have been able to get prior authorization for either of these procedures?I dont think so.Niether were indicated .Too bad for him...he was just exposed to a serious amount of unnecessary radiation.What a contradiction this man is.Have any of you ever included these procedures as part of a physical in an asymtomatic ,healthy 48yo man?And what does this say to the country when hes ramming thru healthcare legislature that many Americans oppose.

25 guage IVs

Easy to get but cant do anything with them. Our medical centers are overwhelmed right now with outofstate Medicaid. The patients who have it think that they are entitled to everything but somehow cant seem to find anyone in their state who will take it. Their own medical centers have cut back so far that they are on "divert" for almost everything. As a result, the patients have to go out of state where they have to be seen because of EMTALA. Of course this Medicaid pays next to nothing so our centers are even farther in the red.

There is this belief that the problem is that we have so many uninsured and we have to get them insurance. The insurance is worth not when it does not pay what it costs to take care of the patients. Sure, you can jump up and slap your back and say you got people insurance, but you have done is make it worse. The state that the Feds tout about healthcare reform, has actually just pushed its patients out of state and stuck someone else.

If we want to make medicine cheaper, we have to make it more efficient and more competitive. We cant be efficient when the nurses who do most of the healthcare have to spend 85% of their productivity doing Federal CMS JACHO mandated paperwork. Where patients are not able to negotiate the price of their own care. Where diagnostic tests and procedures are determined because of potential lawsuits rather than evidence based studies. When the healthcare industry has to support the trial lawyer industry. Where the Federal Government is the one who actually sets the prices of all medical care. (All Medicaid, Tricare, BCBS etc fees are tied to the Medicare rates).

If the Feds expand Medicaid, the rest of healthcare will collapse. It is like a 25 guage IV in a septic patient. Not really good for much.

Three beers

I dont know why patients lie when you ask them how much they drink or if they use illegal drugs. We are not asking to arrest them or anything. I have even tried the "its off the record" thing and explain that it is important so we know what to look for and to prepare for things. It doesnt matter. The worst alcoholic will always say he only has about three beers a day and the worst heroin addict will tell you the needle marks are from chiggers. The little old lady will go into DTs and the businessman will have SVT from crystal meth. You came to us for help, so let us help you. We ask the questions for a reason. The reason could save your life.

(re)tardive dyskinesia

It seems that whenever a politician is about to see why healthacare costs so much, they jerk their head away and refuse to look at the situation directly. I would love to give them some cogentin, put them in a Miama J and force them to actually spend some time in the trenches and see what is happening.

First and formost, I want them to take their dog to the vet. The vet does not take insurance. The vet gives you an itemized bill for the care. Interestingly, for a check up that includes vaccinations and routine blood tests, the vets in our area charge $115. For the same exam with one fewer test and vaccination for a child, Medicaid pays $27. Hmm! What would happen if the vet had to see dogs who had, Medicaid? He would have to charge others more!

When you mandate that someone gets a service at a rate below what it actually costs to do, you have to make up the difference somewhere. Since Medicaid and Medicare have not increased their reimbursements, the shortfall has to be made up by the private payors. So, private insurance goes up. Congressman are yelling because the healthinsurance rates in the state for private insurance companies are going up by 20 to 30 % and blame the insurance companies. The reality is that the state has cut its Medicaid so to keep its healthsystem running the money has to come from private payors. The state has also increased the number on Medicaid and done nothing to decrease the number of illeagals.

Who is really to blame for the cost of healthcare?

Try-to-care

I wasn't sure at first so I had to check it out. It turned out that it is true. The health insurance that the government gives to our soldiers and their families is TRICARE. It was already bad enough that it paid less then Medicare and far less than the Blue Cross that other federal employees have, but guess what? By law it is tied to the Medicare rates. So as of monday, our troops and their families will have their TRICARE cut by 21%. If there is anyone who deserves a "Cadillac" Health Insurance policy it is our troops. Instead, we give it to Congressmen and office sitting, every holiday taking governent employee. Does the Federal Government even try to care?

Why shoot for par when all you get is a boogie!

On March 1st, the Federal government has decided to impose a 21% cut in physician reimbursement for any Medicare covered service. Physicians themselves have not had a pay increase since 1983 and infact reimbursement has gone down because of inflation. Anyway, if you participate in Medicare, your revenue that runs the practice is going way down. Since Medicaid is tied to Medicare and Medicaid is 60% of Medicare, Medicaid is now so low that what was left of the physicians who took it are leaving. Before the cut, Medicare was paid about 75% of what private insurance pays for your care.

