tag:blogger.com,1999:blog-39748712545512767442024-02-19T06:05:33.615-08:00The Hospitalist RefugeeThe Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.comBlogger21125tag:blogger.com,1999:blog-3974871254551276744.post-80537631874144068562009-06-01T05:50:00.000-07:002009-06-01T06:13:01.119-07:00How Early Is Too Early?As much as I truly do like what hospital medicine represents, I have come to the very strong conclusion that there <em>are</em> greener pastures.<br /><br />As the days of my contract tick ever-so-slowly away, I wonder how soon is too soon to seriously start the job hunt. Given that I'm looking to geographically relocate a not-insignificant distance, and that I really don't even have a solid idea about what state I'm shooting for, I figure it's not too early to put the feelers out and ask for some courtesy tours.<br /><br />But I did get a lil bummed out by some of the Sermo posts talking about how it took one guy 3 hospitalist jobs before he found one he was happy in. For reasons mostly out of my control, I think I've had more jobs post-residency than I had before it. It would be nice to settle down in a position that I can think of as a career rather than a means-to-an-end.<br /><br />As a lifelong Midwesterner who has lived in some pretty great Midwestern cities, I'm bracing myself to find that as the Quality-of-Life index goes up, the quality of the hospitalist job plummets. Maybe that's not universally true. But as someone who lives in a great city and commutes to work in a town precious few would voluntarily choose to live in, I can tell you that small town hospitalist jobs can be as malignant as any in a cosmopolitan city. (Even if you've read your contract with a fine-toothed comb.)<br /><br />I suppose I need to decide if I would ever work directly for a hospital again. As many cons as that comes with, one of the most regal screw-jobs I've ever heard of came at the hands of a private physician group (granted, that friend is in Emergency Medicine, so maybe that's more par for the course).<br /><br />I'm glad I've found a profession I like. Now I need to find the good peeps I want to work in a town I want to hang my hat for years.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com3tag:blogger.com,1999:blog-3974871254551276744.post-47539879833343756612009-05-17T07:20:00.000-07:002009-05-17T08:01:36.509-07:00Hasta Luego ChicagoSo, I am finishing up the Society of Hospital Medicine 2009 meeting. I walk away with mixed feelings.<br /><br />For one, it was refreshing to hear that many of the struggles that our hospitalist program has are not unique. On the other, it's clear that a lot of places "get it" and are light years ahead of my program when it comes to clearly defining the limits and scope of what a program of a certain size can/should do. As a Med/Peds physician, the special interest group was mostly cathartic, but did give me renewed purpose in trying to effect positive changes.<br /><br />While my current job is decidedly NOT where I want to practice (geographically or operationally), hospitalist medicine IS the environment I want to stay in. I'm hopeful that when it comes time for me to find the next hospitalist job, our profession will have matured (with hopefully the leadership of SHM) enough that there is consistency and stability in the market.<br /><br />I thought the discussions on Quality Initiatives summed up the issues very succinctly, and I especially enjoyed the fact that SHM convinced one of Satan's Minions from United HealthCare to weigh in. I thought Dr. Susan Freeman (of the Jedi Knights) was exceptional. Watching her counterpointing Steven Stern was tremendous. But at the end of the session, it had the feel of two warriors shaking hands, knowing that the real war was about to begin.<br /><br />I didn't hear anyone bring up the fact that "bundled payments" in 2009-2010 has very different implications than it did the last time it was tried. A shit-ton more of us are employed by hospitals now. When trying to divvy up the breadcrumbs, and as "not-for-profit" hospitals guard their profit margins, what's the place of the hospital-employed physician at the table?<br /><br />The discussion of readmission rates and post-hospitalization care was important, but I was quite disturbed at the murmurs of suggesting that hospitalists now take over some of those outpatient duties post-discharge. Hospitalist medicine emerged because primary care doctors could no longer effectively do clinic AND inpatient medicine. In our community, the primary care doctors that we started admitting for immediately boosted their clinic schedules. And that's fine... unless we can't get your damn inpatients to follow up with you. I think that this is an area where the onus does fall back on the primary care doctors. In our community, they used to be responsible for all the unassigned admissions AND their follow up. I just bristle at the suggestion that the job of the hospitalist needs to start morphing back into the very profession we all found so dissatisfying.<br /><br />Finally, as someone who drives a fair distance to serve a rural-esque population, it struck me at the "Exhibition Hall" how disingenuous recruiters are when trying to convince physicians in a hot market to give up major aspects of what make a location desirable in exchange for promises of cash. I almost wish they would be banned from the whole enterprise next year. I realize they represent a significant revenue stream for SHM, but can we at least separate the people who have clinical information for us from the snake oil vendors? We're not stupid. A hunting/fishing "paradise" that's less than an hour (55 minutes at 85mph) from a regional airport makes lofty compensation promises that always <em>always</em> come with strings attached.<br /><br />I really wish they would just say, "This place sucks, but here's what we're going to offer you in terms of compensation/work schedule that we hope makes up for it." Instead of pictures of babbling brooks and fields of wildlife, those booths need to read like an offer letter. Just a suggestion.<br /><br />All in all, it was a great experience, and I look forward to next year. But for the love of god, get more chairs.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-22251194627542803942009-03-10T11:43:00.000-07:002009-03-10T11:44:21.173-07:00Does Congress Get It?While working directly for a hospital has some advantages, I have become increasingly aware of how the conflict of interest between hospitals and the physicians they employ is bad for healthcare. For quite some time the way hospitals get paid and the way physicians get paid has been in direct conflict. This is why "Length of Stay" is a term laced with gold. While I do not believe I have ever discharged a patient inappropriately, I would be lying if I said that it didn't cross my mind when a patient that is in that illustrious "gray zone" wants to stay "one more day". I have yet to decide if this is a good thing or not. It certainly becomes an issue with my customer... I mean patient satisfaction.<br /><br />But when Congress talks about cutting payments to physicians, do they freaking realize that an increasing number of physicians (and almost NO primary care physicians) are not the ones who receive these payments? The hospitals get them. Most primary care physicians under the age of 40 are working directly for a hospital under a contract that has a payment structure that may or may not take into account how much cash the hospital collects from insurance companies and (increasingly) the government. When the government attempted to Robin-Hood from the proceduralists and give a lil to the little guys (the primary care doctors), a lot of hospitals, including my own, they attempted this by increasing the RVUs granted to PMDs and reducing the RVUs granted to proceduralists. So a lot of hopsitals convinced proceduralists that they would have to take a modest pay cut because they couldn't bill as many RVUs. And did most hospitals pass said-cash-flow on to the intended recipients? No. They pocketed it. And now the PMDs were genereally left in the exact same position having to see just as many patients for the same salary.