Tongue Patch Weight Loss System Affects Sex Life

The tongue patch is the next greatest thing in weight loss options.  I foresee some unintended consequences with this approach.  Go here for some effective non surgical weight loss options. 

For other great weight related posts visit 

• How to lose weight after pregnancy (video).
• Losing weight one pound at a time through public display.
• Three Clicks Weight Loss Blog.  Unusual motivation to lose weight. 
• My 120 pound journey:  An inspirational weight loss journey.
• One woman's journey to seek out super morbid obesity.

Should State Physician Licensure Be Abandoned?

Milton Friedman argued for abandoning state physician licensure  to a bunch of doctors at the Mayo Clinic in 1978:

I can think of no benefit I receive nor that my patients receive by me being forced to pay a license fee every year to practice medicine.  My patients gain nothing by having my state require physician licensure to declare me fit to offer medical advice.

If a patient wishes to obtain health care advice from a physician who has been professionally trained, or if they wish to obtain medical advice from their astrologist, they should have an equal opportunity to seek out such advice.  Me paying the government for my right to give out advice is not a monopoly of the  AMA.  It'sa monopoly of the government.

I will gladly relinquish my requirement for state physician licensure and the associated yearly fees.    Just tell me how to sign up.

Portugal Drugs Decriminalized And Guess What?

Portugal drugs were decriminalized and you'll never guess what happened:

Why should  a patient require a prescription to get any medication, including narcotics?  If a patient wants the assistance of a physician, they should seek the assistance of a physician.  Patients should have the same right to get their own Synthroid as I do my own.  If they want to obtain Oxycontin for their pain, they should have every right to go down to their pharmacy and get it. Deregulate medicine and you make it much more accessable to the masses at a cheaper price.  But without all that regulation, the government would fail to support its own self fulfilling necessity.  In Portugal, we see the legalizing drugs does not create addicts.  Addicts create addicts.

Credit Card Best Practices: Revolt Your Heart Out

Bank of America jacked up her rate upt to 31%.  What was her  credit card best practices checklist response?  She made a YouTube video about it and won a reprieve.  So what does she have next on her agenda?  That's right.  She's taking on Uncle Sam.  I wonder if her plan of not paying her credit card would go over as well under Obama's tax and spend kingdom.  Maybe they'll tell her she doesn't have to pay any taxes as long as she doesn't make a video about it.  Implementing your credit card best practices checklist might work for a bank needing to avoid bad publicity.  But it ain't going to work with the government.

Watch the video of revolt.

On second thought where do I sign up for this tax revolt thingy?  This credit card best practices checklist response might work if you can embarrass a Congressman or two.

The Dancing Baby, Beyonce Style (Cool Video)

Hilarious video  of the dancing baby, Beyonce style.  You'll laugh you're butt off.  See more cool dancing here.

Safe Care At The Hospital From An Innovation Expert

Paul Levy full time blogger, part time hospital CEO, is unique in his drive to bring transparency to his hospital organization. His safe care practices are revolutionizing hospital quality.  In these safe care videos below, he describes efforts at his hospital to improve the quality and safety of care by holding his hospital system accountable in the eyes of the public. It really is a radically new way of doing business. I think it's great. I would love to practice in an organization that takes a proactive effort to make their care safe and accountable.   The inertia of change in medicine is slow.  It's the culture of care that makes all the difference in the world.   Taking pride in the work that you do makes all the difference in the world.

Take for example hand washing.    What if you had 5,000 people in your organization who had access to patients?  What if you had a reliable way to measure how compliant each individual was with their hand washing and then published their data for the world to see?  That's how you make safe care an automatic part of the culture.  If Dr Smith, the surgeon, was only noted to wash his hands 5% of the time, he may lose business and the hospital may lose business and he would surely be mocked by his peers for unsafe care.   If Mr Smith washed his hands 100% of the time, he may have patients flock to him and the hospital and his peers would compete for his great safe care numbers.   The key is to set up systems processes that encourage quality care on an individual basis and everyone will succeed.  See Paul Levy's take below on a variety of issues.

How To Provide Safe Quality Hospital Care

How To Have A Better Hospital Experience

How To Stay In Touch With Friends And Family In The Hospital

Has A Hospital Ever Lost A Body?

 How does a hospital lose a body for four days?


Bad smell in the hospital was the tip off for a lost body in the hospital?  That wouldn't  set off any alarms in Happy's neck of the woods.

Sit Down Dinner Makes Teenagers Crings

But the benefits of a sit down dinner for family health are undeniable.

Researchers from the National Center on Addiction and Substance Abuse  have found that teens who have family dinners fewer than three times a week were more likely to use drugs and alcohol and be less successful academically than those teens who had  family dinners five or more times a week.

