September 16th, 2009 by KevinMD in Better Health Network, Health Policy, Opinion
Tags: Finance, Health Savings Accounts, Healthcare reform, HSA, Personal Responsibility
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by Charles W. Patterson, MD
Health care reform has long been one of my main interests and currently, it seems to be everyone else’s. The President said he thought a single-payer system would be best, but submitted a proposal he thought could be passed. The outcome is in doubt.
Actually, the single-payer system is the second best possible solution. The government would hold the money but would remain vulnerable to political manipulation, bureaucratic inefficiency.
The best system would be a well regulated “Everybody Hold Your Own Money and Pay Your Own Way System.” It would empower patients to deal directly with their caregivers without third-party interference or regulation and lead them to become sensitive to the potential benefit and the cost of their care.
This could be accomplished without taxes and without insurance premiums by a properly designed system of health care savings accounts (HCSAs). These should be funded with pre-tax money from regular automatic savings, like payroll deductions, and everyone should have one from birth. Children’s accounts should be funded by their parents. In only a couple of years, normally healthy people would save enough to stay ahead of their health care expenses. They would save the same money they now pay in insurance premiums, so once in place, the new system would cost less because no money would go to insurance company administration and profit, and unnecessary procedures and tests would decrease because people would keep the money they didn’t spend.
When any account becomes large enough to cover anticipated needs (with, say, 90 percent probability) the extra money could be rolled over into a retirement account, or children’s HCSAs. At death, a person’s HCSA could be rolled over to heir’s HCSAs, after an inheritance tax which would be used to fund HCSAs for the poor and unhealthy. Everyone would keep the money they didn’t spend, so they would not spend it unnecessarily.
Government’s role would become only regulatory. A commission might be needed to determine a fair market value for services and patented drugs, but it is likely that market forces would control these and make the mix of available services more appropriate to people’s needs.
To insure that account money was spent on effective care, and not wasted or stolen by fraud, standards of medical practice should be established with a Wikipedia-style online system to allow each licensed practitioner and researcher to propose, amend and vote on standards of practice in his or her’s field. A true consensus statement would then be available on every relevant standard of practice, which would be more up to date and represent truly effective practice, better than the opinions of a panel of “experts.”
The quality of evidence on any issue varies from one study to the next, and leaves room for differences in opinion about what is good treatment. HCSAs should be allowed to pay for all procedures which received an overwhelming vote of approval, and not for those with overwhelming disapproval. The more money in an account, the lower a procedure’s vote would need to be to have it included. The list of approved procedures would change, and its quality would improve as fast as new evidence and experience accumulated.
Regulations should also end patents for new drug which do the same thing as established drugs, as well as new preparations of established drugs. Advertising of prescription drugs should end, because it leads to unrealistic expectations and misdiagnosis. And these regulations should require saved money to be invested conservatively.
Charles W. Patterson is a psychiatrist.
*This blog post was originally published at KevinMD.com*
September 14th, 2009 by Emergiblog in Better Health Network, Opinion
Tags: Census, Emergency Medicine, Hospital, Nursing, Predicting Volume, Shifts, Staffing
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Emergency has something in common with Labor & Delivery.
Neither department has control over their census.
Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.
ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.
Labor and delivery has one advantage over the ED.
They can have someone on call.
I’ve never worked in an ED that has had an “on-call” nurse.
****
I will never understand the logic behind staffing an ED based on the previous 24 hour census.
If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.
Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.
****
Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.
But what happens when the patients overwhelm the staff, both in acuity and numbers? Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.
This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.
Of course, at night it is feast or famine.
Either the feces hits the proverbial fan or…it doesn’t.
Which is exactly why we need a nurse on-call.
The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.
All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.
(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)
*This blog post was originally published at Emergiblog*
September 14th, 2009 by EvanFalchukJD in Better Health Network, Opinion
Tags: Congress, Health Insurance, Healthcare reform, Obama, Public Plan, Reactions, Reform, Speech
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Eight quick reactions to the President’s speech:
1. It was a good speech. Reaction around the blogosphere and elsewhere seems to be dependent on how you felt about reform plans going in. If you were in favor, you thought it was terrific (warning strong language at the link); if you were against, you thought it was disingenuous.
2. The interesting question is how people who weren’t sure will react. By this I mean people who are anxious that reform will affect their health care in ways they don’t like. There is still the mixed message that created this anxiety in the first place. On the one hand, the President repeated “Nothing in this plan will require you to change what you have. “ Sounds like no big deal. On the other hand, he quoted Ted Kennedy as saying the plan “is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.” Sounds like a very big deal. Which is it?
3. The boorish Congressman who screamed “you lie!” at Obama during the address must have been confused and thought he was at a town hall meeting. But I’ve always thought it would be cool if we had a “Question Time” like they do in the UK. Presidents would have to face much more interesting and uncomfortable questions than they otherwise get, and it would make for a terrific spectacle. Obviously this wasn’t the time or place for that sort of thing. And if we ever do get an American Question Time, representatives will have to come up with better questions than “you lie,” too.
4. The President talked about “30 million American citizens who cannot get coverage.” This is different from the 46 million “uninsured” he usually talks about. The Associated Press thinks the other 16 million are people who could buy or otherwise get coverage but choose not to, as compared to those who want coverage but can’t afford it.
5. I was surprised to hear the President give more than just a nod to the Facebook health care status update meme. I mean he quoted it directly: “in the United States of America, no one should go broke because they get sick.” This must be the first time a President has ever quoted something from Facebook in an address to Congress – it’s some kind of a milestone for social media. Thoughts on that meme are here.
