Friday, September 12, 2008

Broken Healthcare

The Blog that Ate Manhattan made an interesting post today discussing the broken healthcare system when a scenario was related in which an insurance company would not pay for home nursing services for weekend wound checks. They instructed the patient to go to the ER for this follow up while the physician's office was closed.

I had a similar situation a few months ago. I was collaborating with a urologist on a mutual patient which was an elderly lady with recurrent urinary tract infections. This time, she had developed a UTI which was resistant to all oral antibiotics and the only antibiotic the bacteria was sensitive to was Amikacin. The urologist recommended we admit her for IV antibiotics. However, the patient was stable and afebrile as well. So when I asked him if we could treat her with IV antibiotics as an outpatient with home health he agreed.

Sounds like a good plan, right? Keeps the patient out of the hospital which prevents her from potentially aquiring a hospital-aquired infection, saves the system money, etc. Nope. Medicare would not pay for this service. Additionally, the hospital owns a home health agency and I spoke with the social workers, discharge planners and even one of the administrators. They refused to do it. In essence for the DRG, they are willing to risk further infection and potential "never events."

The unfortunate patient had to come into the hospital and fortunately did not have an adverse event. She did end up growing a second bacteria on re-culture and had to have 20 total days of IV antibiotics before she was sent home.

The system is definitely broken.

Sunday, September 7, 2008

I'm Still Here

To anybody who has been kind enough to follow my blog: Please accept my apologies for not blogging recently. Our office has been so busy in the past few months and the past several weeks have become even busier. We have six physicians and in the past few months, one got pregnant with triplets and is out on maternity leave and another is in the Army Reserve. He had the terrible misfortune of being deployed for 90 days to Hawaii. I kid with him but in his defense, he already did 90 days in Iraq last year. That was bad enough but Doctor #3 had a trip planned out of the country for over a year and so we are currently staffing our six doctor practice with three docs. Our office is open 7 days per week so we have been burning the candle at both ends.

I will definitely be back soon. By the way, the patient in my last blog came by the office the other day to meet everybody involved in his care. It's nice to have one in the "win box."

Saturday, August 16, 2008

Making a Difference

On a daily basis I see many patients in my practice. Some are obviously sicker than others. I do see seasonal patterns such as more URIs in the winter. It can wear on me at times. Sometimes I come home and talk to my wife about how many times I don't feel like I make much of a difference. Some of the things that make me feel this way include Medicare, the payment issues, having to rush patients through just to pay the overhead, etc. I get discouraged and many times wonder if it is even worth it to practice medicine in today's climate. I love being a doctor but practicing medicine today can be frustrating and discouraging. However, on a recent afternoon in our office, things changed at least for a short time.

I realize there is a lot of debate in the blogosphere about giving patient examples and privacy. However, I am going to give you a case example and let me give a disclaimer that I have seen to it that there is not a privacy violation here.

We recently made a difference in the life of someone. We were finishing up the day when an older middle-aged man came stumbling through the door, clutching his chest, stating that he was having chest pain. Our receptionist yelled for a nurse who brought him immediately to a treatment area. No sooner than he lay down on the gurney, he lost conciousness and stopped breathing. We already had O2 on him. We have a crash cart and we immediately hooked him up to see that he was in ventricular fibrillation.

I could go through this step by step, but to make a long story short, we performed ACLS in the office with multiple cardioversions, a few rounds of epinephrine, Lidocaine, called 911 and got an ambulance there. I intubated the guy there in the office and got him stabilized enough to transport to the hospital. He left in ventricular tachycardia with a pulse and BP.

They got to the ER and the cath team was waiting. He had a dominant RCA and had an extensive thrombus. The cardiologist did a thrombectomy and placed a stent. He spent the night on the ventilator and weaned off the pressors and was then alert. This patient lived to see another day and will have a productive life (with lots of secondary prevention).

What was a routine day in the office turned into quite an adventure. I know that we made a difference in at least one life today. For the record, I didn't do it--WE as a staff did it and this patient would most likely be dead if not for them. This was a great day to practice medicine!

Thursday, July 31, 2008

Governmental Drug Reps

Can you believe this? The WSJ today reported that the US Government is actually thinking about creating their own "impartial" drug reps to come detail us in our offices about drugs. This is to counter the bias in the commercial drug reps that come to the office.

This makes my blood boil on several levels. First, this implies that I am too stupid to read about a medication and make my own decision on whether or not I will prescribe it. Secondly, with healthcare being in the very real financial crisis it is currently in, we don't need the government wasting more money to send someone to my office to waste more of my time. I guess they figure that the 7 minutes I have to see a patient to get my $20 payment is way too much time and I need to spend it doing something productive like listenting to the government. Next, who reading this believes the US Government is in any way, form or fashion impartial about anything? If you do, I have some cheap ocean front property to sell you in Nebraska.

Our practice has virtually banned drug reps as it is and it is really nice not having to pretend that you have any belief in what they are telling you. Now, the government is going to send out it's own brigade. That's just what we need. More protection from the government. I wonder how much that is going to cost the taxpayers? Also, I wonder how long it will be before they mandate we talk to these government-mandated reps?

Here are a couple of ideas. Instead of adding to the cost and bureacracy of this country, just fine the drug companies if they are not honest. I mean, the implication is that the government is saying that drug reps are out there bascially lying for their company. Pull any funding they may receive if they are found to be lying. Why not hold them accountable rather than making us suffer.

It is a slippery slope we are on towards Socialism and we are on the steepest angle heading for the finish line.

Wednesday, July 30, 2008

Canadian Healthcare

Could this be where we are headed?

