Archive for the ‘Policy’ Category
Thursday, April 14th, 2011
A Florida lawmaker is attempting to criminalize many aspects of medical care of pain patients, making some Florida pain management specialists and pharmacists at risk of ending up in jail.
Rep. Rob Schenck of Spring Hill, Florida created House Bill 7095.
According to this article in the Miami Herald, Rep. Schenck is proposing stiff penalties for “people who prescribe powerful narcotics like OxyContin, Xanax and Vicodin.” He is also proposing to make it a misdemeanor if pharmacies do not obtain copies of fraudulent prescriptions.
In the article, Rep. Schenck states that he proposed his legislation to save the 7-10 people who die from prescription drug overdoses each day in Florida. You can tell the got a lot of input from practicing medical providers about this well thought out plan.
Section 1 of the bill allows the state to obtain copies of medical records from health providers or pharmacies if the state believes that practitioners or pharmacies are practicing below the standard of care, inappropriately prescribing or dispensing controlled substances, using inappropriate billing codes, or are inappropriately soliciting patients. Doesn’t say how reasonable the state’s belief must be before they can demand the records, only that the state has to have a belief.
Section 4 of the bill, among other things, makes it a third degree felony if a practitioner dispenses samples of any controlled substances without first writing the practitioner’s name, the patient’s name and the date dispensed on the package labeling. See the referenced statue here (.pdf file).
Section 9 of the bill makes it a misdemeanor if any person employed by a pharmacy who knows or should have known that a patient is attempting to obtain controlled substances from the pharmacy through “fraudulent methods or representations” and does not report this “fraud” within 24 hours. The report must contain, “at a minimum,” copies of prescriptions, identifying information on the physician and the patient, and a “narrative” about the transaction, including video or photo surveillance of the transaction if available.
Being able to report drug seekers is one thing. Potentially going to jail if you don’t report them is quite another.
And how many people think that the state will jump into action and run right out to the drug seekers’ homes and arrest them? Bueller? Bueller … ? Bueller ….. ?
Section 18 of the bill basically states that “dispensing practitioners” who have purchased more than an average of 2000 unit doses of controlled substances per month from suppliers are going to be on the state’s hit list. The Department of Health is going to identify those practitioners that pose “the greatest threat to public health” and “coordinate with local and federal law enforcement agencies” to shake down go and place a friendly visit to those practitioners and “quarantine the controlled substance inventory of such dispensing practitioners on site.” Then they’ll seize and destroy any controlled substances they believe are not appropriate.
Florida laws already revoke the license of any physician hit with more than three malpractice judgments.
South Florida also happens to be fourth on the list of Judicial Hellholes in the United States.
Now Florida is taking steps to criminalize medicine and pharmacy.
I think I’ve figured out why I keep getting so many recruiting e-mails that need doctors to work at hospitals in Florida.
Why would anyone want to take a chance on practicing medicine in that state?
[wp_campaign_2]
Posted in Policy | 53 Comments »
Sunday, March 6th, 2011
Kevin MD published an op-ed in USA Today titled “Violence is a symptom of health care dysfunction” which discusses patient frustrations as one source of violence against health care workers. I’ve been busy this week and the comments section is apparently closed on Kevin’s post, so I didn’t get the chance to put my 2 cents in … yet.
The premise of Kevin’s post is that our system is broken and we need to better protect our health care workers. Agreed.
A second premise is that there is a deterioration of the doctor patient relationship. Also agreed.
But Kevin then says that “Patients are rightly frustrated, and some are lashing out.” The way this sentence is phrased almost makes it seem as if it is OK for patients to lash out when they are frustrated.
Kevin ends his op-ed piece by stating that health care providers could use more empathy and that patients need to realize that health care professionals are doing the best they can and should avoid violence.
Again, the impression that I was left with after reading the last couple of paragraphs in the article was that health care providers need to empathize with patients in order to stop the violence.
So I have a couple of thing that I need to set straight.
First of all, it isn’t just patients that are frustrated about the health care system. Providers are just as frustrated about the state of affairs. Patients think they’re frustrated? Take that level of frustration and multiply it times 24 hours a day, 7 days a week. Now put yourself in a position where federal agencies are micromanaging you, where the people you are trying to help have the potential to wig out and injure you, where your payments are being decreased, where your liability is being increased, and where you often work way more than 40 hours per week. Welcome to medicine. Not only do we have your frustrations, but we also have a plethora of other frustrations on top of that.