I suppose I was the exception.  Happy rarely had a sit down dinner with family growing up, but I like to think I turned out just fine.  However,  someday I hope to make a sit down dinner part of my daily family schedule.

I Think I See Medical Billing Fraud. What Should I Do?

I think my physician committed medical billing fraud.  As part of our fertility evaluation, Mrs Happy underwent a bone density scan at the physician's office  . I asked the technologist why she was getting it.  She said that doctor uses it for research purposes.  The technologist said we were under no obligation to pay for it IF our insurance company denied the claim. 

I know that no insurance company would pay a claim that was being used for research purposes.  The fact they did feels dirty.  It feels like medical billing fraud.  None of our fertility evaluations were covered by insurance.   So I thought nothing of it.  Three months later, I received an explanation of benefits indicating that the bone density scan had been paid for by our insurance plan. And paid for quite well.

I have no doubt in my mind that this study was medically unnecessary.  I have no doubt in my mind that the only purpose of this study was to generate research data for the doctor's data base.  Was this medical billing fraud?  Would the insurance company have paid the claim if they knew it was only being done for research purposes?  What is my obligation as a physician a patient's husband?

What Is The Farthest Distance Between Two McDonald's Restaurants? (Picture)

The farthest distance between two McDonald's restaurants in the United States is in South Dakota, with a distance of 107 miles.  This neat map of McDonald's map density in the US was found at Carpe Diem (follow link).

Nurse Ethics Punished In Texas

What an incredible display of nurse ethics being wrongly punished in Texas.  Go read the whole story about nurses being punished for standing up to their patients and holding their nurse ethics in high regard.  If you can't trust the people around you to uphold the ethics of your own nursing field, who can you trust?

Are Electric Motorized Scooters Street Legal?

So I'm driving home from work the other day when I see a man driving this electric motorized scooter down the middle of the road  like he owns. No license plate. No rear view mirrors. No turn signal. No headlights. Just a guy with a neon flap jacket draped over his seat,  puffing away on a cigarette. Are electric motor scooters street legal? And if so exactly when did these become street legal?  Perhaps next week I'll see an extreme electric scooter off roading with muddin' tires.

 At least for the street legal versions, I'm waiting for the sidecar version to make its debut. That way this guy can take his whole family to Sizzler.

Does A Ban On Smoking In Public Places Increase Bar Fights?

I figure if state smoking bans continue to sweep across America, the smokers are bound to revolt.   What better way to express yourself at a bar than starting a bar fight?  Right?  Well, at least we'll know they won't get heart attacks, nor will their victims get heart attacks while engaging in the battle for smoker's rights.

If you are wondering if a ban on smoking in public places has any health benefit, check out the impressive data that keeps coming forward.   Back in January I commented on the 41% reduction in heart attacks in a Colorado county after a smoking ban in public places went into affect.  It set off a nanny state fire storm in my comments.  Now comes a report  out of the journal Circulation (abstract) that continues to confirm the dramatic reduction on acute coronary events in districts that legislate state  smoking bans.

 smoking bans

A 36 percent reduction in heart attacks after three years is a phenomenal outcome.  There isn't a single medical intervention I know of  that has that immediate and profound effect on outcomes.    Do you realize the Medicare National Bank is planning a 2% reduction in payment to hospitals if they do not meet quality performance markers.

2%.

There isn't a quality initiative or payment initiative the feds could come up with to save the kind of money  that  lifestyle modification could do.  36% reduction.  That is amazing.  We are twiddling our thumbs trying to prevent 30 day readmissions in people who smoke when the answer lies in the patient's actions.  Perhaps we could prevent 1/2 the readmissions with coordinated care models.  But we could prevent 80% of the sentinal admissions by making the beneficiary responsible for their actions.  That is your answer to health care solvency.  With that said here is what needs to happen immediately:

1. A nationwide smoking ban on smoking in public needs to be enacted by Congress.  That means all public places, indoors and outdoors.  It's time that smokers are banned to their homes where they expose nobody but themselves and their family to the dangers of  first, second, third and fourth hand smoke.  It's time we protected our Apple computers from an early death.  
2. If Congress does not have the political will to implement a ban on public in public places, they should immediately give a proportionate percentage increase in Medicaid funds to states that have instituted such a ban based on the actuarial dollar savings generated by the reduction in health care costs and ongoing morbidity related to acute MI and its associated heart failure diagnosis.  
3. The tax on a pack of cigarettes should be raised immediately to $20.  
4. Medicare cost sharing arrangements should increase by 100% starting in calendar year 2011 for all beneficiaries abusing tobacco  who fail to comply to a strict tobacco free compliance policy. 
5. All Medicaid beneficiaries will be required to go tobacco free to maintain their benefits or be subjected to the same cost sharing arrangements as their Medicare counterparts, regardless of their ability to pay, or lose their benefits entirely.

