Rationing

 Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Do you recall the severe rationing of food and water the Chilean miners had to endure to survive?   The rationing was done to stretch their limited resources.

I would argue the state of Arizona’s new policy to not cover organ transplants for patients on Arizona Health Care Cost Containment System (AHCCCS) or their version of Medicaid is a similar form of rationing.

AHCCCS, as many Medicaid programs, is underfunded.  They are trying to operate on a limited budget.  Something has to give.

Sadly in this case, many (NPR reports 98) had already been granted approval for organ transplants which they may not receive.  Francisco Felix, 32, who due to Hepatitis C needs a liver transplant, is reported to have made it to the operating room, prepped and ready for his life-saving liver transplant when doctors told him the state's Medicaid plan wouldn't cover the procedure.  The liver he was to receive went to someone else.

In this prolonged economic downturn, I wonder how many parents have had to tell their children who were accepted into their dream college they will not be able to go, the family income has changed and it is no longer affordable?

In a perfect world, everyone would have health insurance.  Health insurance companies (private, state, and federal) would have unlimited resources so that all “evidence-based” medically necessary care/procedures/medications would be covered.

Hell, in a perfect world, we wouldn’t need health care.

It isn’t a perfect world.  There are limited resources.  Tough decisions must be made in doing the most with the available resources.

Is this the sort of rationing of medical care we will be seeing more of in the future?

I Need to Reschedule You

Over the past 20 years, there have been very few times I have asked patients to reschedule.  Even though I tell patients they have nothing to apologize for when they then to cancel, I always apologize.   This is especially true when it comes to asking them to reschedule surgery.

Yes, I know you have asked for time of work.  Yes, I know you have arranged for someone to help care for you, for your children, etc.  Yes, I realize you may have airline tickets to come into town to stay with family here while recovering.

Yes, I keep all that in mind, so if I ask you to reschedule it truly will be a handful of good reasons:

I am sick or need surgery myself.  I had to ask a patient to reschedule her breast reduction early in my solo career.  I had an acute herniated disc (C6-C7) which left me with numbness in my left  index and long fingers and loss of triceps function, not to mention the pain.  I had to explain to her that it was not safe for me to do her surgery until after my own.  [She did reschedule.]

A family member is sick or dying.   I had to ask a patient last May to reschedule after my mother had her stroke during her CABA.  After we made the decision to AND (allow natural death), we did not know how long it would be.  I did not want to be in surgery when it happened.  I thought it was reasonable.  [She never rescheduled.]

I have a funeral to attend.  I have not canceled or rescheduled a surgery for this (yet), but have rescheduled a few office visits.  As I and my friends get older, I can see this happening more frequently in the future.  I will try to be considerate of both my friend/family and my patients.

Usually, when I ask a patient to reschedule it will be a last minute thing.  I regret this, but as you can see from the reasons I allow myself to make this request it will always be last minute.  Some things are tough to plan.

Believe me when I say I am sorry to have to ask you to reschedule.  I truly mean it.

Team Work

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

There’s an article in the Oct 20, 2010 issue of the Journal of the American Medical Association (JAMA) which discusses surgical team training and team work in the operating room.

Most surgeons have crews or individuals in the operating rooms they prefer to work along side.  Things just go smoother.  We work more as a team, more as one.

Why?  Personalities.  Communication styles that work well together.  Skills that compliment.  Each person knows and does their job, not trying to do someone else’s.  Each knowing that even the smallest task is important to the whole.

Ideally, we could create teams like this at all times in the operating room.  In reality, its not so easy.  Change in personnel happens.  Team members get sick, so there is great need for cross-training and flexibility.  Personnel (including surgeons) need to be able to work with these changes.

I know currently the comparison is to racecar teams that change the tires, etc with great efficiency or the aviation industry with their check lists.  While we should learn from these industries, we must not forget that medicine is far more diverse. 

Surgeries are not all the same.  The cars are.

Ask your personnel.  I know OR nurses and scrub techs who detest certain surgeries and try very hard not to be in those rooms.  Some like eye surgeries.  Some like orthopedics.  Some like the laparoscopic cases.  Others do not.  Others even after doing similar cases with you multiple times, never seem to pay enough attention to be able to “anticipate” what comes next.

The really good OR nurses and scrub techs will put aside their distaste for the procedure (or surgeon) and function within the team framework.  Others will let their boredom distract them.

In the racecar industry, the guys changing the tires are thrilled to be there.  Thrilled to be part of it all. 