Second, some of the patients commented in Kevin’s op-ed about wishing they had an old-school doctor patient relationship. If you’re expecting a Marcus Welby experience in the emergency department, it isn’t going to happen. Most of the time is you show the staff a little respect, chances are good that you’ll get respect in return. Not all the time, mind you. Everyone has a bad day, so you might not have the warm fuzzies after every emergency department visit. However, if you come across as a foul-mouthed, demanding, bad attitude wretch, I can almost guarantee you that you will be treated as a foul-mouthed, demanding bad attitude wretch.
But I also have some good news. If you want a Marcus Welby relationship with your physician, you can have one. Find a doctor you like and actually stick with the doctor. Stop playing hopscotch with your doctors every year when your health plan changes and then complaining when the new doctor you see once or twice (before you change doctors the following year) hasn’t committed your complete medical history to memory. Yes, I know that doctors move and that residents graduate, so patients aren’t always at fault. But I see a whole lot more of the former scenario than I do of the latter scenario.
I don’t care if patients are “rightly frustrated” about the health care system. Never should society accept violence against another person as an outlet for those frustrations. It isn’t OK to punch a police officer because you’re “rightly frustrated” about your speeding ticket. It isn’t OK to threaten a judge because you’re “rightly frustrated” with his ruling. I’ll bet that even hospital administrators would agree that it isn’t OK to stab them with a knife if you’re “rightly frustrated” about the way that they are running a hospital. Violence can never be an acceptable outlet for frustrations.
Kevin has become a prolific medical blogger because his opinions are consistently well-grounded and well thought out. I agree with his position 99+% of the time which makes me think that the way he phrased some of the statements in his op-ed piece did not express his true intent and created an unintended picture in the minds of many readers, including me.
The fact that so many health care organizations and so many health care providers tacitly accept violence against health care workers as an outlet for patient frustrations just shows how low our health care system has sunk.
Even Marcus Welby couldn’t fix that.
Posted in Policy, Random Thoughts | 12 Comments »
Thursday, February 24th, 2011
 I wrote the story below before all of the Wisconsin issues popped up, but the “doctor fraud” scandal segues nicely with the issues in the patient encounter I wrote about.
Kevin, MD had a post yesterday linking to an article in The Atlantic about how physicians in Wisconsin were standing on street corners and writing work excuses for protesting teachers. Videos in the Atlantic article showed the the doctors were writing notes for “stress” based solely on a patient’s history without performing physical examinations. The Atlantic article questions the physicians’ integrity and states that the “profession of medicine has a black eye in this case.”
The author of the Atlantic article is a physician who also writes on health care policy. He calls doctor’s work notes “an employer’s desire to verify through a respected, independent, medically qualified third party the fact of an illness and the true need for convalescence.” I respectfully disagree.
In many of the cases that I see from my practice and those discussed with me regarding other physicians’ private practices, doctor’s work notes have become little more than a legal CYA document for employers and a hoop that employees have to jump through in order to take time off of work.
Can people with a cold go to work? Sure. But if everyone else at work gets sick, then the employer complains to the hospital about why the employee was allowed to return to work. If the employee is given a note not to return to work until symptoms resolve, then the employer complains to the hospital that the doctors are giving the patients too long off of work.
If doctors write for prescription medications for a work injury, or write a patient off of work for more than one day, then employers complain because the care the patient received makes the injury reportable to OSHA.
Employers also put physicians in an ethical bind when they require a doctor’s note for patients who took off time for an illness and are then feeling better and want to go back to work. I can write a note stating that patients are cleared to go back to work, but then patients return and state that the employer needs a doctor to certify that the patients needed to be off of work for the prior “illness” which is now gone and for which the patient never sought medical care.
Commenters to Kevin’s article stated that the doctors were creating inappropriate “legal documents,” were being unethical and were “disgracing the medical profession.”
I think that these statements smack of hypocrisy. Physicians in private practice are monetarily pressured to keep patients happy by doing what the patients want. Hospital based physicians are pressured by the hospitals and by Press Ganey’s patient satisfaction scores to provide sometimes inappropriate care to patients to make the patients happy. In case you had any doubts, refusing to write a note required by a patient’s employer will not make the patients happy. Here’s another example of a patient upset at not getting a 9 month work note from Serenity Now Hospital.