<br /><br />So if we actually cut physician payments 21%... tell me, Dear Reader, how do you think a hopsital who employs a physician is going to take that? Are they going to sustain the salaries of the primary care doctors (and the rest of us for that matter) out of the mountains of profit these not-for-profit hospitals make? Or are they going to continue to do business as usual, and give their doctors a take-it-or-leave-it offer? Or are primary care doctors now going to be instructed to see 60 patients a day to maintain their already-behind-the-curve salaries.<br /><br />I was hoping for some real healthcare reform. There do need to be changes. But what I see coming down the pipeline scares the living shit out of me. They know not what they do.<br /><br />Maybe our lawmakers should be required to have Medicare/Medicaid. Shit. Give it to them on my dollar, I don't care. Let them try to find a doctor who's able to spend an appropriate amount of time with them and still make more than the receptionists.<br /><br />Idiots.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-70150593449958363832009-02-12T11:50:00.000-08:002009-02-12T12:14:02.213-08:00Just Tell Me Where My Obligation EndsNothing has lit up the blogosphere quite like the infamous human litter. I would feel like I'm slighting my duties as a semi-intermittent blogger if I did not chime in.<br /><br />As a Med/Peds physician, I have no problem with saying that our society does have certain obligations (entitlements) to certain populations. Children and the elderly. Everyone else in between is another discussion for another day.<br /><br />The problem I have with the way our healthcare system is structured is not that we have decided as a society to provide assistance to these groups (I think that we <em>should</em>, which is vastly different from saying that we <em>have to</em>) but that the public at large has translated this initially-voluntary offering of assistance into the mantra of "healthcare as a right".<br /><br />Should an elderly couple, having worked their entire lives, be entitled to some help with prescriptions at the age of 65? I do not think this is unreasonable.<br /><br />If we decided, as a society, that we can no longer afford to do so, are we somehow denying that couple civil liberties? Absolutely not.<br /><br />As a disclaimer, I am not really sure how to categorize myself politically. I think it would be a tragedy to live in a world where we subsidize some of the most outrageous BS <em>ever</em> and let infants waste away because we aren't offering assistance for formula. But I do start to take deep offense to those who see such assistance as a means to an end, rather than a safety net. Like our new friend Nadya Suleman.<br /><br />As most physicians who have spent any time in outpatient primary care, the patients who seek disability for back pain are suspicious at best. (Have you really given physical therapy a decent shot? Really?) Given Ms. Suleman's observed pattern of behavior, I would guess she had to browbeat her physician (or change PCPs a few times) to get that disability paperwork filled out.<br /><br />And how does a woman who is "disabled" able to "work double shifts" to "save up" money for more <em>in vitro</em>? If you could save up for that much <em>in vitro, </em>maybe we need to assess how much gets paid out for SSI.<br /><br />Rumor has it one of her pre-octuplet kids is autistic. If that's true, I truly take an exception to my rant. Autism is a horrifically underfunded chronic condition that only lots of expensive speech therapy, etc. has been shown to significantly affect. (This is where No Child Left a Dime fails.) If I had an autistic child, it would be a 2nd full-time job to give that kid the attention he/she needed to ensure peak potential. The kind of care an autistic child needs is truly out of the price-range of most Americans to pay for out of pocket. I have no problem subsidizing that.<br /><br />But all sympathy for her struggle with an autistic child evaporates when you see what decisions she made next. It reveals her to be pathologically selfish. If she gave a rat's ass about her autistic child, she wouldn't take the little time she had for him/her and divide it amongst 8 more. Oh yeah... AND go back to college.<br /><br />Her deftness at filling out disability paperwork must have made it quite easy to get 2 of her other kids on the federal/state subsidy payroll. Let me guess.... "bipolar disease" and "ADHD". What normal child growing up in this environment <em>wouldn't</em> start showing some signs of these conditions?<br /><br />Now that we hear (shockingly) that this hospital wants the state to reimburse them for this care, I am waiting on bated breath for SOMEONE in power (ahem.... Obama) to comment on where the Era of Responsibility begins, and where the Era of "Oh, don't worry about that horrifically boneheaded decision you made.... let us take care of that for you" ends.<br /><br />I'm actually hoping she gets piles of cash from a bunch of moronic sympathetic viewers. But I want to hear when my obligation ends. If I lived in California, I'd be even more pissed. How many book deals does one need to sign before you can't get food stamps anymore?<br /><br />I think my rage over this selfish woman has peaked. But if I find out that she has ever put a cigarette to her lips in the last 10 years, I will probably have a stroke myself. Then all of <em>you</em>, dear readers, will be paying for my tube feeds.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-17544917886000973902009-01-28T11:50:00.000-08:002009-01-28T12:27:54.362-08:00Forfeitted FreedomsSo, despite the fact I have a better life as a hospitalist than I had as an outpatient slave, I am finding that the experience of being a hospitalist is making me ever-less hopeful about the state of our country.<div><br /></div><div>Back when I was a wee-tot in residency, I really didn't give a thought to where my taxes went. I made less than most tenured cashiers at grocery chains. I just wanted to know what the hell I was doing with patients. I just wanted to get through another night of call. I was striving for competence to heal the sick. I gave very little thought to my post-residency future (since I was in the extreme-minority not scraping for a proceduralist fellowship). Only 5% of my training was spent in the outpatient setting -- the environment I would be spending 95% of my immediate post-training years.</div><div><br /></div><div>When I became a hospitalist, and that number went to 0%, my perspective had changed dramatically. Here I was trying to pay off mountains of debt, negotiating to become the employer of a not-for-profit profit machine, and paying more in taxes than my gross income had been throughout my residency years. By the time I had managed to set aside some cash into the 401(k), I watched it vanish. And now I'm watching trillions of dollars of my future being prostituted to keep the imaginary-wealth of the last 10 years from vanishing.</div><div><br /></div><div>I've become pissed off enough at the corporate suits for asking me to help their multimillion salaries remain inflated while the public-at-large groans that doctors make too much. I'm in the trenches -- the front-line -- of healthcare in this country, and I'm scraping for my piece of the pie. I will never make a million dollars a year (at least, not practicing medicine). But my job is indirectly subsidized by the federal government, as now a huge sector of the automobile and banking industries are. So to hand irresponsible owners of companies that make shitty cars, and banks that make horrific choices, astounding piles of cash, while our government cannibalizes medical education subsidies to pump more money into the failed and pathetic "quality" incentive programs to physicians, cases me tremendous anger. </div><div><br /></div><div>"Expanding healthcare" does not mean giving more people the same shitty government-funded "coverage" that no physician with any degree of autonomy will accept. They'll still pay (and I'm making numbers up here) the same insulting $40 to for the 30 minute office visit for an elderly person with diabetes, and the same outrageous $30,000 to cut off their feet.