We should strive to work as a team.  We should each learn our job and give it our best.  Like all teams, there have to be second and possibly third strings for backup when a team member is absent (personal sickness, family illness, jury duty, etc). 

The study’s lead author Dr. James Bagian is a former NASA astronaut.  The VA training took a page from the aviation and the nuclear power industries, which have used checklists and improved communication to reduce risks.  The adoption of surgical team training saw a mortality rates drop from 17 deaths per 1,000 cases to 14 deaths per 1,000 cases.

The Medical Team Training program includes 2 months of preparation and planning with each facility's implementation surgical care team. This is followed by a day-long onsite learning session. To allow surgical staff to attend as a team (surgeons, anesthesiologists, nurse anesthetists, nurses, and technicians), the operating room (OR) is closed.

Using the crew resource management theory from aviation adapted for health care, clinicians were trained to work as a team; challenge each other when they identify safety risks; conduct checklist-guided preoperative briefings and postoperative debriefings; and implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation, and how to conduct effective communication between clinicians during care transitions.

The learning session included lecture, group interaction, and videos. After the learning session, 4 quarterly follow-up structured telephone interviews were conducted with the team for 1 year to support, coach, and assess the Medical Team Training implementation. Follow-up calls were usually conducted with the OR nurse manager or an OR nurse, a surgeon or chief of surgery, and other staff nurses, and administrative support staff also frequently participated.

. 

REFERENCE

Association Between Implementation of a Medical Team Training Program and Surgical Mortality; Julia Neily; Peter D. Mills; Yinong Young-Xu; Brian T. Carney; Priscilla West; David H. Berger; Lisa M. Mazzia; Douglas E. Paull; James P. Bagian; JAMA. 2010;304(15):1693-1700.; doi:10.1001/jama.2010.1506

Improving Teamwork to Reduce Surgical Mortality; Peter J. Pronovost, MD, PhD; Julie A. Freischlag, MD; JAMA. 2010;304(15):1721-1722. doi:10.1001/jama.2010.1542

Will My Opt-Out Status Affect You?

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I opted out of Medicare several years ago.  This means I don’t see Medicare patients other than in the emergency room when I’m on unassigned call.   I don’t submit bills to Medicare or to those patients.  I just let it slide.

Last Wednesday, I received the following letter from a large radiology group in my home town:

September 2010
RE:  PECOS Enrollment
To our referring physicians and their office managers:

At __________we have begun a project to identify ordering physicians who are not enrolled in Medicare’s Provider Enrollment, Chain and Ownership System (PECOS).  Our purpose is to remind physicians of the importance of enrollment to them and to us.

Beginning in January, 2011 those providers filing Medicare claims listing an NPI number on the claim of an unenrolled provider will have their claims denied.  This would apply to any claim you send in and to any claim we submit for services provided to your patients because we are required to list your NPI number on our claims.  This applies both to patients referred to our private offices and the hospitals where we provide radiology professional interpretations or services.

So, you can see our effort is not purely altruistic.  We have a financial interest in reminding you of the importance of PECOS enrollment.  In trying to ascertain whether you are enrolled, we are using an online program you can find at www.oandp.com/pecos.  Simply enter your NPI number in the entry block and press enter.  If you enter a valid NPI number, your name will appear and beside it will be a symbol indicating where Medicare recognizes your PECOS enrollment.

Since Medicare is continually updating the files, we may have accessed the system before your enrollment was completed.  We will continue to monitor the situation in hopes you will enroll if you intend to continue seeing Medicare patients.  If you have already enrolled or have no plans to enroll, please excuse our intrusion.

Sincerely,

This bothers me.  It is not likely that I will be sending them any patients from my office, but that doesn’t mean there won’t be the occasional patient with my name on their chart in the ER.  IF I need to take a Medicare patient to the operating room from the ER, will the hospital not get paid?  Will the anesthesiologist not get paid?

Will my non-participation in Medicare affect my fellow healthcare providers receiving payment?  If so, that is just not right.  I voiced this concern to Senator Blanche Lincoln shortly after receiving this letter.  She agrees with me.

This radiology group is usually correct in their policy interpretations, but I still went searching for more information.  I found this summary:  What You Need to Know about Enrolling and Ordering/Referring in the Medicare Program.  It includes this

Physicians who have validly opted out of Medicare will not need to complete a Medicare enrollment application.