If a physician writes a note off work for a patient because that patient had vomiting “last week” and can’t go back to work without a doctor’s excuse, I don’t think that “legal document” is any less fraudulent than the notes being written on Wisconsin street corners. Yet there is a public outcry in one instance and the other instance is considered “business as usual.”
Just like in medicine, employers are going to get what they pay for. If you require a doctor’s note for an employee to return to work, patients will always be able to find a physician to write them a “note” for work. A work note doesn’t necessarily mean that the employees were really sick. Sometimes it only means that some physicians bow to societal pressures more than others.
The fact that physicians have to be put in that position gives society just as big of a “black eye” as the physicians.
####################################
A patient comes into the emergency department with a harsh cough for several days. Little bit of a runny nose. No fever. Might be influenza, might be some other upper respiratory tract virus. Upset over not getting antibiotics. Given some cough medication and discharged.
Then comes the money question: “What about work?”
“What do you mean?”
“Aren’t I contagious?”
“Probably. But you could technically be contagious for another week or two. Do you think you need to stay off of work that long because you have a cough?”
Wrong thing to say.
“I work around people, though.”
“If you cover your mouth when you cough and you wash your hands regularly, you shouldn’t have a problem.”
“I work in a fast food restaurant, so I’m around food that customers will eat.”
“So you can’t avoid coughing on their food? I guess you could wear a mask … you know what, sir … what else is there that you need for me to do for you today?”
“I need a note for work. My boss won’t let me back until I’m not contagious.”
“I can’t predict when you won’t be contagious any more.”
“Before, you said it could be up to two weeks.”
“So you want a note for two weeks off of work because you have a cold?”
“My boss won’t let me work if I’m contagious. What if I get other people sick?”
This ended up being another one of those no-win situations. If I say “I’m not giving you a work note for your cough,” then the person goes and gets people sick at work and the business complains to the hospital administration. Don’t roll your eyes, it’s happened before. If I write a note like the patient wants, then I look like a dimwit for giving someone off of work for a cold … and the employer complains to administration because the patient was given an extended absence.
So I wrote the following note:
This patient is suffering from a viral upper respiratory infection. This disease can last for up to several weeks and can be spread from one person to another by direct inhalation of viral particles or by coming into contact with contaminated surfaces, including hands. The spread of disease can be reduced by covering one’s mouth when coughing, by washing hands frequently, and by wearing a mask. You, the employer should consider these factors in deciding whether this patient is able to continue working at your facility.
What would you do?
Posted in Medical-Legal, News Commentary, Patient Encounters, Policy | 36 Comments »
Wednesday, February 16th, 2011
I had a whole story ready to post about another very sick child that we treated, but decided to leave a more general issue instead.
When there are critically ill patients, the staff has to think quickly and act quickly. Interruptions are counterproductive to our job during those times. Think about trying to concentrate on something – whether it be driving and trying to find a street address, talking on the phone, or trying to figure out a crossword puzzle – and being interrupted by your kids. The interruptions knock you off track from the task at hand.
There was a 6 month old who was critically ill in our department. With children, tasks such as starting IVs and intubating them are more difficult, and you also need to check the dosages of medications that they’re being given since pretty much all medications for children are weight-based. All the medical providers really need to focus.
So how do we manage a situation in which the parents are interrupting the care of their infant child?
I understand that seeing all of these things happen to your child is a scary experience. I understand that parents want to be there with their sick children. I’m a parent. I’ve seen it with my children.
Should the physician trying to save a child’s life stop what he or she is doing to explain to the parents what is happening – which may affect the survival of the child – or should the physician get done what needs to be done and talk to the parents later?
Some parents are very good about staying out of the way and just watching what is happening. But some parents will push you out of the way to stand next to the child, holding the child’s arm and caressing the child’s head when you really need access to the arm and the head.
If the family’s expectations are not met while you’re trying to save the child’s life – whether it is because you didn’t answer questions to the family’s satisfaction, whether you asked them to do something they didn’t want to do, or whether you said something to the staff that the family took the wrong way, then you may find yourself at the end of a complaint to hospital administration.
If you everything necessary to meet the family’s expectations, but doing so causes delays in caring for the child and the child suffers a bad outcome, then you may find yourself at the end of a malpractice lawsuit.
