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Duped: The House Healthcare Bill And Bureaucratic Duplication

I don’t mind health reform. In fact, I believe we need it. But when reform bills fund projects that already exist, or fund special projects for other non-health care professionals, like lawyers, I have to wonder what Congress is doing.

The recently passed House bill (H.R. 3962 pdf) contains a multitude of grants and “demonstration projects.” I wasn’t sure what some of these grants were meant to support, so I looked them up. I was surprised to find that many of the grants duplicate programs or departments already in place. While this list is by no means comprehensive, I thought I would provide a few comments on a few of these grants shown in italics):

  • Grant program for “community-based collaborative care”
    (Seems this is really a grant to fund telemedicine programs and HL-7 hospital coding standards so computers can talk together. While ultimately this should be a good thing, the grant actually has little to do with collaboration of health care in the community right now.)
  • Grant program to develop infant mortality programs
    (Why is more money needed when a department already exists for this?)
  • Grant program for reducing the student-to-school nurse ratio in primary and secondary schools
    (Forget teachers, stick with nurses for schools I guess)
  • Grant program so “No Child is Left Unimmunized Against Influenza”
    (And yet, I’m sure we’ll soon have a Pay for Performance measure for that)
  • Grant program to implement medication therapy management services
    (Once again, never mind this has already been done)
  • Grant program for community-based overweight and obesity prevention
    (been there, done that, but it seems we can never get enough of this.)
  • Sec 2221 (pg 1246) Grant program for nurse-managed health centers
    (APN’s doing “primary care.” Can’t help wonder why the AMA loves this bill. Where’s there support of what we do?)
  • Grant program to support demonstration programs that design and implement regionalized emergency care systems
    (already being done in certain communities. The natural question is how much money is anticipated for the multitude of communities in need.)
  • Grant programs to prepare secondary school students for careers in health professions
    (What ever happened to “Career Day?”)
  • Grant programs for community prevention and wellness research (What is “wellness” anyway?)
  • Grant program to promote positive health behaviors in underserved communities
    (Sounds like attitude adjustment training: “Don’t worry, be happy,” I guess. Interesting that Senate Bill 319 already addresses this for women and children. Men, it seems, don’t matter.)
  • Grant program for state access programs (These grants already exist, too!)
  • Grant program for national independent monitor pilot program for skilled nursing facilities and nursing facilities
    (What is this? An independent monitor to “oversee” large chains of skilled nursing facilities for some defined period of time. What about Medicare’s Nursing Home Compare program?
  • Grant program for training in dentistry programs
    Already exists
  • Grant programs for innovations in interdisciplinary care (Yep, got this in place already, too)
  • Grant program for health insurance cooperatives
    (Helpful cash for insurance interests)
  • Grant program for wellness programs to small employers
    (I can hear it now: “Don’t drink, eat or smoke too much…” and place some nice posters on your wall…)
  • Grant program to disseminate best practices on implementing health workforce investment programs
    (A bill already exists on the House floor: H.R. 2810)
  • Grant program for national health workforce online training
    (looks like medical schools might be in trouble!)
  • Grant program for state alternative medical liability laws
    (a grant to see if liability reform might work – fair enough – but will it change anything?)
  • Grant program for public health infrastructure
    (um, don’t we already have an Office of Public Health and Science?)

But the “demonstation project” that was created specifically for lawyers: Section 2537 (pg 1464) – a demonstration project of “grants to medical-legal partnerships” was most concerning.

What’s this you ask? Is it for health care?

Not really. It’s actually a grant just for lawyers who practice poverty law so they can “assist patients and their families to navigate health care-related programs and activities” for the next five years. Never mind that’s why we have doctors, nurses and social workers.

Bottom line, there are plenty of places this bill could (and should) be cut to save costs.

But hey, when it comes to health care reform, it seems there’s something for everyone when the taxpayer’s paying!

*This blog post was originally published at Dr. Wes*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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