Still, I am not reassured.   The policy doesn’t seem to take into account that I may through unassigned ER call see the occasional Medicare patient.  The policy seems to “assume” that since I opted-out, I never see any Medicare patients.  If this were the case, I would never affect my fellow physicians/hospitals payment.  I’m left wondering if I will affect their payments for that occasional patient I see through the unassigned ER route.

I will tell you that I have gone to the NPI site and reviewed my information.  I have gone to the Medicare (PECOS) site and attempted to registered my information.  I will not be re-enrolling as a Medicare provider at this point in time.  

Insurance Premium Increase

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Physicians aren’t exempt from the struggles with personal health insurance coverage, affordability, denied coverage, etc.   When I finished my training and opened my practice 20 years ago I had to buy individual coverage.   All options included a rider that excluded coverage on my uterus and ovaries due to fibroid surgery during training.  So when I had my TAH & BSO a few years later, the entire cost came out of my pocket.  Fortunately, I knew how to ask for cost reductions, but still…

My husband and I are both small business individuals.   I have always carried our health insurance under my name (office).  Over the years we have gone to a health savings account with a high deductible to keep the cost reasonable.  Fortunately, we have been mostly healthy.

Last month, we received a letter from Assurant Health telling us of a policy change that includes a $75 ER visit charge.  I thought this might be their way of avoiding a policy increase, but no.  Last week I received the notice regarding an increase to our policy.  Currently, our premium is $619.76 per month plus a mandatory $100 deposit into the HSA each month. 

The notice included the “good news”  -- “Congratulation!  You’re a Healthy Discount candidate.”  To determine your eligibility for the Healthy Discount, follow these simply instructions:  1.  Answer all six questions below.  Please consider the last 12 month when answering these questions……”

• Been recommended or scheduled for surgery that has not been complete?
• Been recommended to have or is anyone contemplating infertility treatment or been treated for infertility?
• Received or been recommended to have any treatment for alcoholism, alcohol or drug abuse or addiction or mental or nervous conditions?
• Been cited for operating a moving vehicle under the influence of alcohol or drugs?
• Received a diagnosis for any serious medical condition such as heart disease, stroke, cancer, diabetes, HIV, AIDS, or any other progressive disabling condition?
• Been incapacitated or hospitalized due to an accident or illness?

The “good news” is that since we can answer no to all six of those questions, our new premium will be $761.71 per month rather than $842.87 per month.  The mandatory $100 deposit into our HSA remains the same.
A simple 23% increase rather than a 36% increase. 

Earlier this year policy increases of up to 39% in California, Indiana, etc led The House Committee on Energy and Commerce to summon the chiefs of WellPoint, UnitedHealth Group, Humana and Aetna to the Hill to answer questions.  Policy increases by other companies seem to be flying under the radar.

If you missed them, check out the posts by Shadowfax here and here on Assurant Health.

Bathing, a Source of Water Pollution from Medicines

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I have written two posts in the past on proper disposal of unused medications.  I have always been mindful of the medicines as a source of environmental water pollution.

This past week the American Chemical Society reminded (head-slapped me) that topical medications are a source of environmental water pollution from their active pharmaceutical ingredients (APIs).   

Yes, the simple act of bathing washes hormones, antibiotics, and other pharmaceuticals down the drain into the water supply.

Ilene Ruhoy, M.D., Ph.D. and colleague  Christian Daughton, Ph.D. looked at potential alternative routes for the entry into the environment by way of bathing, showering, and laundering.  These routes may be important for certain APIs found in medications that are applied topically to the skin -- creams, lotions, ointments, gels, and skin patches.   These APIs include steroids (such as cortisone and testosterone), acne medicine, antimicrobials, narcotics, and other substances.

Ruhoy feels some APIs in topical medications have the potential of having a greater impact than those released in feces and urine.  Topical medications are un-metabolized and full-strength when washed off.  Those in feces and urine have been metabolized and are not full-strength.

APIs may go right through the disinfection process at sewage treatment plants, and enter lakes, rivers, and oceans.  Trace amounts of the active ingredients of birth control pills, antidepressants, and other drugs have been found in waterways. Some end up in drinking water – at extremely low, trace levels.

"We need to be more aware of how our use of pharmaceuticals can have unwanted environmental effects," Ruhoy said. "Identifying the major pathways in which APIs enter the environment is an important step toward the goal of minimizing their environmental impact."

Things you can do as a responsible citizen:

*  Use the topical prescription as directed, in the amount needed (more is not better, especially for the environment).

*  Do not flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so.