I know that some people will suggest “meeting in the middle.” That is fine and usually works well in most situations.
However, there are times when “meeting in the middle” doesn’t work, and those times may cost a child his or her life.
Should we excuse all family members from the room during critical care moments to decrease the likelihood of medical errors related to interruptions?
If we’re talking about “patient safety issues,” situations like this occur a lot more frequently than some of the other things that JCAHO tries to regulate.
Does JCAHO need to regulate family visitation?
Posted in Joint Commission, Policy | 29 Comments »
Sunday, February 6th, 2011
 Do parents have a “right” to videotape doctors and hospital staff while they deliver their babies in the hospital?
Many hospital delivery rooms are banning cameras or recording devices due to threat of medical malpractice and “litigious atmosphere.”
Judges do it. Try walking into a courtroom with a video camera and videotaping a judge doing his or her job. Your camera would get confiscated before you got through the entryway to the court house. Judges even have immunity from prosecution for negligent actions while on the bench. Doesn’t matter. Can’t videotape them.
Police do it. In some states, it is illegal to videotape a police officer. One Maryland citizen is facing 16 years in prison for videotaping a state trooper that pulled him over for speeding.
Why is there a “stir” if doctors want to do it?
Another story about the issue from the LA Times is here. Money quote in the Times article: “The sue-happy mentality undermining quality medicine, and discouraging quality health care professionals, is a fundamental part of our broken health care system that must be fixed.”
See also this article in the Seattle Times.
Personally, I wouldn’t care if a patient wanted to videotape me and our interaction … as long as I got a copy of the video as well. I don’t have anything to hide. However, I also think society has to respect the wishes of people who don’t wish to be videotaped.
If patients want to make it a “right” to videotape doctors and hospital staff taking care of them or their family members without the staff’s consent, shouldn’t it also be a “right” for doctors or hospital staff to videotape patients without their consent?
Be careful what you ask for …
Posted in Medical-Legal, Policy, Random Thoughts | 38 Comments »
Wednesday, January 12th, 2011
Not sure how I feel about this.
Boston Emergency Medical Services debuts an ambulance with a mini-crane and reinforced stretcher to transport patients weighing up to 850 pounds. It cost $12,000 to retrofit the ambulance.
My problem is this: I think we need to do our best to provide medical care to all patients. But patients need to take some basal level of responsibility for their own health. If you’re saying that you got to be 850 pounds due to a “glandular problem,” you’re blowing smoke. See this post (hat tip to MDOD) and then come talk to me.
Let’s say you want to go hiking in some secluded location or you want to go spelunking far beneath the surface of the earth. When you take those risks, you implicitly accept the chance that if something happens to you, there’s not going to be an acute care clinic at the 3,000 foot mark on the mountain you want to climb. If you get hurt, you aren’t going to have access to the medical care that might otherwise be available to you. You may take your cell phone with you and may make arrangements for air medical transport if needed, but even with those precautions, you just might die from your injuries based solely on the risks you took – and no one is to blame but you.
If alcoholic patients drink to the point that they develop liver failure and then they continue drinking alcohol, most hospitals will not perform liver transplants. You got yourself into that situation, you refuse to help yourself get out of that situation, the system isn’t going to invest massive amounts of resources into your care – and no one is to blame but you.
Should people who eat themselves to death be treated any differently?
Should it ever be right to tell patients that if they let themselves get so obese that traditional ambulances can’t carry them that dispatchers will tell refuse transport and they will be responsible for their own transportation to the hospital?
If we continue down the road that we must accommodate the medical needs of every morbidly obese patient, are we then going to require that all hospitals purchase CT scanners and MRI scanners to accommodate patients of all weights – if those scanners even exist? Will every hospital be required to maintain an additional set of beds, commodes, bathroom fixtures, blood pressure cuffs, and a plethora of other utilities solely to treat morbidly obese patients.
Or perhaps we create regional system of care for morbidly obese patients. One regional hospital gets all the necessary equipment to manage the medical needs of morbidly obese patients and any morbidly obese patient requiring testing or admission must be transported to one of these centers. Hospitals can transfer trauma patients if they don’t have a trauma surgeon, shouldn’t they also be able to transfer bariatric patients if they don’t have a bariatric specialist?
