Most hospitals have slim margins, and budgets are set based on anticipated average patient reimbursement at Medicare rates. Some private insurers pay higher rates than Medicare, and the differential is often used to offset the cost of treating Medicaid patients. Medicaid reimburses at about half what Medicare pays, which is usually not enough to break even. Out of financial necessity, Medicaid patients are often given limited access to care and services. This is done in some subtle and some not-so-subtle ways. In a recent conversation with an orthopedist friend of mine, he confided in me candidly:
“Some of my colleagues in private practice can’t pay their office overhead if they treat Medicaid patients. So we see poor people with severely arthritic joints left in pain at home. In addition, with bundled payments, the surgeon gets a fixed amount for the patient’s operation and recovery. What incentive is there to send the patient to a rehab facility? It just takes money away from the surgeon. So the poor have to suffer with very long wait times to see someone who will operate on them, and then afterwards they’re on their own for recovery. Patients who go straight home are at higher risk of falling and may have much poorer outcomes. Surgeons get financial incentives for good outcomes, so it becomes a double disincentive to treat Medicaid patients. You don’t get enough for the operation, and you’re likely to get penalized for their poorer outcomes. Some surgeons I know wont touch a patient with Medicaid for any elective procedure. I have ethical problems with that – so I work at a non-profit hospital where we treat everyone. But I have to do higher volume to break even. I work 90 hours a week and barely see my family. I don’t know how much longer I can do it.”
It is common practice among nursing homes to have a limited number of “Medicaid beds.” The facility simply declines to admit more than 20% of patients with Medicaid. I hear case managers on the phone all day long, looking for a post-acute care facility who will accept a Medicaid patient. For the few non-profit facilities who don’t turn them away, deep financial costs are incurred as they struggle for survival.
The reality is that Medicaid rates are so low that having this insurance is not much better than none at all. As I’ve explained previously in the outpatient world (see an example of an insanely low Medicaid reimbursement for eye care), Medicaid is tantamount to charity care. The news that 21.3 million Americans might receive Medicaid coverage in the next decade should not be hailed as a leap forward. As I see it, that’s just a larger group of people with debilitating arthritis who can’t get hip and knee replacements and are left to suffer in pain at home.
Severe osteoarthritis of the hands
One of my patients came to see me today with severe right knee pain. This is not a new problem, and in fact, we have been dealing with flare ups of her osteoarthritis for years. It mainly affects her knees and hands and today her right knee was swollen and felt like the “bone was rubbing together” with each step. She could hardly walk because of the pain.
Osteoarthritis is also known as degenerative arthritis and it is one of the most common maladies of aging joints, affecting millions of people. The cartilage in joints wears down and inflammation causes the bones to build up spurs and small micro tears. It affects women more than men and the cause is unknown. There are likely genetic factors as it tends to run in families. Arthritis can occur in any joint but the most common are the fingers, wrists, hips, neck and spine and knees. Stiffness (especially in the morning) and pain are the main symptoms that limit mobility.
You can see Read more »
*This blog post was originally published at EverythingHealth*
There’s an old saying in medicine: “Use the new medicine while it still works.” This is more than just a cute quip. The saying encompasses a few different phenomena. When a drug is tested on a few thousand people, the luck of the draw may show a greater effect than would be seen in a larger, more diverse population. Also, less common side effects will become more evident in a larger sample. Once several million people take the drug, it may turn out that the drug isn’t as spectacular in a large, diverse population, and that certain side effects, though rare, are serious.
This is one of the reasons I’m a very conservative and skeptical physician. Today’s miracle drug may be tomorrow’s Vioxx. Less conservative doctors may make much more enthusiastic recommendations. I found one physician promoting pomegranate juice for rheumatoid arthritis (or at least linking to the article on Joe Mercola’s site without comment). It sounds harmless enough, but what’s the evidence? (You can hunt for the page yourself; I’m not linking to Mercola.)
The statement is based on a pilot study out of Israel consisting of data from six patients. The measures used seem quirky, but are irrelevant anyway. There are no conclusions that can be drawn from such a small sample. Despite this, the authors conclude (and Mercola and the doctor who posted the link presumably endorse) that, “Dietary supplementation with pomegranates may be a useful complementary strategy to attenuate clinical symptoms in RA patients.”
Really? Based on what? Read more »
*This blog post was originally published at ACP Internist*
It’s Wednesday, so I would like to tell you about some cool things I learned this past week about the science of how exercise can be used as a treatment for three common ailments.
First, some background about exercise: The great thing about exercising every day that you eat is that this magic potion is not a shot or a pill. It does not involve a doctor burning or squishing anything in your body. There are no HIPAA forms, no insurance pre-certifications, and not even a co-pay. It’s as we say, easy and free. And drum roll please…exercise is active—not passive.
Here’s the Mandrola take on how exercise might treat three specific medical conditions: Read more »
*This blog post was originally published at Dr John M*
Recently I gave in and went to see a rheumatologist after more than 3 months of intense morning stiffness and swelling of my hands (especially around the PIPs and MCPs) and wrists which improved during the day but never went away. It had gotten to the point where I could no longer open small lid jars (decreased strength), do my push-ups or pull ups (pain and limited wrist motion), and OTC products (Tylenol, Advil, etc) weren’t working. I can’t take Aleve due to the severe esophagitis it induces. I didn’t want to write a prescription for my self-diagnosed (without) lab arthritis.
BTW, all the lab work came back negative with the exception of a slightly elevated sed rate and very weakly positive ANA. The rheumatologist was impressed with the swelling, pain, and stiffness and was as surprised as I by the normal lab work. He thinks (and I agree) that I am in the early presentation of rheumatoid arthritis. He wrote a prescription for Celebrex and told me to continue with the Zantac I was already taking (thanks to the Aleve). The Celebrex is helping.
So I was happy to see this article (full reference below) come across by twitter feed. H/T to @marcuspainmd: Useful review of NSAIDs effects & side effects for arthritis pain: Read more »
*This blog post was originally published at Suture for a Living*