</div><div><br /></div><div>Hospitals are employing an increasing number of physicians. Our government has made sure the economics are stacked against doctors trying to actually open their own practice. Those of us unlucky enough to be employed directly by hospitals know that they have <span class="Apple-style-span" style="font-style: italic;">absolutely no desire</span> to see people get healthier. Their bottom line will suffer. If primary care physicians were empowered to spend the time they need with people to better manage chronic illness (and I really think they're doing the best they can under the current borderline-immoral conveyor belt of patients many are browbeat into seeing) then you're going to see less hospitalization. Less mindless flow of cash to the hospital to proceduralize people to death.</div><div><br /></div><div>I'm constantly brainstorming about what we need to do to fix this. I'm not terribly optimistic about Obama's ability to do this, since I am increasingly hearing the outraged voices of people who have come to demand access to taxpayor-funded entitlement-based reimbursement of medical services shouting that no one has the right to tell them how to live their life.</div><div><br /></div><div>Under normal circumstances, I agree. I would have no problem with people who want to eat themselves into oblivion. It wouldn't bother me if I saw the COPDer on oxygen smoking at the casino. It would hardly phase me to see the IV drug abuser using her PICC line to shoot up crushed oxycontin mixed with spit. EXCEPT THAT I'M PAYING FOR THIS SHIT.</div><div><br /></div><div>If I have a stake in paying for you healthcare, then <span class="Apple-style-span" style="font-weight: bold;">hell yes</span> I can tell you how to live your life. And this is independent of my standing as a physician. I think this goes for anyone playing by the rules who is not reliant on the government to pay for their healthcare. You want to live your life as you please? Fine by me. When those choices make you sick, you're ON YOUR OWN. Oh, you want me to pay for your CPAP and Q2 month admissions for COPD? Put down the fork (or the hamburger wrapper), get off your ass, and put out the cigarettes. Or buy your own health insurance.</div><div><br /></div><div>And we really need to stop using the term "insurance". Think about what would happen if we treated <span class="Apple-style-span" style="font-weight: bold;">car insurance</span> and <span class="Apple-style-span" style="font-weight: bold;">homeowners insurance<span class="Apple-style-span" style="font-style: italic;"> </span><span class="Apple-style-span" style="font-weight: normal;">in the same vain that we talk about "healthcare insurance". I would demand that Geico pay for my oil changes, new tires and brakes, even though I drive my car like a rental. When the lightbulbs go out in my house, I'd call up AllState and demand someone come over to replace them... even though I just leave the lights on all the time. What would our motivation be to take care of our vehicles and homes if the government just took care of it? Oh... but they'll only pay for 60% of the cost of the oil changes... what do you think that would do to Jiffy Lube?</span></span></div><div><br /></div><div>Something has to change. Fast. The healthcare bubble is going to pop. But I fear that our concern is being misdirected. Americans are unhealthly largely because of their refusal to take care of themselves. And if I read one more article about an outraged smoker who is simultaneously pissed off about not being able to smoke in public, and about the cost of her COPD medications... I might just lose my mind.</div><div><br /></div><div><br /></div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-9656352471517714082009-01-02T17:55:00.000-08:002009-01-02T18:18:22.684-08:00Too Big to Fail?So I've been pondering the very real prospect of a healthcare bubble bursting, and what form it would take. I do believe that a lot of our country's leadership will see the solution as being a single-payor Medi-doesn't-care-for-all system. I must admit, this scares the crap out of me. Even though the way I, as a hospitalist, am paid assigned disproportionate value to fixing broken people over keeping them well, any meaningful change to our healthcare system could make my contract obselete. What if RVUs went away? What if the financial interests of the hospitals were no longer in opposition to that of their employed physicians? How can I know I'm going to be able to pay my bills? The thought of being forced into government employment makes me want to wretch.<div><br /></div><div>But something occured to me that gave me solace. When billions of dollars of banks and financial institutions were ready to crush under the weight of their incompetence and greed, our government deemed them too large to fail. I have no numbers (but I would love it if someone were able to direct me to them), but I wonder how comparatively "big" all of the country's health insurers are. What is their annual revenue? How many people are employed in aggregate by all of these institutions? It may not eclipse the financial sector... but I imagine it's not insignificant. If we can't fathom the loss of Ford... what about Blue Cross/Blue Shield?</div><div><br /></div><div>I have no idea how one could create a single payor system, and yet preserve all of these institutions that have made a career out of keeping money out of the hands of those providing the healthcare, and filling their coffers. Are they all going to be voluntold into federal/state employment? With all the resources we had, we couldn't figure out how to get a company that makes shitty cars to make better cars. How the <span class="Apple-style-span" style="font-style: italic;">hell</span> would these same people figure out how to restructure the entire healthcare system?</div><div><br /></div><div>I think for once, all these companies who have restricted my practice of medicine may protect me from the absolute destruction of physician autonomy.</div><div><br /></div><div>The enemy of my enemy...</div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-83930240356884334702008-12-28T07:33:00.001-08:002008-12-28T08:02:20.067-08:00I Think the Tide is TurningIt would take a <span class="Apple-style-span" style="font-style: italic;">lot</span> for me to go back into outpatient medicne. More than I think the beancounters are willing to concede. Nonetheless, in the short time since I opted out of Primary Care, I sense a change in the national discourse. I am hearing less and less about the problem of the uninsured, and more and more about the pending disaster of those-with-insurance-with-nowhere-to-go. While most of the information in <a href="http://www.kansascity.com/637/story/954354.html">this article</a> is not new to most of us, it does highlight that the crisis is growing if a major metropolitan area is starting to worry.<div><br /></div><div>Rural communities have had trouble keeping doctors since before I went to medical school. But the pool of primary care physicians has shrunk enough that larger and larger rural communities have begun to feel the pinch. I would venture to say that the new generation of physicians wants to live near more "stuff" than previous ones. Just look at residency programs. </div><div><br /></div><div>Program directors of most internal medicine, pediatric and family practice programs have known for some time that recruitment to the Midwest (even to major cities) is inherently harder than places with 320 days of sunshine, oceans or mountains. If you're going to work 120 hours a week for less pay than a tenured grocery store cashier, you might pick the hospital in paradise versus the one in the frozen tundra.