This post is not meant as an attack on morbidly obese people, but more intended as a reality check. What should be a rational method of dealing with morbidly obese patients? If we require EMS and hospitals to make all these expensive modifications for morbidly obese patients, where do the accommodations end for other patients with other medical conditions needing costly medical care?
And how long is it going to be before the Law Firm of Dewey, Cheatem, and Howe files a claim against a hospital when a patient dies because the hospital didn’t have those modifications?
Posted in Access to Care, Policy | 57 Comments »
Saturday, January 8th, 2011
There are a lot of bonehead stories about the Joint Commission in the news lately. I just had to post this one.
CMS and JCAHO are now investigating Lehigh Valley Hospital in Pennsylvania for using stun guns on unruly patients.
In one instance, a patient was using an IV pole as a pugil stick before security guards used a TASER to put him to the ground. In two other instances, patients were beating on security guards when they were “tazed.”
Protecting yourself is apparently a “violation of state and federal health rules.” As a result of the stun gun incidents, the hospital was ordered to retrain certain staffers in responding to behavioral emergencies. Security and emergency department staff had to be trained in comprehensive crisis management. The hospitals also had to establish a task force to track “incidents” and ensure that staffers had used the “least restrictive measures” when restraining a patient.
When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area.
Wouldn’t it be … interesting … to watch an “unruly patient” attack a CMS investigator and then watch hospital staff utilize mandatory CMS protocols to intervene?
Sir. SIR! How about you stop disarticulating that man’s elbow. Really now. Would you like some juice instead? We have apple, grape, and cranberry. Maybe some nice Saltines and peanut butter? No? Hey! Now if you don’t stop poking your fingers in that man’s eyes, we’re going to have to bring you to a secluded area. I’m not kidding, Mister. And you, Mr. Investigator – stop trying to fend off his attack with your clipboard. Don’t you know the patient could injure his knuckles if he hits that clipboard instead of your face? OK, Mister. I see the Investigator’s blood dripping all over the place. Someone might slip and get hurt. You are officially creating a patient safety hazard. NOW you’re getting CITED! SECURITY!
That should calm those unruly patients.
Posted in Joint Commission, Medicare, Policy | 6 Comments »
Wednesday, December 29th, 2010
 “Severe pain can trigger suicide in hospital ERs” the headline reads. If they’re still calling it an “ER” you already know they’re clueless.
The article at the National Library of Medicine cites a new “Sentinel Event Alert” from the Joint Commission (.pdf download) urging emergency departments to be on the lookout for patients who may commit suicide in the Emergency Department.
Since 1995, there have been 827 reports of patient suicides in the United States. Of those, about 14% are in non-behavioral health units, making a total of about 116 non-psychiatric inpatient suicides in 15 years. That’s about 8 inpatient suicides per year out of 198 million inpatient days per year (644 inpatient days per 1000 population in US x 307 million US population) for a total chance of an inpatient committing suicide on any given day of … 1 in 24.75 million. Now I admit that the numbers may be off by one in a couple million or so because reporting suicides is voluntary for hospitals, so not all suicides get reported.
The Joint Commission also breaks down the number of suicides reported in the emergency department since 2005 — 8% of 827 reports or about 66 patients. In 15 years in all the emergency department in the country, 66 people killed themselves. That adds up to about 4 patients per year. Let’s round up to 5 patients per year who kill themselves in emergency departments. During that same time period, the number of emergency department visits per year averaged 100 million. Latest statistics show that we’re up to about 117 million emergency department patient visits per year. So the number of suicides committed per patient visit in the emergency department is about … 1 in 25 million – give or take a few million.
Now the Joint Commission’s “Sentinel Event Alert” wants hospitals to take a bunch of additional affirmative steps to make sure that even less than 1 in 25 million patients commits suicide.
Hospital staff is more likely to buy a winning lottery ticket than they are to find an inpatient who will commit suicide on any given day. Yet not only are hospital staff required to keep a close look-out for suicidal patients, but they and/or the hospitals will be held responsible for a “never event” if an inpatient actually does commit suicide.
You want an example of how people expect medicine in the United States to be “perfect”? Here it is.
I’m sure that all of the JCAHO minions are furiously typing out a counterargument that “WhiteCoat is a cold heartless person. He doesn’t care about trying to save people who might commit suicide.” Yeah, well cool your keyboards. Maybe we can ask a patient if they’re depressed or suicidal. Give them a number to follow up with a counselor. I might agree to that.
