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Medicare Cut Effective Today: Who Should Doctors Be Angry At?

Instead of blogging (again) about Congress’s failure to stop the 21% Medicare SGR cut, which went into effect today, I could just re-run my April 16 post. I wrote then:

“It is the failure of both political parties, over many years, to honestly deal with the SGR, including the cost of getting rid of it, which has resulted in the current ongoing SGR farce. And yet members of Congress wonder why the public holds them in such low regard.”

Blogging in DB’s Medicare Rants, Dr. Bob Centor captures the outrage felt by most physicians:

“I am mad. Every physician I know is mad. Patients should join us in expressing anger. Physicians cannot trust Congress if they cannot repair this absurdity.”

(Bob references ACP’s statement, released on Friday; click here to read it in its entirety.)

That Congress allowed politics again to get in the way of doing what is best for patients makes my blood boil. Voters can and should hold them accountable.

But I also have to tell you, anger directed at ACP by some members also makes my blood boil. Typical is one who emailed that “ACP has been suckered just like everyone else” for “trusting” Congress to fix the SGR in exchange for supporting health care reform.

The effort to link the SGR to ACP’s position on health care reform makes my blood boil, because the SGR has been around since 1997. It has nothing to do with health reform. The fact is that Republicans and Democrats alike have been unwilling over the past decade to come up with the political will (and money) to repeal the SGR, and we now are facing the accumulated consequences of their failure. (To be fair, a majority of the House of Representative passed legislation late last year to repeal the SGR, but it never advanced in the Senate.)

Here again, Bob Centor has it right when he explains that he supported health care reform because “addressing the problem of the uninsured was so important that it trumped the weaknesses in the bill.”

Bob continues: “This was the chance to start down the road to universal coverage. I see SGR as a totally separate issue. The lack of the SGR fix represents profound weakness of our political process. This issue tells us that both parties are more interested in posturing than solving problems.”

It makes my blood boil when uninformed people cynically allege that ACP supported health care reform in exchange for SGR repeal. The thing is, there never was any such deal, nor should there have been. ACP favored health reform because every American should have access to affordable health insurance coverage, and because the legislation advances most of the organization’s policies on coverage, workforce, and delivery system reform.

Yes, repeal of the SGR is and was a top priority, with or without health reform.

And yes, it is maddening that we can’t get a majority of the House and 60 U.S. Senators to vote to fix the SGR, once and for all.

Members of Congress, Democratic and Republican alike, need to hear from doctors and patients that you are mad, and why.

Anger may help light a fire under Congress’ feet, but it probably won’t be enough to ensure 60 votes in the U.S. Senate for getting rid of the SGR.

Instead, it is going to fall to doctor’s professional organizations, like ACP, to do the hard work of finding an approach that will actually pass. Sure, be angry — but direct your anger at those responsible for the SGR debacle, not at those of us who are trying to fix it.

Today’s question: Are you angry about the SGR? If so, what are you saying to your members of Congress?

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

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One Response to “Medicare Cut Effective Today: Who Should Doctors Be Angry At?”

  1. Benita Kurtzman says:

    I am mad at the AMA and the ACP for supporting a healthcare reform bill that did not include an SGR repeal – it was the one chance to finally get it done. Congress has ignored the issue and kicked it down the road for years and they needed their backs against the wall to force the issue to be taken care of. It was the time of leverage for the medical organizations and they did not use it and hence, we are in this position. So, let your blood boil as much as you like, because from what I gather, the majority of physicians agree with me and are especially angry with the AMA when they LIED and said they speak for all physicians. The Healthcare reform bill is meaningless to doctors who treat seniors, because they will need to close their doors before it even really goes into effect.

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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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