</div><div><br /></div><div>This is why I think that the loudest cries are going to start coming from the larger cities in the nation's midsection. I'm not seeing a lot of Locum Tenens agencies begging for help in Manhattan or San Francisco. </div><div>It's going to be a while before there <span class="Apple-style-span" style="font-weight: bold;">aren't</span> physicians willing to work for the CMS pittance in exchange for a 1-bedroom rental in a cultural epicenter. But when we've reached the day when an above average primary care physician salary can't attract <span class="Apple-style-span" style="font-style: italic;">anyone</span> to a smaller city with imperfect weather, but major sports teams, an art museum, a symphony, an international airport, and premium shopping... maybe that salary isn't so above average...</div><div><br /></div><div><br /></div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-82933103187314221392008-12-04T12:22:00.000-08:002008-12-04T12:41:39.936-08:00AARP Has Sold Their Soul to the DevilOne of my new-found perks of being a hospitalist is being able to enjoy daytime television <span class="Apple-style-span" style="font-style: italic;">not</span> related to contracting influenza or wasting an otherwise-perfect day off. In nearly every way, I am the antithesis of the target demographic for the commercials -- particularly the <span class="Apple-style-span" style="font-weight: bold;">AARP Medicare Supplement Insurance</span> ad.<div><br /></div><div>Normally I zone out during healthcare-related advertisements, but the commerical was on literally every 15 minutes. Then I noticed the fine print at the bottom. Then I became quite irritated.</div><div><br /></div><div>The AARP Medicare Supplement Plan is United HealthCare in disguise. Yes. The insurance company which scored the lowest in a comprehensive survey of physicians.</div><div><br /></div><div>This is the same insurance company which, after a long bloody exchange, is being dropped next year by one of the largest health centers in my area. Why? Because their reimbursement is laughable. And they refuse to pony up.</div><div><br /></div><div>Fortunately, as a hospitalist, I now get to ignore most insurance company hassles. I don't have the energy, and am not willing to waste the time, to figure out exactly how much of a screw-job the AARP Medicare Supplement Plan is. But I have to wonder what lurks behind their banter:</div><div><br /></div><div>1. "I get to choose my own doctor!"</div><div><br /></div><div><span class="Apple-tab-span" style="white-space:pre"> </span><span class="Apple-style-span" style="font-style: italic;">Really? Can you <span class="Apple-style-span" style="font-weight: bold;">find</span> a primary care doctor? If so, do they accept the AARP Plan? If so, do they</span><br /></div><div><span class="Apple-style-span" style="font-style: italic;"><span class="Apple-tab-span" style="white-space:pre"> </span>give your doctor additional reimbursement to supplement Medicare's insulting breadcrumb?<br /></span></div><div><span class="Apple-style-span" style="font-style: italic;"><br /></span></div><div>2. "I don't need a referral to see a specialist."</div><div><br /></div><div><span class="Apple-tab-span" style="white-space:pre"><span class="Apple-style-span" style="font-style: italic;"> My concerns about finding a primary doctor notwithstanding, what if your specialist wants to</span></span><br /></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><span class="Apple-tab-span" style="white-space:pre"> </span>order $5,000 of diagnostic evaluation? How much of that will you cover? Do you require<br /></span></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><span class="Apple-tab-span" style="white-space:pre"> </span>doctors to fill out mountains of pre-authorization paperwork? What if Medicare refuses to pay,<br /></span></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><span class="Apple-tab-span" style="white-space:pre"> </span>will you pick that up for these people? <br /></span></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><br /></span></div><div><span class="Apple-style-span" style="white-space: pre; ">3. "It's been endorsed by the AARP!"</span></div><div><span class="Apple-style-span" style="white-space: pre;"><br /></span></div><div><span class="Apple-style-span" style="white-space: pre;"><span class="Apple-tab-span" style="white-space:pre"> </span><span class="Apple-style-span" style="font-style: italic;">Because we've never witnessed otherwise-respectable institutions sell off their souls one piece</span><br /></span></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><span class="Apple-tab-span" style="white-space:pre"> </span>at a time for a lil extra dough? Particularly in this economy? How do you know that someone<br /></span></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><span class="Apple-tab-span" style="white-space:pre"> </span>at the top-rung of the AARP doesn't play golf with the marketing director of UHC?<br /></span></div><div><span class="Apple-style-span" style="font-style: italic; white-space: pre;"><br /></span></div><div><span class="Apple-style-span" style="white-space: pre; ">Regardless of these dubious claims, what about prescription drug coverage? I agree that physicians need </span></div><div><span class="Apple-style-span" style="white-space: pre; ">to be more vigilant about using generics, but what about the usual suspects? Is Plavix still going to cost</span></div><div><span class="Apple-style-span" style="white-space: pre; ">these people $100 a month?</span></div><div><span class="Apple-style-span" style="white-space: pre;"><br /></span></div><div><span class="Apple-style-span" style="white-space: pre;">What does it say about our entitlement programs when an entire business can survive on covering</span></div><div><span class="Apple-style-span" style="white-space: pre;">healthcare costs that Medicare refuses to?</span></div><div><span class="Apple-style-span" style="white-space: pre;"><br /></span></div><div><span class="Apple-style-span" style="white-space: pre;">Finally... I wonder how close a year's worth of premiums to UHC would come to a concierge medicine</span></div><div><span class="Apple-style-span" style="white-space: pre;">retainer fee? And which one would improve the quality of our elderly's care more.</span></div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-31219958926171742382008-11-10T10:47:00.000-08:002008-11-10T11:07:41.548-08:00Quit WhiningI ran across an article in the New York Times that addresses the issue of overworked public defenders. <div><br /></div><div><a href="http://www.nytimes.com/2008/11/09/us/09defender.html">http://www.nytimes.com/2008/11/09/us/09defender.html</a><br /></div><div><br /></div><div>Right to Counsel is in the Bill of Rights. Despite the fact most Americans think it is, <span class="Apple-style-span" style="font-weight: bold; text-decoration: underline;">healthcare is not</span><span class="Apple-style-span" style="text-decoration: underline; "><span class="Apple-style-span" style="font-style: italic;">.</span></span></div><div>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.</div><div><br /></div><div>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:</div><div><span class="Apple-style-span" style="font-style: italic;"><br /></span></div><div><span class="Apple-style-span" style="font-style: italic;">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.</span></div><div><span class="Apple-style-span" style="font-style: italic;"><br />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".