So, physicians accross the country are deciding this weekend. If we participate (Par) in Medicare, you get at least the 21% cut. So if you shoot for the par, the government gives you a bogey. If you opt out, Medicare patients must pay you out of their pocket and then try to get reimbursed from the government. There is one catch, if you opt out you have to wait 2 years to opt in. Anyway, it looks like many docs are opting out. I can only imagine the outrage when all the seniors who have to pay for their care and then try to get the government to reimburse them!

It is what it is. Perhaps this is what is needed to knock some sense into Congress. People might see how screwed up the government is because now its their money that they have to get back!

Medicaid Kaiser Soze

The whole Kaiser Soze situation has got much worse in the last few months. As the percentage of patients with goverment insurnace goes up, the number of docs who will actually see it is going way down. When I met with our Senator I explained this to him. He had some data that showed the number of docs who had signed up with Medicaid and was of the belief that this meant that those docs would see all the Medicaid patients. I had to set him straight on the Medicaid Kaiser Soze pricipal. When you have to take call, many docs will take Medicaid so they get something for having to see the patient in the ER on the basis of something is better than nothing. But when it comes to seeing them in the office, just try to get an appointment! The long and short of it, just because you have signed up for Medicaid does not mean you have to see them. In our area the pediatricians have been so devastated by Medicaid and SCHIP that they will say they take those insurances but they have so limited their office templates that they are basically not seeing any government payors.

I told the Senator, its like Kaiser Soze, Medicaid is everywhere but when you call and try to get an appointment, it is nowhere.

Defensive Medicine Almost Kills

I have heard attorneys try to argue that defensive medicine does not exist or that it is not prevalent, I have even heard them that the reason doctors order so many tests is because they make money on them. I would love to have those attorneys spend a few nights in the ED and see the reality. First, we dont get paid for the test, we dont get paid for the results. We do pay if a year later we have to face a lawyer who asks why we didnt order the test. This has got so ingrained that our medical students and residents dont ask what tests should be run but what tests can be run. So it was the other night. A patient came in with what appeared to be a classic migraine. One that they had before. The doc ordered the standard tests, (doesnt matter if they have insurnace or not, because it doesnt matter to an attorney), one of the tests was a uncontrasted CT of the head. The intracranial part was normal but there was some question of a tortuous carotid vs a skull base lesion. Since he could not rely that the patient would follow up to have this evaluated, the doc ordered the contrast scan of the skull base. The patient then had a bad reaction to contrast and went into shock and had to be resuscitated back in the ED and ended up intubated.

So, was the doc ordering the tests to get money? No, we dont get paid by the test. Why was the second scan ordered, CYA? The result of the defensive medicine? The patient got intubated, spend time in the ICU and had a MI from the epi given during the contrast reactionn

"Qu'ils mangent de la brioche",

I came accross this from the CBC news. Newfoundland and Labrador Premier Danny Williams is set to undergo heart surgery in the US. So, why would he leave the Canadian Health System for his care. Could it be because of the wait, the lack of specialists, the lack of post-operative services such as dialysis? He is after all in charge of healthcare in his province! What does he know that he doesn't want the rest of Candada to know?

http://www.cbc.ca/canada/newfoundland-labrador/story/2010/02/01/nl-williams-heart-201.html

La costra nastra damas

Just so I can say you heard it here first. Well actually we were sitting in the lounge when one of the docs was asking for advice about how best to take care of a radiation injury to the pelvis of a lady and we got to talking about nukes. Somehow we figured out how to take care of here and then went to other radiaton injuries, which then went into nuclear weapons. This led to Iran, and then out came the prediction. The general consenses was that Iran is going to touch off a small yield nuke on or about 2/11/2010. I am not sure how we got there, but there it is. The nuclear prediction of a bunch of docs. Lets see if we are right.

Oz scintillation retinopathy

(When you cant see the man behind the curtain.) I was watching the news and one of our Congressman was going off on how the drug companies are behind the high cost of medications and how they are so much cheaper overseas. (Part of the Progressives view that all corporations are bad!) Anyway, I thought about it and did a little checking. When we go on our medical missions we stock up on meds. I can get 1000 Cipro tabs for $24 from a medical wholesaler. I then got on the phone to Walgreens and they told me 20 would be $16. I then ran a bunch of common meds, propranolol, amoxicillin, predni sone. It was all the same, the mark-up at the pharmacy was enormous! I tried some brand names that were not generic, and guess what, it was the same!