Thanks to DrO at MedPolitics for this video link:

Inmate Healthcare

I have blogged previously on my practice's involvement with healthcare delivery to local inmates at our jail. We care for a population of approximately 1,000 inmates. This is a big problem for taxpayers and is only going to get worse as time passes. We have an aging, sicker population. We could speculate for hours on why more people are commiting crimes-drugs, money, etc.

Our society demands justice and it seems like our default method of rehabilitation is incarceration. In my opinion, there are certainly people that need to be behind bars. But there are many crimes that could be punished more effectively out of jail and then the burden of healthcare would not be placed on the taxpayers. A prime example of what is rampant in the correctional system regarding healthcare is here. Susan Atkins, one of the Manson murderers has a $1.4 Million tab in the past four months with a malignancy of the brain. Now, she is obviously someone who needs to be behind bars but her case illustrates what is going on throughout the country in correctional healthcare. The state of California taxpayers are having to pay this bill for her. At least for now, because inmates are unable to have a choice in their healthcare, their healthcare is a right as defined by the Supreme Court. And I do believe that inmates deserve good medical care while they are being held. It is the delivery and payment of the care they receive that needs to be changed. I realize we have many who think it should be a right for everyone but that's another discussion altogether.

Should taxpayers have to pay the medical bills for inmates? I don't think so. I know that many of the problems we face are non-violent offenders such as people who owe child support and things like that are coming into the system with chronic medical problems that only one trip to the hospital will greatly exceed any penalty they owe. Let's take an example in my practice-my partner went to the jail not long ago to suture a guy's head who got in a fight there. Took about an hour to go up there get to the medical unit and do it. He was talking to the inmate and they guy could bond out for $100 but he didn't have it. Now, had that guy needed to go to the ER for a CT, what would we have accomlished as a society? His crime was writing a bunch of bad checks. I don't dismiss his crime but for crying out loud, let's use our heads in sentencing these people. In my previous post regarding correctional healthcare, I talked about an inmate with HIV who was in jail for breaking into a Coke machine. His medications cost about $1500/month. The whole machine didn't cost that much. Find another sentence.

Another twist to this situation is that if an individual has private insurance, Medicare or Medicaid, the moment they are incarcerated, the insurance is stopped. It can be reinstated after release but many times this takes 60-90 days. So, in the case of someone with an illness which requires expensive medications, the taxpayers have to start paying for the inmate's medications immediately. Then comes the problem of release. Let's say a non-violent offender on Zyprexa for a mental illness with Medicaid gets incarcerated then released a month later. The taxpayers paid for a month of the Zyprexa and now the person has no way of affording his or her medication when he or she is released for 60-90 days. This, especially in the case of mental illness, leads to a high recidivism rate. Unfortunately, many of the mentally ill in the jail have been placed there because of something they did while they were not controlled on their medications. They then get incarcerated for a non-violent crime and lose their Medicaid. When they are released, there is no way to get their medications because they have lost their insurance and any of the free psychiatric services are booked up for months at a time. What happens? They then either commit another crime because they are off their medications or they actually intentionally commit a crime in order to get put back in so they can receive their care. I have actually had county inmates tell us that when they have dental problems, they will commit a small crime so they can get put in jail and get their teeth pulled for free.

I will briefly mention, as well, that many jails pay the "retail" fee to hospitals for services for inmates. This is another area in which the taxpayers are penalized. However, we can't completely blame the hospitals for this because what we have learned from the hospital association is that a common practice is to "release" an inmate from custody when they go to the hospital for something. The hospital is then left with a "self-pay" patient to care for since their insurance has been suspended. So they have been looking out for their interests in this as well. Fortunately, we were able to negotiate a Medicare rate with our hospital on behalf of our county and this step alone has saved almost $500,000 per year. If an inmate goes to the hospital, the county gets a fair rate, the inmate doesn't get released on the doorstep and the hospital gets a fair payment within 30 days.

This is a complex problem with very few answers. Our group has made suggestions which would greatly reduced the local taxpayer cost to our state legislators but this has really fallen on deaf ears. One would hope the case in California will open they eyes of the powers that be but I wouldn't hold my breath.

Saturday, July 26, 2008


Apparently, my last post was offensive to some.  Please allow me to elaborate.  First, I would not intentionally offend anyone with my comments.  This post was purely in fun.  I realize that everyone may not have my sense of humor about things but I tend to look at things in a humorous way most every day.  My wife reminded me that I have several chronic medical conditions myself and I poke fun at that daily.  My daughter is legally deaf in one ear and we call her Helen Keller.  My wife suffers from migraines.  My son has Asperger's Disease and we call him the Rainman.  That being said, my comments were not meant to harm-only to have some fun.  I try to remain lighthearted.  

To address one of the comments made regarding my previous post, I think most physicians are frustrated caring for patients with Fibromyalgia.  At least in my case (and I believe in others') the frustration is not so much with the patient or the illness, rather a reflection of the larger problem with healthcare.  When our system currently dictates a physician see 30+ patients a day in order to pay overhead expenses, we can get easily frustrated when a patient comes in that we know is going to take time.  It does not matter if it is a patient with Fibromyalgia, an ICU patient when you have an office full of patients waiting on you or another complex patient in your office that day.  That is not a reflection of the individual and certainly not meant to be an excuse.  But it is what it is.  Hopefully, as time progresses and we see some true healthcare reform, we will see the monetary value of primary care increase and physicians won't have to rush through patients like we do at present.

In conclusion to this post, I would say that humor is a good way to diffuse a situation, frustrations, etc.  This post was meant to be humorous, that's all.