</span></div><div><span class="Apple-style-span" style="font-style: italic;"><br /></span></div><div><span class="Apple-style-span" style="font-style: italic;">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".</span></div><div><span class="Apple-style-span" style="font-style: italic;"><br /></span></div><div><span class="Apple-style-span" style="font-style: italic;">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.</span></div><div><span class="Apple-style-span" style="font-style: italic;"><br /></span></div><div><span class="Apple-style-span" style="font-style: italic;">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.</span></div><div><span class="Apple-style-span" style="font-style: italic;"><br /></span></div><div><span class="Apple-style-span" style="font-style: italic;">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.</span></div><div><br /></div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-21538041759653843622008-11-05T00:49:00.000-08:002008-11-05T01:07:22.464-08:00Just Keep 'Em Another DaySo 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.<br /><br />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.<br /><br />What I had to further explain was that spit <em>also</em> has to be swallowed, and that it was only a matter of time before his dad filled his lungs with drool.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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 <em>really</em> 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?<br /><br />The answer, Dear Reader, is yes.<br /><br />So, what I <strong>really</strong> 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.<br /><br />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.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-66141883728593332882008-10-25T22:03:00.000-07:002008-10-25T22:11:51.527-07:00Customer SatisfactionSo, I know I've harped about this to multiple associates of mine for years now... but I couldn't help but have my rage stoked anew when I walked by the cafeteria, and there, in a shiny glass case with track lighting (like an exhibit of fine art) were color printouts of the graphs depicting the "improvement" in "Overall Patient Satisfaction" in our various departments.<div><br /></div><div>The administration was apparantly quite proud of the bold increase from 58% to 62%. But who else is going to be?</div><div><br /></div><div>Any physician should look at such a display and belly-laugh over the absurdity of trying to treat a hospital like Dillard's. Any patient should look at a number that translates into an "F" and wonder what kind of shit-can their mom has been admitted to.</div><div><br /></div><div>I wonder.... what are the national averages for "overall patient satisfaction"? What is a reasonable number to expect? The surveys allow responses from 1 to satis"FIVE" (I seriously have to suppress the vomit everytime I hear that). So if a patient had a pretty good experience, but the scent of feces wafting into their room knocked it down to a 4 out of 5, that's 80%. (B minus). </div><div><br /></div><div>WHY DO WE EVEN BOTHER?</div><div><br /></div><div>I honestly don't know if there is any sort of compensation/reimursement tied to this absurd metric. What would happen it it actually became 100%? I am fairly certain 100% patient satisfaction is synonymous with any of the following:</div><div><br /></div><div>1. Falsification of data.</div><div>2. The return of only 2 surveys for that month.</div><div>3. Bad consumer-based medicine being practiced.</div><div><br /></div><div>I wonder how many cumulative dollars are spent nationwide by hospitals trying to make this number look pretty? </div><div><br /></div><div>Press-Ganey must laugh their way to the bank every single day.</div><div><br /></div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-76464028990307791542008-09-23T17:05:00.001-07:002008-09-23T17:26:03.605-07:00How JCAHO hurts patient care.My hospital recently had a JCAHO visit. I realize that they could, with one sweep of the hand, ensure that my hospital would never receive another Medicare dollar, and thusly shut the place down. But I have always found it difficult to give a rat's ass when these trolls are around. I honestly don't care. And maybe I should. But I don't.<div><br /></div><div>But I did make some observations about what happens in a hospital when JCAHO arrives. The Joint Commission Pixie Dust is pumped through the ventilation system, and causes the following:</div><div><br /></div><div>1. Administrators are actually in the hospital longer than most of the physicians. A truly amazing effect.</div><div><br /></div><div>2. Nurses spend even less time at the patient bedside, making sure all of their computer documentation is perfect.</div><div><br /></div><div>3. The housekeepers shove chairs off to the sides of the hallway with ninja-like speed to ensure that "8 feet" of open corridor is free at all times.</div><div><br /></div><div>4. CT scans take an hour longer since stretchers cannot be kept outside the patient room, waiting for the CT tech to finish his bon-b0ns and call the patient down.</div><div><br /></div><div>5. The staff bathrooms are wallpapered with countless ridiculous "acronyms" (in all shades of neon), as if it's going to make nurses remember to go through the 8 steps of "TEAMWORK" when wiping a patient's ass, and 4 steps of "CALM" when soothing a patient threatening you bodily harm.</div><div><br /></div><div>6. The unit clerks turn all the patient charts face-down with obsessive-compulsion so that we feel better about patient "privacy". (Nevermind the dry-erase board with all the patient names on it within plain view. Or the to-be-taken-0ff order rack where a sheet of paper is sticking out of the chart <span class="Apple-style-span" style="font-weight: bold;">and<span class="Apple-style-span" style="font-style: italic;"> </span><span class="Apple-style-span" style="font-weight: normal;">their name is visible.) This adds an extra 5 minutes to my day looking for the damn chart.</span></span></div><div><br /></div><div>7. My morning coffee is thrown away as a "rogue beverage" before I've even seen 2 patients each morning.</div><div><br /></div><div>8. Everyone loses the ability to think critically, and literally loses their fucking mind.</div><div><br /></div><div>I really wish we could quantitate the resource expenditure. Individuals pulled from their usual jobs to perform "emergency" functions. All the phone calls to doctors and nurses, pulling them away from patients (and, incidentally, billable activities) to make sure the DVT prophylaxis form is filled out for the patient with no legs. How much do we SPEND to get the insulting Medicare breadcrumbs?</div><div><br /></div><div>It just makes me realize how desperately hospitals need to learn some way... <span class="Apple-style-span" style="font-weight: bold; font-style: italic;">any way</span> to function without the pittance of the government handout. Because the care of our patient suffers every time we try to appease a bureaucrat. Let us not even venture into how a private organization like JCAHO got such a blessedly profitable mandate to fall into their lap.</div><div><br /></div><div>Our government doesn't realize that every time they try to fix something with a mandate, they fuck something else up. And make healthcare more expensive, less efficient, and more dangerous for us all.</div><div><br /></div>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-19851984208197940442008-09-16T18:26:00.000-07:002008-09-16T18:30:28.702-07:00Why People Overuse The ER<div>This should be handed out in ER waiting rooms:</div><div><br /></div><a href="http://www.slate.com/id/2199645/">http://www.slate.com/id/2199645/</a>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-21653577756999851252008-09-05T12:30:00.001-07:002008-09-05T12:30:40.018-07:00Run ScreamingThe theocracy is coming....