But JCAHO and our government have a page and a half long list of “recommendations” that medical providers are supposed to follow in order to prevent suicide – include “doing suicide screenings in the ER, screening all patients for depression when they’re admitted to a hospital, checking anyone deemed to be at risk for items they could use to harm themselves, and encouraging staff to call a mental health professional to evaluate patients believed to be at risk.” I uploaded the alert to EP Monthly’s site here in case JCAHO decides to take it down or the link goes dead.
Let’s say that we implement all of JCAHO’s recommendations – just in the emergency department. Not only do we need to perform all the screening, we also need to DOCUMENT that we perform all the screening because when the clipboard brigade comes knocking for an audit, you better be able to prove that you actually did the screening that they “recommend.” Conservatively, let’s say that such screening and documentation takes 10 minutes. Multiply that by 117 million patient visits. If every emergency department in the country implements JCAHO’s recommendations, emergency department staff will spend an extra 2o million hours each year looking for a needle that is in a haystack the size of Texas (which just happens to have a population of 25 million).
Those screening and documentation procedures add up to 20 million hours less patient care. That’s 20 million hours that won’t be available to treat patients waiting in the waiting rooms. Twenty million less hours to dispense medications, discharge patients, and monitor critically ill patients. More than 100 million extra pieces of paper to document adherence. And those numbers don’t even count all the extra time spent doing additional screening and documentation when the patient make it to the medical floors.
What’s the cost to the system? If we assume that emergency department nurses make $35/hour, those 20 million hours add up to $700 million per year … to screen for a problem that occurs 5 times per year. Then add in the cost of the paper and of all the supervisors who then have to go through the charts to make sure that the documentation is present (and properly completed) and the time cost throughout the country easily surpasses $1 billion. Well, if only half the hospitals in the US implement the recommendations, the cost is only a measly $500 million.
These safety recommendations were created by the government’s Patient Safety Advisory Group, a group that was chaired by an astronaut named James Bagian and co-chaired by a pharmacist named Michael Cohen. Now you have another example of what happens when non-clinicians create policy for those of us in clinical practice.
But at least patients are safer …. right?
Posted in Joint Commission, Policy | 33 Comments »
Friday, August 13th, 2010
 A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth.
Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics.
Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government.
The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession.
Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons), homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents.
In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007.
Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program.
With the increase in visits, there are longer waits and less availability of medical care.
Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years.
The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures.
Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what?
I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.
Posted in Access to Care, Medicare, Policy | 26 Comments »
Monday, July 26th, 2010
Socialized health care is great, and it’s a money saver, too. That’s why England is looking to decentralize it.
The health care budget in Great Britain has tripled in the past 13 years and the budget needs to stabilize.
According to the manifesto titled “Equity and excellence: Liberating the NHS” which was presented to the Parliament, England is planning to change the way in which health care is being delivered.
They’re planning to abolish primary care trusts, which currently make decisions about who gets what health care. They want to increase the choices available to patients. In fact, the plan sets out by stating that “Patients will be in charge of making decisions about their care.” “Shared decision-making will become the norm: no decision about me without me.” Patients will also be able to rate the quality of care provided at hospitals and clinical departments so that other patients can make an informed decision whether to go to those facilities.
Government micromanagement will also decrease. In fact, the document’s Executive Summary specifically states “The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.”
The Health System will only evaluate clinically credible and evidence-based outcome measures, not process targets. “We will remove targets with no clinical justification.” Does that mean that they won’t have to play medical Bozo Buckets in England?
Providers will also be paid based on outcomes and performance.
So far, sounds like a lot of changes heading in the direction of free market medicine.
The plan would also both increase payments to … and increase involvement of … primary care providers.
And there’s a lot of feel good discussion of how the plan will increase quality of care and efficiency of care – all while reigning in costs.
One of the experts in the Times article highlighted a problem with the plan “The real mistake [is creating a plan] motivated by the principle of efficiency savings. History shows clearly that quality will suffer as a consequence.” Goes back to that whole principle about “Fast care, free care, quality care. Pick any two.” It appears that British patients may be faced with a decision whether they want to pay more money for better quality.
But I still have to credit Great Britain for this new plan, because I think there are a lot of good ideas here.
