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!