The data is compelling.  There is no excuse for our government to support a bankrupting insurance scheme that is unsustainable while its population disregards their personal responsibility to reduce costs.

We can prevent 80% of heart attacks, strokes, diabetes and cancer through lifestyle modification.  As long as the government mandates health care as an entitled right and forces the burden onto the tax payer, they have an obligation to force the populace into mandated lifestyle modification. And for those who choose not to participate, the burden of cost should be disproportionately placed on the shoulders of their actions.

The numbers speak for themselves.

Should A Provider Bill For Both A Procedure And An E&M Code?

First of all, I"m not a certified coding compliance officer, so these are just my opinions.  With that said, a reader poses the question:

A couple of comments here.  First of all, the 99105 code requires you to place the NG in order to aspirate or lavage.  If you are placing an NG for tube feeds or to give meds, I'm not sure this code would suffice.  I have no idea what the code would be to get paid for placing an NG to give meds or tube feeds.I have a few questions about CPT® medical coding.  I work as a Physician assistant hospitalist in xxxx.  My employer is asking me to bill certain codes but don't think they are appropriate.  Please let me know what you think.

In my facility, nurses do not place NG tubes but we do.  The company wants me to bill 91105 (gastric intubation, and aspiration or lavage for treatment, ie ingested poisons).  and a subsequent visit 99231( low level hospital follow up visit). for the visit.  I am ok with the 91105 code but to bill the subsequent visit to evaluate the patient for the need of an NG tube does not make sense. First of all, sometimes GI doctors put in the order to place an NG tube so why should I evaluate the pt for an NG tube.

The other question is the company wants me to bill for monitoring patients getting CT with IV contrast.  In NY, I guess there is a law that a patient getting IV contrast has to be monitored just to make sure they don't have a reaction.  This would also be a subsequent 99231 billing.

As for the billing of a follow up note 99231 in order to make a determination on whether an NG is appropriate, I have no problem with this.  When I ask my gastroenterologists to do an EGD for an upper GI bleed, they do a full, level five consult 100% of the time and because they are the ones making the decision on whether to do the EGD or not, they have every right to charge a consult note.

Now, when  I order a CT guided lung biopsy by they interventional radiologist, they never do a consult note.  But they could if they structured their group to do one.

Sometimes when I get asked to put in a central line by another service, I could, If I wanted to, do a complete consult note and then bill the procedure note.  I don't because I find it ridiculous, like you.

But I could and it would be medically necessary.  In fact, you could probably bill a consult level code and get paid for it everytime you were asked to put in an NG since you need to evaluate the patient first, just like the GI docs do for EGD, just like the cardiologists do for cath, just like the surgeons do for surgeries.

As for the billing while monitoring IV contrast, again, you could probably bill a full consult note if you wanted to take the time to do it.  Remember, a consult requires the 3 Rs

1)  Document the requesting physician (Dr X)

2)  Document the reason (Evaluate the safety of IV contrast administration)

3)  Document the response back (Usually a dictation).

Now, you could choose to do just a follow up code and the Medicare National Bank would be glad to pay you less.  But I suspect you could probably bill something higher than a level one.  Remember, It doesn't take much to get a 99232.  If they have renal insufficiency, you might even be able to bill a 99233 if your documentation supports it.

If you are spending time doing anything, even if it involves using a vein light to get IV access and monitoring  IV contrast or or putting in an NG, you should get paid, or your employer should get paid for your services.  Thus is the nature of fee for service.

You can learn more about coding for free in my lectures on medical billing and coding. 

What Is Your Favorite Primary Hospital Discharge Diagnosis?

What is your favorite discharge diagnosis?  How about "Catastrophic Noncompliance"

Hospital Funding And Hospitalists. Is There Future Integration?

Pages 75 and 76 of the Senate Health Care Finance bill lay out the future plans for hospital funding: A move from pay for reporting to pay for performing.  This is the governments version of value-based purchasing.  And here are the future plans for hospital funding:

The Chairman‘s Mark would establish a  Hospital Value-Based Purchasing (VBP) program in Medicare that moves beyond pay-for-reporting on quality measures, to paying for hospitals‘ actual performance on these measures.  This value-based purchasing program would provide value-based incentive payments to acute  care IPPS hospitals that meet certain quality performance standards beginning in FY2012. The  first year of the program would be a data collection/performance year.  Beginning in FY2013,  hospital payments would be adjusted based on performance under the VBP program.