6. The President talked about the uncompetitive insurance market, noting that “in 34 states, 75 percent of the insurance market is controlled by five or fewer companies.” It sounds like he’s not just talking about the “public option” when he talks about creating competition in these markets. His idea of insurance exchanges and a federal health insurance regulator seem to be direct challenges to the state-by-state system of insurance regulation. It will be interesting to see the reaction of state insurance regulators to this speech.
7. I was right: the President didn’t talk about the three things I said he wouldn’t talk about. In fact, he said almost nothing about the delivery of care- it was all about how to pay for it.
8. The President got some laughs with his comment that he thinks “there remain some significant details to be ironed out.” He’s right, and there’s the rub. Whether and how that ironing out happens was the question before the President’s speech, and it’s still the question today.
*This blog post was originally published at See First Blog*
September 13th, 2009 by Happy Hospitalist in Better Health Network, Opinion
Tags: Boycott, CEO, Diet and Exercise, Healthcare reform, Obesity, Personal Responsibility, Responsibility, Value, Whole Foods
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How expected. The CEO of whole foods says that government is not the solution to out of control health care expenditures. He says we are. The American people are responsible for out of control health care expenditures. He preaches a life of personal responsibility, of personal choice and actions that lead to health. And what does he get for it?
Pragmatists on all sides of the health care question (and probably every political question) believe that, on the whole, human nature does not change, and we’ve got to fight or not fight the health care war with the citizenry we’ve got, not the one we wish we had. Utopians like Mackey, on the other hand, believe that public-policy debates are only a middle step in the real solution to our problems, which is to change human nature. The solution to our health care woes, Mackey seems to believe, is for all of us to become like him—hyper-rational in evaluating our options, hyper-responsible in following through on them, and devoted to healthy living (that plant-based diet!).
Yes, that is actually the solution, to become more hyper-rational in evaluating our options, hyper-responsible in following through on them, and devoted to healthy living. The fact that this commentator makes a mockery of personal responsibility, instead choosing to support couch potato, Chetoo eating, Oprah watching smokers with for all their health care needs because, well, that’s just what humans do, is pathetic.
If you want someone else to pay for your health care, be prepared to play by their rules. And the rules have to change. Or there won’t be any money for anyone.
Ninety-nine trillion dollars says so. Making humans entitled to the side effects of bad habits because that’s just what humans do is a race to the bottom mentality. It’s at the core of the finance
quandary. Encourage bad habits by paying for them, and you get bad habits. Nobody can sustain that model of third party financing.
Would you insure a house who’s participants stated up front they would burn it down? Would you insure a car from a driver who said he would intentionally drive it into a brick wall? If not, why would you buy insurance for people who intentionally did things we know destroys them?
The CEO of Whole Foods should be hoisted onto the podium next to Obama for all the world to applaud. Obama should declare a God given right to live healthy (and he should quit smoking for good) and a God given right to pay more for your insurance if you don’t. It’s about personal responsibility. It’s not about handing you a plate of free insurance and saying go smoke ’em if you got ’em.
*This blog post was originally published at A Happy Hospitalist*
September 13th, 2009 by MotherJonesRN in Better Health Network, Opinion, True Stories
Tags: ANA, Midlife Crisis, Nursing, Patients, Peace
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Nurse Andrea Bartlett is literally having a meltdown. She is in the midst of her midlife crisis. Nurses like her are easy to spot. She’s having a hot flash, note the hand to her forehead and the look on her face that says, “Crap, I’m going to pass out,” and she’s reliving her hippy Peace Corps days by working as a Congo nurse. I bet she is kicking herself for leaving home, especially at her age. After all, who in their right mind would give up their Mac computer and iPhone.
It’s official. I’m having my midlife crisis. I knew I had hit crisis mode the day one of my patients tried eloping from the unit. I saw the patient racing down the hallway towards the door, and my brain said, “Run, catch the patient,” and, after a few strides, my joints started screaming, “Brain, we hurt. Go to hell.” Fortunately, the techs and a few nurses, all of whom are youngsters, ran right pass me like little gazelles and effortlessly caught the patient before he bolted off the unit. I felt like a relic. I wanted to cry all day long.
If anyone over the age of 55 tells you that they aren’t going through their midlife crisis, they are in denial, or they are lying through their teeth. I started making some changes at home after that fateful day at work. I can’t afford a facelift, a tummy tuck, or a red sports car, so I started redecorating my living room, a la Peter Max. I said goodbye to my Martha Stewart country living room by replacing everything that was made from gingham and lace with burgundy silk pillows, hand blown glass bottles, and Bakhtiari carpets. I even scored this 1960s leather chair, matching footstool, and hoop lamp from one of my best friends. Yeah, they’re groovy. I can’t wait for my husband to finish off my bookshelves. Maybe I’ll start a new hookah collection when he’s done.
Having a midlife crisis isn’t just about getting gray hair, saggy boobs, and a wider girth. It’s about getting to know who you really are as you hit the midpoint of your life. This midlife journey is especially bewildering and fear provoking for nurses. Everyone is in a big hurry to get an advanced nursing degree before “it’s too late.” Too late for what? I see nurses frantically checking out school websites, and exchanging information about online classes. Some nurses want to expand their knowledge base so they won’t have to work as bedside nurses anymore, while others want to go back to school because of a mandate put out by the ANA. The ANA doesn’t recognize anyone without a nursing degree as a professional nurse. The ANA can kiss my ass. I’m not going back to school, and I refuse to burst one brain cell over a class assignment that has no relevance in my life.
God willing, I have at least twenty-five years before I check out of the world and I plan to have some fun before I head for the Pearly Gates. My short-term goal is to buy the new Beatles Boxed set in stereo and to finish redecorating my house. I’m going to light up some incense, play my tunes, and party on. My long-term goal is to make love, not war, get on the peace train, and to follow the sun.
Can you dig it?
*This blog post was originally published at Nurse Ratched's Place*
