March 12th, 2007 by Dr. Val Jones in Health Policy
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In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).
The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought? PROBABLY NOT. Will some important detail slip past them? SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART. I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.
All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.
Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 9th, 2007 by Dr. Val Jones in True Stories
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In my last post I described how VIPs don’t necessarily get better medical care. In this post I will describe a case study of a bully whose behavior wasted endless resources and time. This is a true story.
The son of a business tycoon experienced some diarrhea. He went to his local emergency room immediately, explaining to the staff who his father was, and that he required immediate treatment.
Because of his father’s influence, the man was indeed seen immediately. The physicians soon realized, however, that there was nothing emergent about this man’s complaints. After several blood tests and a stool sample were taken, he was administered some oral fluids and monitored for several hours, they chose to release him to recover from his gastroenteritis (stomach flu) at home.
The man complained bitterly and said that he wanted to be admitted to the hospital. The physicians, with respect, explained that he didn’t show any signs of dehydration, that he had no fever, his diarrhea was indeed fairly mild (he had only gone to the restroom once during the hours of his ED visit – and that was when he was asked to produce a stool sample). The man’s pulse was in the 70’s and he had no acute abdominal tenderness.
The man left in a huff, and called his father to reign down sulfur on the ED that wouldn’t admit him.
And his father did just that.
Soon every physician in the chain of command, from the attending who treated him in the ED right up to the hospital’s medical chief of staff had received an ear full. Idle threats of litigation were thrown about, and vague references to cutting key financial support to the hospital made its way to the ear of the hospital CEO.
The hospital CEO appeared in the ED in person, all red and huffing, quite convinced that the physicians were “unreasonable” and showed “poor judgment.” Arguments to the contrary were not acceptable, and the physicians were told that they would admit this man immediately.
The triumphant young man returned to the ED for his admission. Since the admitting diagnosis was supposedly dehydration, a nurse was asked to place an IV line. The man was speaking so animatedly on his cell phone, boasting to a friend about how the doctors wouldn’t admit him to the hospital so his dad had to make them see the light, that he moved his other arm just at the point when the nurse was inserting the IV needle. Of course, the poor woman missed his vein.
And so the man flew into a rage, calling her incompetent, cursing the hospital, and refusing to allow her to try again.
At this point, the ED physicians just wanted him out of the emergency room – so they admitted him to medicine’s service with the following pieces of information on his chart:
Admit for bowel rest. Patient complaining of diarrhea. Blood pressure 120/80, pulse 72, temperature 98.5, no abdominal tenderness, no white count, patient refusing IV hydration.
Now, this is code for: this admission is total BS. Any doctor reading these facts knows that the patient is perfectly fine and is being admitted for non-health related reasons. With normal vital signs, and no evidence of dehydration or infection, this hardly qualifies as a legitimate reason to take up space in a hospital bed. And when the patient is refusing the only treatment that might plausibly treat him, you know you’re in for trouble.
The man was discharged the next day, after undergoing (at his insistence) an abdominal CAT scan, a GI consult, an ultrasound of his gallbladder, and a blood culture. His total hospital fee was about $8,000.
Do you think he paid out of pocket for this? No. He submitted the claim for payment to his insurance company. Their medical director, of course, reviewed the hospital chart and realized that the man had no indication for admission, and refused medical care to boot, so he denied the claim.
So the son appealed to his father, who then rained down sulfur on the insurance company, threatening to pull his entire business (with its thousands of workers insured by them) from the company if they didn’t pay his son’s claim.
The medical director at the insurance company dug in his heels on principle, assuming that if he continued to deny the claim, the hospital would (eventually) agree to “eat the cost.”
In the end, the insurance company did not pay the claim. The CEO of the insurance company called the hospital CEO, explaining that it was really the doctor’s fault for admitting a man who didn’t meet admission requirements. The hospital CEO agreed to discipline the physician and eat the cost to maintain a good relationship with the insurance company that generally pays the hospital in a timely manner for a large number of patient services.
I ask you, my friends, does this seem fair? It’s because of these cases that doctors become (sadly) hard of hearing when it comes to patients who appear well, but may indeed have a serious condition.
In my next post, I will describe a true story of a baby whose life was saved because of her mother’s insistence.
P.S. There are many comments on this post, featured at Kevin MD.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 1st, 2007 by Dr. Val Jones in Medblogger Shout Outs
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Dr. Rob, the author of “Musings of a Distractible Mind,” is really good at explaining difficult concepts. If you haven’t read his description of healthcare’s coding system, you should take a peek. It explains why documenting care is so complicated, how doctors try to “game the system” and what happens to them if they do.
Here’s a small excerpt:
“You see, what you get paid for an office visit is not based on what you do at that visit, it is based on what you document. The more you can document, the higher you can bill… There are several responses to this situation by physicians:
· Undercode to avoid the accusation of fraud
· Use EMR to document more and bill at a more appropriate level
· Code at the higher level without documenting higher and risk audit, jail, etc.
· Stop accepting insurance and just accept cash up front based on your own criteria
· Do other things besides office visits – such as surgical procedures, labs, x-rays, or other procedures that pay much better than the office visit. The pay for EKG with interpretation is nearly as high as that of the decision making that the physician makes that may save the life of the patient.”
So next time your doctor is delayed in seeing you… she’s probably trying to document all the right check boxes and codes for the last patient she treated!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 26th, 2007 by Dr. Val Jones in Expert Interviews
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I had the chance to speak with Jim Herndon recently about how the current healthcare climate is affecting orthopedic surgeons. He said that there are 3 things that worry orthopods:
- Decreasing Medicare reimbursement. In 1990, reimbursement for a total hip procedure was $2,200. In 2007, the reimbursement is $1,190. Medicare is planning to further cut reimbursement 30% in the next 4-5 years.
