Monday, November 10, 2008

Quit Whining

I ran across an article in the New York Times that addresses the issue of overworked public defenders.  

Right to Counsel is in the Bill of Rights.  Despite the fact most Americans think it is, healthcare is not.
Given the attitude most Americans take towards their "right" to healthcare, let's talk to the public defenders the way the government's entitlement programs have been talking to physicians.

These public defenders are saying that their workload is too high.  They say they cannot ethically take on any more cases and expect to do a good job with the individuals they are currently representing.  They are SUING (what else do lawyers do) to give themselves a shut-off valve.  Well, if the CMS attitude permeated this argument, I imagine it would go something like this:

Right to Counsel is guaranteed American citizens in the Bill of Rights.  When you chose law school, you should have understood your duty to society.  The pay should not matter to you, as this is a needed service that you should be gracious to provide.  Yes, budget cuts have meant you can't make as much money as you'd like, but there are plenty of public defenders who are turning the conveyor belt up a little faster and still making everything work.

Perhaps we should introduce a productivity model for you?  We can assign a relative value to the cases that you provide.  So that way if you are truly tackling harder cases that demand more of your time, you will get paid more for those services.  Fear not!  We will not arbitrarily and year-after-year whittle that payment down to, in-effect, get you to see a few extra clients a month for "free".

And if you think about doing a shitty job for any of these citizens?  We will enact a quality initiative, where you must provide, in writing, and on a form designed by semi-retired attorneys, evidence that you are doing everything you should be doing for this client.  Then you can reclaim your pay cut as a "bonus".

And don't even think about leaving your profession for greener pastures, because there are SCORES of your colleagues who will be more than willing to manage a small team of legal aides (who we will endow with broader litigation privileges) who can handle the easier cases at a fraction of the cost to us.

And if that doesn't work?  Maybe we'll just start letting lawyers from other countries take a "brush-up" certification course on American Law.  Their work ethic and selflessness regarding compensation would be quite an asset.

So we recommend that you roll your sleeves up and see more clients, or we will be forced to further restrict your compensation and, sadly, be forced to "guide" the way you practice medicine -- er, LAW.

Wednesday, November 5, 2008

Just Keep 'Em Another Day

So I spent almost an hour on the phone with a family member trying to explain why it was a bad idea to send his dad to a skilled facility as a full code.

You see, his dad has been so severely demented as to be in the <3rd percentile for how long he'd already survived. Not surprisingly, when a big ol' stroke hit, he completely lost his ability to swallow. Solution? PEG tube. Let's just Terri Shaivo everyone.

What I had to further explain was that spit also has to be swallowed, and that it was only a matter of time before his dad filled his lungs with drool.

I'm good at these discussions. I really am. I have much better success than the average physician in getting families to do the right thing when it comes to code status and palliative care.

But this guy wouldn't hear of it. To paraphrase him, I was one in a long line of doctors trying to pressure him into killing his mom. He actually brought up Kevorkian. For once I was glad I was having this conversation on the phone with him.

So, after I realized that my efforts to procure his dad a humane end to his mortal coil were futile, I proceeded with discharge. Which was complicated.

So, total time spent arranging discharge, in this case, was truly 1 hour and 45 minutes. Since we have prolonged services codes, I asked our hospital coder what the threshold was for being able to add more time for a really long discharge. Surely, I proposed, that if it took 3 hours to discharge someone, I wouldn't get the same crappy 1.9 RVUs for that?

The answer, Dear Reader, is yes.

So, what I really wanted to do... but did not.... was to scratch this discharge day, get my damned prolonged services codes for a daily visit, and send him out the next morning.

It feels like that would be the wrong thing to do. At the same time, I just willingly screwed the Medicare National Bank's pooch.