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.
Thursday, July 31, 2008
Wednesday, July 30, 2008
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.
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
Fibromyalgia-Revisited
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.
Friday, July 25, 2008
Fibromyalgia
In response to my previous post regarding our all-time favorite Chief Complaints, Rob posted that one of his most dreaded complaints is Fibromyalgia. We all have things we prefer over others. Let's face it, the physicians who enjoy managing Fibromyalgia are in the minority. That being said, my wonderful wife reminded me that when I was in residency, my Rheumatology professor gave me a mnemonic for Fibromyalgia:
P: Pain syndrome
E: Energy decreased
S: Sleep disturbances
T: Trigger points
Now you will never forget how to diagnose Fibromyalgia. Remember, this is all in good-natured fun (for uptight folks).
P: Pain syndrome
E: Energy decreased
S: Sleep disturbances
T: Trigger points
Now you will never forget how to diagnose Fibromyalgia. Remember, this is all in good-natured fun (for uptight folks).
Wednesday, July 23, 2008
Chief Complaints
As physicians, we all have our favorite things to see. Some prefer managing diabetes. Some prefer hypertension. Some prefer acid-base disorders. You get the picture. I think we all have some disease process we prefer over another. The opposite holds true as well.
There are certain Chief Complaints that make me cringe before I go into an exam room. For me, these are the complaints that usually take much more time to work up, more time to listen to the history because there is usually a long story that goes with it, few objective findings on examination and the labs are usually normal. For me this also includes those complaints that, after the workup is complete, it takes more time to convince that patient that there is nothing wrong than it would have taken to treat something had it been there. Some of these have the potential to be very real illnesses and I just don't particularly enjoy working them up. But we do what we have to do to take care of the patient no matter how we feel about the complaint.
The Chief Complaints I hate to see on the chart are (in David Letterman style):
10. Rash.
9. Abdominal Pain.
8. Headache.
7. Dizziness.
6. "I want to get a prescription to lose weight."
5. Insomnia.
4. Constipation.
3. "I need my pain meds."
2. Fatigue.
1. "Dr. Blogger, your mother called and her doctor is out of town and she needs to talk to you about her meds."
For the record, this is not meant to be derogatory towards any patient. Just things I don't personally like to work up. Yet, like other physicians whose list may be similar or different, we have a desire to take care of the patient and his or her needs so we jump right in and take care of it (except in the case of #1 and she has to just wait on her doctor).
I would be interested to hear others' lists.
There are certain Chief Complaints that make me cringe before I go into an exam room. For me, these are the complaints that usually take much more time to work up, more time to listen to the history because there is usually a long story that goes with it, few objective findings on examination and the labs are usually normal. For me this also includes those complaints that, after the workup is complete, it takes more time to convince that patient that there is nothing wrong than it would have taken to treat something had it been there. Some of these have the potential to be very real illnesses and I just don't particularly enjoy working them up. But we do what we have to do to take care of the patient no matter how we feel about the complaint.
The Chief Complaints I hate to see on the chart are (in David Letterman style):
10. Rash.
9. Abdominal Pain.
8. Headache.
7. Dizziness.
6. "I want to get a prescription to lose weight."
5. Insomnia.
4. Constipation.
3. "I need my pain meds."
2. Fatigue.
1. "Dr. Blogger, your mother called and her doctor is out of town and she needs to talk to you about her meds."
For the record, this is not meant to be derogatory towards any patient. Just things I don't personally like to work up. Yet, like other physicians whose list may be similar or different, we have a desire to take care of the patient and his or her needs so we jump right in and take care of it (except in the case of #1 and she has to just wait on her doctor).
I would be interested to hear others' lists.
Sunday, July 20, 2008
Outpatient Studies
My practice has six physicians. Because of this we open on the weekends and we have walk-in patients. This, of course, has the benefit of generating much needed revenue in this current system where volume seems to be the only way primary care physicians can generate any significant revenue.
We have two hospitals and several outpatient imaging centers in the area. The imaging centers are all closed on the weekends as well. During the weekdays, there is no problem getting "stat" or "asap" studies for things like an ultrasound for a swollen lower extremity, CTs, etc. However, on the weekend this becomes much more problematic.
Since the imaging centers are all closed on the weekends, we have to go through the hospitals to get any type of "stat" or "urgent" study. The interesting thing is that even though we have spoken to the hospitals about it, they refuse to allow our office to order these studies as an outpatient on the weekend. You would think that the added revenue would be an incentive to let us do this.
I can only think of a couple of reasons they would do this. First, they will make much more on an ER visit than just an outpatient imaging visit. Secondly, most of the imaging staff in ultrasound or CT are only on call on the weekends and they don't want us willy-nilly ordering tests that cause them to pay overtime to the imaging staff. I think both of these reasons are in play.
Once again, a huge cost to the taxpayers of this country having to duplicate care and forcing ER visits. What use is there for me to see a patient with a potential DVT, then do an H&P, only to send them then to the ER for another doctor to do the very same thing and order the test I could have ordered as an outpatient. What would have only cost a few hundred dollars now is costing probably close to $5000.
This is another example of one of the problems I see with the healthcare system as we know it.
We have two hospitals and several outpatient imaging centers in the area. The imaging centers are all closed on the weekends as well. During the weekdays, there is no problem getting "stat" or "asap" studies for things like an ultrasound for a swollen lower extremity, CTs, etc. However, on the weekend this becomes much more problematic.
Since the imaging centers are all closed on the weekends, we have to go through the hospitals to get any type of "stat" or "urgent" study. The interesting thing is that even though we have spoken to the hospitals about it, they refuse to allow our office to order these studies as an outpatient on the weekend. You would think that the added revenue would be an incentive to let us do this.
I can only think of a couple of reasons they would do this. First, they will make much more on an ER visit than just an outpatient imaging visit. Secondly, most of the imaging staff in ultrasound or CT are only on call on the weekends and they don't want us willy-nilly ordering tests that cause them to pay overtime to the imaging staff. I think both of these reasons are in play.
Once again, a huge cost to the taxpayers of this country having to duplicate care and forcing ER visits. What use is there for me to see a patient with a potential DVT, then do an H&P, only to send them then to the ER for another doctor to do the very same thing and order the test I could have ordered as an outpatient. What would have only cost a few hundred dollars now is costing probably close to $5000.
This is another example of one of the problems I see with the healthcare system as we know it.
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