<br /><br /><a href="http://www.richarddawkins.net/article,3068,Palin-average-isnt-good-enough,Sam-Harris-Los-Angeles-Times">http://www.richarddawkins.net/article,3068,Palin-average-isnt-good-enough,Sam-Harris-Los-Angeles-Times</a>The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-84343087125551322322008-08-24T13:15:00.001-07:002008-08-24T13:23:32.693-07:00Reason for Consult: OldYou'd think our surgeons would get the hint. Particularly our uber-sub-sub-specialist surgeons. They bring a patient in for a routine gravy-train procedure, and on their ORDER SET... "Consult Hospitalists for Medical Management."<br /><br />How can a consult be on standard order sets? <br /><br />So when we find out it's from this particular group of surgeons, we have the nurses call the surgeon to make sure there really are medical issues for us to follow. Often... there are not.<br /><br />Just so happens the other day this consult came during the day, and I saw the surgeon walking by.<br /><br />"Do you really need us for this one?"<br /><br />The response: "Yeah.... she's 75... ya know... not on any meds or anything but I think it would be a nice 0ne for ya guys... kinda frail."<br /><br />Me, "<blink> ... uh... ok... I'll see what I can do."<br /><br />What I really wanted to say was, "Really, asshole? Do you think Medicare is really going to pay for a consultation by me when the reason for the consult is 'frail'? I assume by 'frail' you mean 'old'. So does that mean there is an age threshold for consultation? Unless you're going to start sharing your revenues from your over-reimbursed procedures, you can manage 'old' all by yourself, big boy."<br /><br />We clearly need to have a medical staff meeting. What a douche.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com2tag:blogger.com,1999:blog-3974871254551276744.post-86613334611583366012008-08-13T13:55:00.000-07:002008-08-13T14:14:37.069-07:00BillboardsOn my glorious drive out to the sticks, I had an epiphany...<br /><br />What if in enlisting the general public to the cause of the primary care physician, one uses billboards to pique the interest of the average American?<br /><br />I sure see enough religious propoganda out there... why not pool physician resources to buy up some billboard space?<br /><br />Not that it's possible to explain something as complex as the death of primary care in the modern era in a space the size of a billboard.... but give little tidbits... and of course a website. The approach I think would be most effective would be counter-pointing the stump-phrases used by our politicians to woo voters: "We're for affordable all-you-can-eat healthcare!" That one is a hard one to counter-point on a billboard... but how about something like....<br /><br /><span style="font-size:130%;"><strong>"Increasing medical school class sizes is just going to make more dermatologists."</strong></span><br /><strong><span style="font-size:130%;"></span></strong><br /><strong><span style="font-size:130%;">"Universal healthcare is pointless if all the doctors only want to inject botox."</span></strong><br /><span style="font-size:130%;"><strong></strong></span><br /><span style="font-size:130%;"><strong>"What good are 100 heart doctors when all you need is your sore throat looked at?"</strong></span><br /><strong><span style="font-size:130%;"></span></strong><br />We just need to start somewhere... the ad campaign could even simply be titled: "Why Can't I Find a (Regular/Family) Doctor?"<br /><br />Any thoughts?The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-27822339862853005642008-08-12T12:06:00.001-07:002008-08-12T12:31:52.146-07:00ExpectationsUnder a highly improbable set of circumstances, I briefly became the primary care physician for an elderly relative of a college friend. I tried to limit my exposure to the octogenarians given the breadth of my practice as a Med/Peds physician, but I was honored by the fact that friends thought highly enough of me to want me to take over her care.<br /><br />Even though I loosely knew the patient from long-ago social contacts, the patient-physician relationship that budded was a comfortable one. Yes, she always tried to turn it into a social call when we truly had a few medical issues to discuss, but fortunately, she was wickedly healthy compared to her age-matched peers. She travelled. She read the paper. She exercised. It also helped that my hospital's productivity whip had not yet started to crack. I had a little time to burn with her at her Q6 month visits.<br /><br />Then a tragedy hit the family far from home. This actually touched me emotionally as well -- this person was also a friend. Not surprisingly, some somatic complaints on the part of my patient began to manifest. Appropriate work-up was negative.<br /><br />But almost simultaneous to the tragedy, I escaped primary care. My partner took over graciously. But the transition was not pleasant. Despite 2 visits very generous in time spent with the patient, she would call hours after her visit to complain to our office manager that the physician did not spend enough time with her. She felt rushed. She did not feel that her complaints were being addressed. This, despite the fact that my partner had a 2-page note from each of these "follow-up" visits. The office manager had to talk to her for an hour to calm the anger. The patient was "shocked" that there were "time constraints" on how long she was allowed to carry on her visits.<br /><br />Obviously, grief plays into this. My departure from the office plays into this. But this is an otherwise rational woman who is pissed off that the current system doesn't allow her the time she feels she is due in her hour of need. She is in counselling, but she sees physician-patient time as a critical piece of that... a piece we're not letting her enjoy bite-by-bite over an hour.<br /><br />I have mixed feelings about this. On one hand, I wish the healthcare system were such that a physician could spend more (even if not to the degree this woman wants) time providing lending an ear... having the hand-on-the-shoulder. On the other hand, our government and populace at large has made it clear they have no intention of paying for it.<br /><br />I have a social ability to tell her to chill out... one that I don't with the average elderly patient. But she's not listening to me. I'm now just one of the cold mechanical voices of healthcare to her. And if this is how someone who's a hybrid social contact-patient is reacting to her primary care doctor... can you even imagine what the expectations of the average elderly patient are of their primary care provider? How can we ever win? These are the seeds of litigation.<br /><br />She served to solidify my belief that for the forseeeable future, primary care is screwed.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-29489972816535497892008-08-07T13:35:00.001-07:002008-08-07T13:56:55.123-07:00How To Save Primary CareI was listening to talk radio today when one of the daily shows devoted a full hour to the challenges of rural medicine versus urban medicine. Their guest was a physician who had substantial experience practicing in an area of the United States far more rural than even I would ever have dared tread. <br /><br />For nearly an hour I listened to him field questions about the unique challenges of being in a rural setting, the problem of access to healthcare, the need to expand medical school enrollment to fill this unmet need, and even universal healthcare. The elephant on the radio was just too great for me to bear, and so I did something fairly uncharacteristic and called in.<br /><br />I made it known I was a young physician who had just recently escaped primary care (but did not elaborate -- I was time-crunched). I asked:<br /><br />"Even if we doubled medical school enrollment <em>and</em> found a way to instantly insure 100% of Americans overnight, that doesn't solve the problem of who is going to be seeing these patients and staffing their 'medical home.' How will this ever be solved when medical students are tempted with subspecialist salaries that are 5-6 times what a primary doctor can make, often with better hours?"