Posted in Health care reform, Medicare, News Commentary, Policy | 6 Comments »
|
|
Doctor’s Work Notes and Medical Ethics
Thursday, February 24th, 2011Kevin, MD had a post yesterday linking to an article in The Atlantic about how physicians in Wisconsin were standing on street corners and writing work excuses for protesting teachers. Videos in the Atlantic article showed the the doctors were writing notes for “stress” based solely on a patient’s history without performing physical examinations. The Atlantic article questions the physicians’ integrity and states that the “profession of medicine has a black eye in this case.”
The author of the Atlantic article is a physician who also writes on health care policy. He calls doctor’s work notes “an employer’s desire to verify through a respected, independent, medically qualified third party the fact of an illness and the true need for convalescence.” I respectfully disagree.
In many of the cases that I see from my practice and those discussed with me regarding other physicians’ private practices, doctor’s work notes have become little more than a legal CYA document for employers and a hoop that employees have to jump through in order to take time off of work.
Can people with a cold go to work? Sure. But if everyone else at work gets sick, then the employer complains to the hospital about why the employee was allowed to return to work. If the employee is given a note not to return to work until symptoms resolve, then the employer complains to the hospital that the doctors are giving the patients too long off of work.
If doctors write for prescription medications for a work injury, or write a patient off of work for more than one day, then employers complain because the care the patient received makes the injury reportable to OSHA.
Employers also put physicians in an ethical bind when they require a doctor’s note for patients who took off time for an illness and are then feeling better and want to go back to work. I can write a note stating that patients are cleared to go back to work, but then patients return and state that the employer needs a doctor to certify that the patients needed to be off of work for the prior “illness” which is now gone and for which the patient never sought medical care.
Commenters to Kevin’s article stated that the doctors were creating inappropriate “legal documents,” were being unethical and were “disgracing the medical profession.”
I think that these statements smack of hypocrisy. Physicians in private practice are monetarily pressured to keep patients happy by doing what the patients want. Hospital based physicians are pressured by the hospitals and by Press Ganey’s patient satisfaction scores to provide sometimes inappropriate care to patients to make the patients happy. In case you had any doubts, refusing to write a note required by a patient’s employer will not make the patients happy. Here’s another example of a patient upset at not getting a 9 month work note from Serenity Now Hospital.
If a physician writes a note off work for a patient because that patient had vomiting “last week” and can’t go back to work without a doctor’s excuse, I don’t think that “legal document” is any less fraudulent than the notes being written on Wisconsin street corners. Yet there is a public outcry in one instance and the other instance is considered “business as usual.”
Just like in medicine, employers are going to get what they pay for. If you require a doctor’s note for an employee to return to work, patients will always be able to find a physician to write them a “note” for work. A work note doesn’t necessarily mean that the employees were really sick. Sometimes it only means that some physicians bow to societal pressures more than others.
The fact that physicians have to be put in that position gives society just as big of a “black eye” as the physicians.
####################################
A patient comes into the emergency department with a harsh cough for several days. Little bit of a runny nose. No fever. Might be influenza, might be some other upper respiratory tract virus. Upset over not getting antibiotics. Given some cough medication and discharged.
Then comes the money question: “What about work?”
“What do you mean?”
“Aren’t I contagious?”
“Probably. But you could technically be contagious for another week or two. Do you think you need to stay off of work that long because you have a cough?”
Wrong thing to say.
“I work around people, though.”
“If you cover your mouth when you cough and you wash your hands regularly, you shouldn’t have a problem.”
“I work in a fast food restaurant, so I’m around food that customers will eat.”
“So you can’t avoid coughing on their food? I guess you could wear a mask … you know what, sir … what else is there that you need for me to do for you today?”
“I need a note for work. My boss won’t let me back until I’m not contagious.”
“I can’t predict when you won’t be contagious any more.”
“Before, you said it could be up to two weeks.”
“So you want a note for two weeks off of work because you have a cold?”
“My boss won’t let me work if I’m contagious. What if I get other people sick?”
This ended up being another one of those no-win situations. If I say “I’m not giving you a work note for your cough,” then the person goes and gets people sick at work and the business complains to the hospital administration. Don’t roll your eyes, it’s happened before. If I write a note like the patient wants, then I look like a dimwit for giving someone off of work for a cold … and the employer complains to administration because the patient was given an extended absence.
So I wrote the following note:
What would you do?
Posted in Medical-Legal, News Commentary, Patient Encounters, Policy | 36 Comments »