- Increasing malpractice insurance costs. Premiums are steadily increasing. In Boston, the average malpractice insurance is about $50,000/year. In Philadelphia, the cost is $150,000. And if you’re an orthopedic surgeon specializing in spinal surgery, malpractice insurance premiums can start at $250,000/year.
- Pay for performance. No one really knows how this will be applied specifically to surgeons (other than the obvious infection rates), but fears are mounting regarding how to show the best possible performance in one’s practice.
Let’s say that a typical surgeon in Philadelphia pays 33% in overhead (the hospital facilities, staff, etc.). Let’s say that he is also taxed 33% on his income. That means that he’d have to perform 382 hip replacements per year, just to pay his malpractice insurance. That’s almost 2 surgeries/day, 5 days a week, 11 months/year.
So what are surgeons doing? They are reducing overhead by setting up outpatient surgery centers (Dr. Herndon estimates that 60% of orthopedic surgery can be performed in an outpatient setting), they are increasing the volume of surgeries they perform, they are buying radiology facilities where they send their patients for XRays, MRIs etc. (Dr. Herndon explains that Stark Laws don’t prohibit this, so long as the physician takes on the risk of the facility – i.e. that he can potentially make or lose money), and they are financing physical therapy practices that supply therapy to their patients.
Orthopedic surgeons in private practice have become very business savvy in order to survive in this climate. But somehow I feel saddened by all this – the business of medicine is a grim reality that can create a wedge between the physician-patient relationship. A patient is left to wonder about the motivations behind tests and therapies – and perhaps even behind recommendations for the surgery itself.
I guess the second opinion has become more important than ever before?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 25th, 2007 by Dr. Val Jones in Opinion
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There is an old question still sparking debate in the blogosphere (see Kevin MD’s links): is health care a right or a privilege? I think it’s worthwhile to consider both sides of the argument, as one’s position on this issue actually provides the foundation for how one proposes to “fix” this broken health care system.
I have searched the Internet for some of the best quotes on the subject (and I’m sure I have missed most of them) to frame the debate. Today’s post is devoted to the “health care is NOT a right” position. My next post will provide quotes from the “health care IS a right” camp. I hope that you will provide your own views pro or con as comments.
Mr. Robinson wonders if (based on the US Constitution) one can classify health care as a “right:”
By definition, rights can not extend past the boundaries of one’s own person. One can not, for instance, exercise one’s right to free speech by demanding that one’s neighbor cease speaking, for by doing so, one would deny the neighbor’s right to free speech. Given that healthcare, for the most part, is the product of someone else’s knowledge, labor, capital, and equipment, it is not within the boundaries on one’s own person. Healthcare can not be a right because it makes demands on other people.
This analogy by Dr. Peikoff sheds some light on what would happen if healthcare were treated as “a right” by the government:
Take the simplest case: you are born with a moral right to hair care, let us say, provided by a loving government free of charge to all who want or need it. What would happen under such a moral theory?
Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops — it’s all free, the government pays. The dishonest barbers are having a field day, of course — but so are the honest ones; they are working and spending like mad, trying to give every customer his heart’s desire, which is a millionaire’s worth of special hair care and services — the government starts to scream, the budget is out of control. Suddenly directives erupt: we must limit the number of barbers, we must limit the time spent on haircuts, we must limit the permissible type of hair styles; bureaucrats begin to split hairs about how many hairs a barber should be allowed to split. A new computerized office of records filled with inspectors and red tape shoots up; some barbers, it seems, are still getting too rich, they must be getting more than their fair share of the national hair, so barbers have to start applying for Certificates of Need in order to buy razors, while peer review boards are established to assess every stylist’s work, both the dishonest and the overly honest alike, to make sure that no one is too bad or too good or too busy or too unbusy. Etc. In the end, there are lines of wretched customers waiting for their chance to be routinely scalped by bored, hog-tied haircutters some of whom remember dreamily the old days when somehow everything was so much better.
This attorney wonders where the “rights” begin and end in the health care environment:
If we speak of a right to healthcare, we need to ask: What kind of healthcare? Perfectly healthy people seek healthcare simply to confirm that they are healthy. Some people seek treatments—vaccines, nutritional and hormonal supplements, surgery to eliminate genetic cancer risks—as preventive measures in order to preserve their health. Some people seek healthcare for conditions that others would not, such as minor colds, common balding, or sports performance enhancement. Few of us would be willing to recognize, or finance, a “right” to whatever kind of healthcare a person might think desirable.
A physician gives an example of what can happen when consumers demand their “rights” to health care:
“Doctor, this guy states he has a bleeding brain tumor and wants a CT scan of his head,” the emergency department registration clerk announced as I entered his room. He looked me in the eye and intoned, ” I want a CT scan of my brain. I have a bleeding brain tumor.” “Do you have a headache, neck stiffness, loss of strength?” “No,” he responded. I proceeded to examine and finding no neurological deficit I inquired why he thought a CT scan was needed. He informed me that a relative had suggested that the numbness he felt in his scalp might have been a sign of a tumor. He was furious when I told him a CT scan was unnecessary and indignantly took my name to make a complaint to the administrator. I had denied him his right.
A patient continues the refrain:
What’s so special about health care? Why not rights to higher education, job training, clothing, computers, child care, cars, etc.? There are a lot of things that will improve a society if everyone had them. This doesn’t mean that we should establish positive rights to provide all these things for those who can’t afford them. We need to keep incentives in place (and perhaps provide education) to encourage people to spend and save their money wisely and to nurture a solid work ethic. Encouraging people to help themselves seems to be a solution for the long-term, not trying to get everyone else to buy the necessities for them.
Do you think that health care is a right?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