<br /><br />Predictably, you could tell I'd struck a chord. He said that it was an excellent question, and that something that was going to <em>have</em> to happen would be a "very painful" reduction in subspecialist salaries. I resisted. I did not say another word. He neglected to mention CMS had attempted a modest shift in the RVU values to do just such a thing.<br /><br /><em>Sidenote: Many hospitals in our area (including mine) took cue and reduced their subspecialist salaries. But the primary care guys? Our RVU thresholds were compensatorily increased to completely negate the positive income effect that Medicare intended to happen. How they got away with it is truly beyond me. They literally pocketed the difference.</em><br /><br />What it got me thinking about was this most recent prevention of the 10.6% cuts that nearly went through. (I'm of the mind that it would have been better for the cuts to go through, and truly watch the shit hit the fan, but oh well.) The biggest asset physicians had was the senior population. When patients stood behind physicians, the policymakers got off their asses.<br /><br />It's awfully hard to convince the average American that someone making $170,000 a year deserves more (or at the very least, deserves to spend more time with less patients to make that amount of income). But that's precisely what primary care has to do. Unfortunately, I think the only way to get the general public to care about the relative-bottomfeeders in medicine is by focusing their attention to those being hand-fed olives plucked from the vine in the ivory tower. <br /><br />I don't like the idea of "turning" on our overpaid proceduralist colleagues. But it has been physicians in those very fields sitting on the AMA and other policy-guiding groups who have protected their own turf at the expense of primary care. And it's time for it to stop.<br /><br />Why is it for decades on end residents were allowed to work 40-hour "days" and 120-hour weeks? Because only after the public started getting wind of "medical errors" by "fatigued doctors" was pressure applied to put an end to it. If Joe Blow couldn't care less about medical errors, believe me, residents today would still be risking their lives on the post-call drive home from work.<br /><br />Just because I escaped the cracks of the whips being applied to the backs of primary care doctors doesn't mean I care any less about the state of healthcare in our country. But if we truly expect anything to change, you have to get the public on your side. Just exactly how we do that... I haven't figured that one out yet.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-54398710219744936902008-08-07T08:15:00.000-07:002008-08-07T09:10:20.298-07:00And We Wonder Why Healthcare Costs Skyrocket...It was one of those "Are you serious?" moments. My partners and I were required to carve out an hour and a half of our day (uncompensated, of course) to listen to a consulting firm that our hospital paid to come in to help "charge capture". <br /><br />The situation we're facing is as follows:<br /><br />The Medicare gods made up a term called the DRG (Diagnosis Related Group). The DRG is supposed to group diagnoses based on the severity of illness, and presumably the resources that patient will require. (Read: How much money do you get from the government to take care of this patient.) Depending on what diagnoses I document in my note, the DRG (i.e. cash-flow) changes. In premise, this sounds like a good idea. Sicker people are more expensive, right?<br /><br />I truly am all for good documention. But for the purspose of conveying important information about the patient's condition and plan for their care to all parties of the healthcare team (doctors, nurses, physical therapists, etc.). I am not down with the shell-game. <br /><br />But as most of you realize, "documentation" became less the basis for paying for the patient's care, and more and more the reason to deny payment for the patient's care. <br /><br />So when the Centers for Medicare and Medicaid Services (CMS) decided to increase payment for the higher DRGs and lower the payment for the lower DRGs, hospital's got a fire lit under their asses. They scurried like cockroaches to figure out how to keep as much of this money as possible. How did they approach it?<br /><br />They started paying consultants to tell us how to document "better". We now have a small army of people in white labcoats embroidered with "Documentation Specialist" circling our charts like vultures, fighting for chart-review time. We now get "suggestions" from them about how to make the patient sound sicker than they are. "Pardon me, doctor. 'Urosepsis' doesn't pay any better than 'UTI'. Do you think it would be appropriate to document 'sepsis with UTI'?" <br /><br />Me, "<blink> <blink> Uh.... sure...."<br /><br />How much money are hospitals shelling out in this effort to squeeze more pennies out of Medicare? CMS's efforts to lower what they're paying out makes the entire system more expensive by driving costs up across the board to claim the breadcrumbs. Healthcare systems grow into the income. It's not a simple proposal to ask them to trim the fat, when there isn't any fat in the system (expect, perhaps, proceduralists' salaries).<br /><br />The part of my little "class" I found most incredulous was CMS's own admission that they expect that documentation will get better once they make these mandates. And so to compensate for the fact that people are expected to document better and therefore capture more money? They're going to lower payments.<br /><br />When is our government going to realize that the promises they have made the American people <strong><em>are going to become interminably more expensive</em></strong> year-after-year unless they start telling people "No."? Their ONLY solution has been to simply give hospitals (and therefore the doctors that employ so many of us) less money, and that this will magically make costs contract.<br /><br />It's beyond absurd. CMS seems to have realized they can't simply decree that they're going to pay 10% less for services that are being used more and are more expensive. So what are they going to have to realize they need to do?<br /><br />Ah yes. The evil R word. <strong><em>RATION</em></strong>. It's going to have to happen. It's not a question of if. This WILL happen. The big question is, when Medicare refuses to pay for Procedure X, will hospitals be held liable for medical outcomes of <strong>not<em> </em></strong>performing said procedure?<br /><br />Oh what a tangled web we weave.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com0tag:blogger.com,1999:blog-3974871254551276744.post-5365321145637284362008-08-04T18:50:00.000-07:002008-08-08T21:08:34.672-07:00$100 Down the DrainI'd argue that I received excellent training in residency. But in retrospect, my lack of exposure to the "Medicine Consult," proved quite the deficiency.<br /><br />Prior to receiving my Hospitalist Hat, the only time I ever billed a consultation was in the outpatient setting for pre-op clearance. As a clinic slave, it was an unexpected little treat. I typically got 3.02-3.77 RVUs for relatively-brainless work, compared to the 1.42 RVUs for the 40-minute octogenarian diabetic time-suck. But as an inpatient guy (in a hospitalist program without the resources to do outpatient pre-ops), a "consult" to me now typically means:<br /><br />1. A surgeon who doesn't want to fill out discharge paperwork (the 75-year old with controlled hypertension who has been on a sprinkle of HCTZ for 50 years, but is in for a ureteral stent).<br /><br />2. A subspecialist (still listed on the ACPs website as Board Certified in Internal Medicine) who doesn't want to be bothered with things like diabetes when there are highly billable procedures to be done.