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Can The Healthcare “Consumers” Drive The Waste Out Of The System

Patients are first. Patients are the reason for the existence of the healthcare system. Physicians are second. They are trained to understand the pathophysiology of illness and to treat patients for their disease. Everyone else is a secondary stakeholder (provider).

All the stakeholders create waste in the healthcare system. If an accurate analysis were performed, most of the waste and the resulting profits would be attributed to the secondary stakeholders. Patient and physicians drive this waste and profits into the hands of the secondary stakeholders. Neither patients nor physicians are aware of driving the waste and profit into these stakeholders’ coffers.

The patient-physician relationship should be a one on one transaction. Patients and physicians are frustrated and many have accepted the disappearance of this human-to-human interaction.

Healthcare insurance companies and hospital systems think they own the patients and the physicians. This will turnout to be a fatal misperception.

To many observers of the healthcare system Read more »

*This blog post was originally published at Repairing the Healthcare System*

Can We Really Eliminate Waste In The Healthcare System?

A recurring theme of the CRB is that the rising cost of healthcare is the main internal threat to the continued viability of the US. Indeed, the very title of this blog reflects the chief mechanism which is being employed, fruitlessly and disastrously, in the attempt to reduce those costs.

Recently, DrRich pointed out that there are four ways – and only four ways – to reduce the cost of healthcare. He did this as a service to his readers, so that when politicians describe in their weaselly language how they will get the cost of healthcare under control, you will be able to figure out which of the four methods they are actually talking about.

While DrRich’s synthesis has been generally well-received, a few readers did offer one particular objection. DrRich, they assert, left out a fifth way to reduce the cost of healthcare, and the very best way at that. Namely, just get rid of the waste and inefficiency.

DrRich has talked about this before, but obviously it is time to revisit the issue.

It is, in fact, a central assumption of any healthcare reform plan ever proposed that we can get our spending under control simply by eliminating – or at least substantially reducing – the vast amount of waste and inefficiency in the healthcare system. Conservatives propose to do this by Read more »

*This blog post was originally published at The Covert Rationing Blog*

Do Physicians Have A Role In Controlling Healthcare Costs?

The Role of Physicians in Controlling Medical Care Costs and Reducing Waste by the RAND Corporation and David Geffen, University of California Los Angeles School of Medicine, Santa Monica was just published in the Journal of the American Medical Association (JAMA).  I do not think the JAMA should have published this article.

1.Why would the JAMA publish such an article?

2. Why are physicians blamed for all the waste in the system?

3. Why is it the physicians’ responsibility to eliminate waste when they are not the cause of the greatest percentage of the waste?

“The amount of money spent on medical care is increasing faster than the gross domestic product (GDP), and the federal deficit is increasing.”

The initial statement assumes that the government deficit is increasing because physicians control government spending for healthcare.

This is only partly correct. Read more »

*This blog post was originally published at Repairing the Healthcare System*

U.S. Healthcare Spending: Why So Much?

Aaron Carroll over at The Incidental Economist has been running an excellent series on healthcare spending in the U.S. and how much more we spend than the rest of the world on a per capita basis, as a percentage of GDP, and by category. It’s an excellent series and I wholly recommend it. Summary graph:

Hint: the U.S. is the lavender-ish line on top. As he says, is there anything about this graph that isn’t concerning? Read more »

*This blog post was originally published at Movin' Meat*

Proposed SGR Fix: An Interesting Twist

This is something I haven’t seen reported on elsewhere, but according to the ACEP 911 Legislative Network Weekly Update, there was an interesting twist in the Democrats’ proposed SGR fix:

The latest plan increases physician payments by 1.3% for the remainder of this year and by an additional 1% in 2011. In 2012 and 2013, physician services would be separated into two categories, or “buckets.” One bucket would be for E&M services (including emergency department, primary and preventive care) and the other group would include all other services. The E&M bucket would increase at the same rate as the U.S. gross domestic product (GDP) plus 2%, while the other group would receive a payment increase of GDP plus 1%.After 2013, the payment formula would revert back to the current SGR formula, which means physicians would face cuts in the range of 30-35% unless Congress intervenes.

So it’s another temporary fix, kicking the can past the next presidential election. But it’s the first one I have seen that attempts to address the gross disparity in reimbursement for procedural services compared to the cognitive services. It bypasses the RUC and almost every other existing mechanism for determining reimbursement under the MPFS.

I’m not sure what happened with this proposal. I don’t think it was in the version of legislation the House passed, so I think it might be dead. But the situation is so in flux that who really knows? If nothing else, it’s an encouraging sign that policymakers know the problem exists and are willing to throw out possible solutions. This one may be dead, but it’s a good start.

*This blog post was originally published at Movin' Meat*

Latest Interviews

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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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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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.

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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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