I found out the only reason I could buy the meds from the wholesaler was my medical license but I could not be a distributing pharmacy. You see here in the US, a patient can only get medications from a distributing pharmacy which can mark up the price as much as the market can bear. The big pharmacy chains can be their own wholesalers and also negotiate with each insurance company a cost for each medication. As a a result of this their proffit goes through the roof.

There is a reason why there are pharmacies on every corner and why drugs cost so much. It isnt so much the drug companies but the pharmacies. (When you get meds from Canada you get them from wholesalers). So, ignore the man behind the screen at the pharmacy because he is robbing you blind.

MAR de Debarquement Syndrome

(When you get dizzy discharging the patient from the hospital). Whenever we go to discharge a patient from the hosital we have to fill out this form that shows all the meds they were on while in the hospital and we have to decide if we want the patient to continue them. The problem is that often we are not the ones who put them on the meds to begin with and further, the list has the meds the patients say they were on before they came in to the hosital. I love it how all the older men always say they are on Viagra and need a script before they go home. I have had anabolic steroids on the list and of course the ever present, I wont be able to go to the pain clinic for a while so I need my Oxy and Percs. I tell the residents the only scripts patients get from us are for the meds that we put them on, none other. When the ever present JACHO form nurse asks about the other meds, I write on the form that "other meds are at the discretion of the original prescribing physician and patient can not be discharged until these medications have been reconciled". I know that by doing this I am "ticking off" alot of the long white coat clipboard carrying administrative types, but it sure does get them moving in a frenzy to check on all the patients medications and make sure that they have someone accountable. Everytime they come back to me and ask me to be the one to approve some of these medications, I explain that I am here to fix the trauma, no be responsible for their their pre-existing narcotic dependence or erectile dysfunction and they can find someone else to admit these patients and I will just consult!

RTW NFW!

Got this in the email this morning! I't looks like I am not the only one!


OK, HUGE annoyance that just won't go away! You see a patient for a sprain/strain (not work comp) and then at some undefined time in the future you get a request from the patient for a return to work note. Ummmm never had you OFF work to start with, so I probably don't need to say it's ok for you to go back (you weren't supposed to be gone from work!).
Better yet, you didn't even see the patient (they were referred because you were the schmuck on call for the ER). And 3 weeks later they call you to request a return to work note. Ummm still NO.
Even better (and today's scenario), the patient went to the ER, you see the patient after for free follow up (medicaid or no insurance) and 3 weeks later you get a call from them saying they want you to send a note for return to work to their "turn the book over" Lawyer! Good God! NO you can't have a RTW note if I didn't take you OFF work to start with. And yes, I know that puts your job in jeopardy, and yes you might lose your job (while you are obviously trying to win some settlement for your terrible fictitious injury). But I'd be happy to send your lawyer a note (for a charge) stating that I never took you off work to begin with!
What is with people???

Umbilical Abortion

I just recieved an article from a friend that shows that in Rustberg, Virgina a woman gave birth and then suffocated the child to death. She was not charged with murder because the umbilical cord was still attached and she had not delivered the placenta. I wonder then where the abortion rights folks think murder begins?

Déjà pensé and Magical Thinking

I was trying to hold back my excitement with Scott Browns elections the other day. My excitement was that hopefully there might be some meaningful discussion about the good and bad of our medical system and a true attempt to tweat it to make it better. In medicine we straddle both the consumer and producer fence of healthcare. As a small businessman, I have to negotiate health insurance contracts for my employees and try hard to pay for it. As a deliverer of healthcare, I have to negotiate contracts with insurance companies to hopefully get paid for what we do. The biggest problem is that there is no competition, both are take it and leave it. There are only two insurance companies that will write small business health insurnace in our area of the state. The difference in price is minimal between the two for the same policies. Interestingly, one if for proffit and the other isn't but that is another discussion. As to how much we get paid, guess what. There is the government which has a set fee schedule, and then the same two insurance companies.

I was hoping that the Massachusetts election might make Congress look at different ideas and consider getting away from the laws that presently make it so that there are only really two insurance companies and do things like allow out of state competition. Why cant we have GEICO, ALLSTATE, PROGRESSIVE, STATE FARM all fighting it out for our health insurance dollars?

I was thinking of this and had my fingers crossed when I sam Obama being interviewed as well as Pelosi and Harry Reid. They just seemed to ignore and come up with a new idea (one that they had before) and just think that if they blame Bush and increase taxes it will all just fix itself.

Collating all the form ID-10ts

I hate administrative meetings. I especially hate meetings whose whole purpose is to come up with a standard form to meet yet another JACHO mandated paperwork boondoggle. These never actually have anything to do with patient care, they are just to document, document, document. Then administrators look at the forms and come up with metrics to keep track of just how good we are at filling out the forms! Forms, forms, forms. I would love to have all these people who want all these forms just to go and fill out ID-10ts on themselves!

