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How Has The Mayo Clinic Fared Since It Dropped Medicare?

Update: this happened 2 years ago. So, I wrote this thinking it was a new development, but it isn’t. Anyone know how this experiment has played out?

I’ve wondered for years if hospital organizations (and big organized clinics) had done the math on whether they could do without Medicare, and apparently Mayo has. More after the quote

President Obama last year praised the Mayo Clinic as a “classic example” of how a health-care provider can offer “better outcomes” at lower cost. Then what should Americans think about the famous Minnesota medical center’s decision to take fewer Medicare patients?

Specifically, Mayo said last week it will no longer accept Medicare patients at one of its primary care clinics in Arizona. Mayo said the decision is part of a two-year pilot program to determine if it should also drop Medicare patients at other facilities in Arizona, Florida and Minnesota, which serve more than 500,000 seniors.

Mayo says it lost Read more »

*This blog post was originally published at GruntDoc*

Rationed Care, Denied Treatment, And “Death Panels”

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients lifesaving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times had a recent story on Arizona’s decision to deny certain transplants to Medicaid enrollees — “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states: “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.” Read more »

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

Blog Workshop At The Canyon Ranch Institute In Tucson

I just got back from a blog workshop at the Canyon Ranch Institute in Tucson, co-led by yours truly and the lovely and charming Kerri Morrone Sparling of SixUntilMe. We had a wonderful time with the locals, acquainting them with social media terminology, and teaching them how to blog and Tweet. We were also immersed in their culture, which largely meant that I lectured (for the first time in my physician career) in yoga pants, and enjoyed small portions of food rich in fruits and vegetables.

A Javelina

A Javelina

Despite the arid, inhospitable environment, the Arizona desert is teeming with life. Quail, rabbits, lizards, javelinas, humming birds and woodpeckers, bob cats and coyotes – all roam around freely near adobe homes nestled between flowering cacti. The extraordinary liveliness of the desert takes the casual visitor by surprise, and the variety of scrubby plants, aloes, and cacti of every imaginable shape, size, and pricklyness is a horticulturalist’s dream.

Since I was on east coast time, I was willing to participate in the 6:30am speed walks in the desert each morning. The lovely landscape inspired reflectiveness in the walkers, though I was somewhat distracted by the roaming hoard of javelinas (very large peccaries who resemble wild boars, smell like skunks, are virtually blind, and live to eat flowering plants). The javelinas had new babies with them – described by one Canyon Rancher as “footballs with legs.”

In between workshop lectures, Kerri and I were treated to some spa services – (regular readers know that I’m a huge fan of massages) which were welcome respites from our very busy work lives.  But best of all, we got to spend some time with Dr. Richard Carmona (who attended our workshop), and we discussed how social media could be the key to inspiring behavior modification in Americans who need to eat more healthily and get more exercise.

As beautiful as the Canyon Ranch is, the healthy lifestyle it promotes won’t reach beyond its own walls if they don’t engage people in ways that fit their budgets and time constraints. Now that 70% of Internet users are engaged in social media, and Facebook, Twitter, blogs, and online support groups are growing exponentially, there’s never been a better time to find ways to reach people with disease prevention messages and strategies. As Washington gears up to support preventive health initiatives as part of healthcare reform, innovative non-profits like the Canyon Ranch Institute can play an important role in helping us get America back on track in terms of weight management and fitness. Online communities like SparkPeople or the Canyon Ranch Institute could be one avenue for change.

Of course, if you can afford to vacation in Arizona, the place itself has a calming, therapeutic effect. If that’s not in the cards for you, you can still emulate the lifestyle in your own javelina-free environment. As I take my regular walks back in DC, I’ll be sure to remember those cute little footballs with legs, and wear yoga pants as often as possible during future lectures (if the NIH looks at me quizzically next month during my NLM presentation, I’ll just blame Rich Carmona).

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

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.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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