*  To dispose of prescription drugs not labeled to be flushed, you may be able to take advantage of community drug take‐back programs or other programs, such as household hazardous waste collection events, that collect drugs at a central location for proper disposal.

*  Call your city or county government’s household trash and recycling service and ask if a drug take‐back program is available in your community.

 
Related posts
Unused and Old Medications (January 1, 2008)
Unused Prescription Medications (June 15, 2009)

 
Sources
American Chemical Society
American Pharmacy Association
White House Drug Policy

Help Fight the BoTax: Send Your Senator a Letter

 Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I am against the Cosmetic Surgery Tax (or BoTax). I feel it is an unfair tax which will heavily affect women more so than men. It will also affect many more in the middle class than in the wealthy class. I’d like to join the Aesthetic Society and all of organized Plastic Surgery in fighting this unfair tax.

For more on how the tax is a bad idea, check out this article Breast-Enlargement Tax That Failed in Jersey Taints U.S. Plan by Nicole Gaouette over at Bloomberg.com (H/T to Jeff Frentzen, PSP Blog)

”It was a real education,” said Cryan, a Democrat who now wants the levy repealed, in a telephone interview. “We essentially discouraged the business from happening at all.”

Susan Hughes, a Cherry Hill, New Jersey, facial surgeon, said her business dropped by 10 percent when patients began crossing the state line to Pennsylvania. Administering the tax strained relationships with patients, and created extra work and costs for her office, she said.

‘You Idiots’

“We become the tax collector,” Hughes said in a telephone interview. “Now you’re going to repeat that on a national level? You idiots!” Hughes’s office manager, Jaime Castle, said she’s also concerned about layering the taxes, making New Jersey residents pay a combined 11 percent. ………….

The following is the template for a letter that patients can use to express their opinion and dissent toward the proposed cosmetic surgery tax:

Dear Senator ______,

HEALTHCARE PLAN IN THE SENATE WILL UNFAIRLY DISCRIMINATE AGAINST US!

I am writing you today about an issue that affects everyone who utilizes plastic surgery services for anything from Botox to Tummy Tucks.

The healthcare bill approved by the US Senate this weekend, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the “Patient Protection and Affordable Care Act.

This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement.

The problem is that we would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. This Bill is objectionable in many ways, including:

· This is a discriminatory tax. According to the Aesthetic Society Annual Statistics, 91% of all cosmetic procedures are requested by women

· This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. We working women, soccer moms, and scores of others who carefully save and budget to improve our appearance and self esteem will be penalized for doing so.

· Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well.

· Our doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. That is not the relationship we want with our medical provider!

Please, do not allow this portion of the tax bill to pass!

Sincerely,

______________________

You can find your elected representative by clicking here.

Standards for This Blog

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Thanks to Paul Levy, Running a Hospital, for allowing me to use his post and with minor changes using it here. 

I thought it would be good to reiterate the standards that I apply for this blog.

First, as noted in the disclaimer and privacy sections below, I cannot comment on individual and legally confidential patient care issues here.  I will not give individual medical advice, as I am not your treating physician. If you submit a comment that falls in to these categories, I may post it or not.  I most likely will not give you an answer you are looking to receive, but more likely a “no comment” reply.

Second, I will not post comments that make ad hominem arguments and use foul language, that "flame" rather than make points in a civil fashion, or that have prejudicial implications about race, religion, ethnicity, or sexual orientation.

Third, I will not post comments that are clearly designed to advertise a for-profit product, service, or company in the health care field. I retain discretion to post comments that advertise something that would be of general interest.

Fourth, I usually will not post comments that are excessively long. This is tricky because sometimes the person has something interesting to say, but my sense is that most blog readers do not want to drag through very long posts and comments. Encountering a really long comment, many will give up and not reach other comments that follow. So please do the opposite of Pascal: If you have something to say, take the time to write a short letter.

Anonymous comments are fine, and I understand why they might be prudent in some cases, but I personally think you can often be more persuasive if people know who you are and where you come from. Also, it feels good to "stand on a soapbox" and be "seen." People have given their lives to allow us to have freedom of speech. Try it!

So, please dive in, keep reading, and send us all your thoughts on the issues of the day. Thank you for your loyal readership and for spreading the word about this blog.

Amendment:

As Dr Wes mentions in the comments section, the comment should be in English.  I confess that is the only language I speak or read well.  I did take Spanish in college, but am not proficient in the language.  I do not seem to have a knack for them which I regret.  So please be sure the comments are in English.  Thanks.