Capgras' syndrome

A while back we were having a discussion about government panels that might determine the limits of care for patients. (i.e. death panels) The discussion focused on how much is spent on patients in the last 6 months of their life. One of our pulmonologists who is on the liberal side had pontificated on how we spend so much resources keeping these people alive that he didnt think the panels were a bad thing. I expressed that these patients are usually spending their own resources as they had been the ones that paid into Medicare and their private insurance all these years and are getting their money back. They and their families are deciding how they want their money spent.

Our death panel pulmonologist now has his father in the neuro ICU after a massive stroke. He wants everything done, a trache, peg, longterm rehab vent unit. The works. I though I was having an acute attack of Capgras' syndome, but then remembered liberals what to decide on how to spend everyone's money except their own.

Écho de la pensée

I was watching the news coverage of how Congress is trying to reshape and run healthcare when out of the blue I heard a familiar voice, faint at first and then louder. A voice of reason from the past, the voice of a spirit echoing my thoughts and ideas!

Piblokto!

I dont know if it is true but it sure seems that the weather affects how busy the ED is. Hot sticky nights seem like a good time to stab someone or to have a major MI and the place is packed, but these frozen nights, the ED is a ghost town. Well, with the exception of some of our regulars and homeless two carbon beverage lovers. The real excitement is when the psyche cases start coming in. This is usually the time of year when they come out of hibernation and begin to act up. You know they are crazy right away because the drunks start moving away from them. I used to think that it was the shorter days that caused people to go nuts in winter, but when I went out into the cold to get into my car and froze my but off, I realized what it was, all that "Crazy Global warming BS".

Verbigeration

When we see a patient, we listen to their complaints and then try to ask questions that help us reach a diagnosis or at least a point from which to procede. Some people however are very evasive and instead of answering questions, just say the same things over again and again. A classic one is "it hurts!". So, you ask "what hurts?" and they reply"it does, it hurts!". So, you have to ask "what is it that hurts?" Instead of answering what "it" is, they then go on to a new complaint that is as vague as the first, saying the same thing over and over. Now this new thing hurts, but we have no idea what the new thing is. Each time, they say the same thing over again and again, but it has no meaning! Eventually, they just on and on and you have no clue what they are talking about. When you try to pin them down on specifics, they get frustrated and just fall back on repeating their nonsensical litany. My favorite is when they say "Let me be clear! " and they aren't. I have had to learn to tell some patients that in order to help them, it is important that they try to answer my questions as specifically as possible.

Just out of curiosity, when is the last time the President had to answer questions from the public or the press?

Like Obama and Guns

There is usually a big rush at the end of the year where people who have met their deductable try to get everything in. There is a smaller rush at the start of the year when people who did not meet their deductable the year before decide to get things done so that they meet it in the coming year. That being said, it is insanely busy right now. People are coming out of the woodwork to have everything done before "I wont be able to get it!" This has been everything from total joints to CABGs. One of my friends had a patient demand to have his bypass even though he did not need it yet because he was afraid that Congress would say that he was too old! I guess Cavuto was right when he said good short term investments would be in firearms, ammunition and healthcare.

Folie à deux

In the course of a clinical day you often meet some stealth DSM IVrs that take a bit of time to figure out. When I was a resident, we used to put a little Rho sign in the upper right corner of their chart to let everyone know that this person might be a bit on the prolixin deficient side of the reality finish line. Somehow, this little sign came up in a chart review in some lawsuit and their was a big stink so now all we can do is make sure that the patients antipsychotics are highlighted in light yellow. (Doesn't show up when photocopied!) Anyway, these are at least patients that have been identified as crazy. Its the de novo ones that are hard that just show up in the office. I dont know why, but it seems to only take one to be nuts, but it takes two to be really off the deep end. The realy psychotic ones always seem to come to the office with someone else who is at least if not more crazy than they are. Quite often, this person is the friend or the spouse who is the driver. (think about that as you drive home) When the patient explains that everyday at 9:30 a choo choo train comes out of their navel, the other will tell you that he they have seen it and that is why the pateint needs disability. Almost as if they are the enabler of the psychosis. The mental sock puppet master, if you will. The friend will then be the one who goes off at you when can find no evidence of railroad tracks on the abdomen and tell you that you are part of the conspiracy and in on it with "the man". It is almost that the degree of psychosis increases exponentially when you get codependent supratentorials together. (Boy, I would hate to be in a room with Nancy Pelosi and Harry Reid!)