<br /><br />3. Either of the above who realizes that they suck at something I can do better.<br /><br />In any event, it really doesn't bother me. Because it's better for the patient. And for a small portion of my day, I get to feel special. "Of course you can't take them to surgery silly. You'll kill them."<br /><br />And even though it's (for the most part) easy work, it's the work no one else wants to do even if they have the know-how. For the most part, internists have been willing to play along. After all, it pays pretty well. Consider:<br /><br />LEVEL 2 ADMISSION = 2.56 LEVEL 3 CONSULTATION = 2.27<br />LEVEL 3 ADMISSION = 3.78 LEVEL 4 CONSULTATION = 3.29<br />LEVEL 5 CONSULTATION = 4.00<br /><br />Now let's say the consult is full-on legit (new-onset CHF). My notes for such a scenario would typically qualify for an H&P III or a Consult III. At our $50/RVU, that equals $189.00 or $200.00. Not an <em>enormous</em> difference... but here's the rub.<br /><br />This Medicare Coding class I just attended has informed me of a new change for 2008 that will start being enforced at some nebulous point between January 1, 2009 and Summer 2009. It's called <strong>Transfer of Care.</strong><br /><br />To illustrate the massive screw-job CMS has crafted for us, Dear Reader, consider the following scenario.<br /><br />An otherwise healthy 56 year old is admitted with chest pain to the cardiology service on January 1st. Their initial troponin was 3, which is why they were not admitted to medicine. But their random glucose is 430, creatinine is 3 and their sodium is 118. Medicine is consulted.<br /><br />The hospitalist dutifully comes to save the day, orders appropriate diagnostic work-up and initiates appropriate treatment. Now, I don't know about most of you, but we typically round on these patients daily. We manage the newly-diagnosed DM, the hypernatremia, and the acute renal failure. Perhaps we will involve other consultants. But we follow them to discharge and reconcile their new medication library. The patient goes home January 7th.<br /><br />A <strong>lot </strong>of people out there bill something as follows (presuming appropriate complexity of care):<br /><br />1/1/08: 99255 (initial inpatient consultation)<br />1/2/08: 99233 (subsequent inpatient care)<br />1/3/08: 99233 (subsequent inpatient care)<br />1/4/08: 99232 (subsequent inpatient care)<br />1/5/08: 99233 (subsequent inpatient care)<br />1/6/08: 99232 (subsequent inpatient care)<br />1/7/08: 99232 (subsequent inpatient care) -- keep in mind, we don't do the discharge here<br /><br />But this would be fraud under the new rules. Because in Medicare's mind, if you are actively managing the medical conditions which you were consulted for, this is considered a <strong>Transfer of Care.</strong> And that means the highest level of care you can bill for your first note is? Are you ready? Can you wait for it?<br /><br /><strong>99233 = 2.0 RVU = $100.00 (in my world)</strong><br /><strong></strong><br /><em>That's right.</em> I almost fell out of my chair. I wouldn't have believed it had my hospital not handsomely paid this consultant service to tell me this.<br /><br />So instead of billing a 99255 (for $192.00), I get $100 for my 99233. Unless I squeak in <strong>prolonged services codes</strong> (which would be hard to justify in most cases), that is all Medicare tells us it's worth to start from scratch with a broken patient and fix them.<br /><br />So how do you preserve the consultation code? You have to document the following:<br /><br />1. That another provider has requested an advice, opinion, recommendation, suggestion, evaluation, direction or counsel concerning the patient problem or treatment options. (Caveat: the consultant is allowed to initiate treatment during the first consult.)<br />2. A report with the advice must be sent by the receiving provider to the requesting provider.<br />3. Make it clear that you are walking away from the patient.<br /><br />The premise here (and it's not entirely without merit) is that the physicians requesting your opinion should be able to handle the diabetes, the hypertension, the pre-renal azotemia, as long as we give them a small refresher course in the form of a consult. They did, after all, go to medical school as well. Some of them are even Board Certified in Internal Medicine.<br /><br />So what is this going to mean? I suspect there will be more snipping between internist and subspecialists. Now, these rules also apply to the subspecialist. But really... who cares about the difference between a daily note and a consult when you're performing your interventional cardiac cath? Or endoscopy? It's but a piss in the wind for those guys. But for some internists (thankfully not our hospitalist group), it's lifeblood. And suddenly the $100 dollars you lost by reclassification of your note as a "Transfer of Care" adds up.<br /><br />I suspected that Medicare would focus some sniperfire on hospitalists before long. I just didn't think it was going to happen with such alacrity.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com1tag:blogger.com,1999:blog-3974871254551276744.post-59792283797669046222008-07-27T10:44:00.000-07:002008-08-04T22:10:00.835-07:00And Off Come the Shackles...I really have no idea if anyone will wind up reading this. Honestly, I don't care. But I've found Medical Blogs to be a catharctic experience in my darkest of days, so if a disillusioned medical student/resident/hospital-employed primary care slave finds some solace in my words... fantastic. The pain of outpatient primary care wasn't something I could find an empathetic ear for. My friends were either not physicians (a good thing, by the way) or free to explore the lucrative subspecialist/shift-work fields in medicine. They weren't stupid enough to whore themselves out to their state for "underserved primary care" work, or to be born into a family that couldn't write a check for their medical education. Bastards.<br /><br />Then I fell into a hospitalist position in a town desperate enough to take my state-owned slave-chains off, and snap on a shiny new pair (owned by the hospital, of course). But I'm okay with it because, presumably, gone are my days of outpatient indentured servitude. Goodbye to the countless hours of uncompensated call. Hasta la pasta to trying to field phonecalls from the ER and floor nurses while perpetually running behind on the always-late 40 patients scheduled in clinic. I don't have to be forced to be a bad doctor anymore.<br /><br />I feel like I've been escorted off the battlefield just as the Medicare airstrike is about to obliterate the remaining stockpiles of food that already malnourish American primary care. Granted, once they've completed their destruction of outpatient medicine, I think they'll focus their full efforts on my new-found refuge. At which point I'm sure our government will put Medicare/Medicaid out of its misery and replace it with something equally inadequate. But whatever.<br /><br />For now, I can spend an appropriate amount of time with my patients, be relatively shielded from the mountains of bullshit paperwork from corporate/government healthcare, get paid a somewhere-close-to-respectable wage for my expertise, and still be allowed to live a chunk of my life off the pager. It only took slightly over a decade of paying my dues to get here.<br /><br />I suppose I see this blog as more of a journal. Am I going to be as happy to be a hospitalist in 3 years? Or will I find other ways to be unhappy? Is it just the nature of being in healthcare? Is it just <em>my</em> nature? Or have I finally found a way to be happy practicing medicine for the foreseeable future? I have no idea.<br /><br />I guess I'm about to find out.The Intoxicologistshttp://www.blogger.com/profile/13752478583846665809noreply@blogger.com5