Measures for the hospital VBP program would be selected from the measures used in the  RHQDAPU program.  The measures would focus on the same areas that are the focus of the  RHQDAPU program: heart attack (AMI); heart failure; pneumonia; surgical care activities; and  patient perception of care.  Beginning in FY2014 and beyond, the Secretary would have the  authority to expand these categories through the quality measure development and endorsement  procedures laid out in the Quality Infrastructure section of this legislation. By FY2014, the  Secretary would be required to expand categories to include efficiency measures.  Such measures  would include Medicare hospital spending per beneficiary for selected medical conditions and  would be adjusted by factors including age, sex, race, severity of illness and other factors that the  Secretary determines are appropriate. The Secretary would have the authority to replace a  measure if it is found that all hospitals are effectively in compliance with the measure or if the  measure no longer represents a best practice.

Funding for value-based incentive payments for qualifying acute care hospitals would be  generated through reducing Medicare IPPS payments to the hospitals.  The reductions would be  used to fund an incentive pool and would be phased-in as follows: 1.0 percent in FY2013; 1.25  percent in FY2014; 1.5 percent in FY2015; 1.75 percent in FY2016; and 2.0 percent in FY 2017  and beyond.  The reductions would apply to all MS-DRGs under which a hospital provides  services. The Secretary would be required to ensure that all funds reduced from hospital  payments to fund the VBP program in a given year be returned to hospitals in the form of value-based incentive payments in that same year (i.e. the program would be budget neutral to the  Medicare program).

The Secretary would be provided the necessary funding to administer the program (amount to be determined).

What you see here is a move in hospital funding to move  from pay for reporting to pay for performance.  For a hospital with 50% Medicare collection on a billion dollars of revenue, 2% is ten million dollars.   Hospitalists have the perfect opportunity to  save a hospital's balance sheet, a balance sheet that could be the difference between going broke or surviving.   It also helps explain why hospitalists, whose own financial implications are often aligned with hospital, are in a perfect position to thrive under the ever changing Medicare landscape.  If you are a hospital that may lose 10 million dollars a year because the outpatient internists or family medicine or even the subspecialist docs refuse to play the Medicare games, are you as a hospital more or less likely to look to hospitalists to save the day.  I think the answer is obvious.

Is Hospital Pricing Transparency Required In Health Care Reform Legislation?

Hidden on page 39 is the answer regarding hospital pricing transparency requirements:

Also,  beginning in 2010, hospitals would be required to list standard charges for all services and  Medicare DRGs.

It's about time.  I think hospital pricing transparency  will do more for prices than any government mandated quality initiative.  If hospital pricing has  compete on price, they will have to, by default, compete on quality.  Quality that reduces the rate of complications which would erode profit margins.  There's a reason why markets operate with efficiency.  The consumer can always go down the street.  Which is also why I am a firm believer in high deductible policies which force the consumer to purchase their health care services, most of which are non emergent, and therefor seek the lowest price at the highest quality.

This one sentence in the Senate bill regarding hospital pricing transparency will do more for the cost conundrum we face than any other change they seek to make.  One major reason why health care is so expensive is because nobody knows what it costs.  With the explosion of high deductible plans, it's time for that to change.  Hospitals that understand the savvy health care consumer don't need a government mandate to make it happen.

WIll Medicare Reduce Payments To Physicians Who Utilize A Lot Of Resources?

It looks like that's what the Senate bill is recommending for the Medicare National Bank. Page 81

Beginning in 2015, payment would be reduced by five percent if an aggregation of the physician‘s resource use is at or above the 90th percentile of national utilization.  After five years, the Secretary would have the authority to convert the 90th percentile threshold for payments reductions to a standard measure of utilization, such as deviations from the national mean. 

People worry that bundled payment models will make doctors order fewer tests.  You don't have to worry. The government is already planning on making it happen.

How To Make Your Penis Stronger

I'm not sure whether to laugh or cry.  Yes.  Definitely laugh.  Want to make your penis stronger?  Don't do that.

Marty and Cooper Go Racing, Sunbathing and Snuggling

click images to enlarge

Read On

Healthy Lifestyles Legislation Is Right Around The Corner

I blog about healthy lifestyles and personal responsibility and choice and why those who make poor healthy lifestyle choices should expect to pay more.  And I get blasted for being an jerk.  So it comes with great pleasure  to inform you Happy haters that your federal government is planning on doing everything I discuss, including discriminating against you if you smoke.  Healthy lifestyles may just prevail.  At least I'm not going to discriminate against you if you age.  On page 2 of the Senate's proposal

Read On

World's Longest Basketball Shot Ever (Video)

When I think of the world's longest basketball shot, I usually think of the Harlem Globetrotters.  Not anymore.  This is the world's longest basketball shot I have ever seen.  That's wild

If you like this wild video, you might like Octomom's birth, the musical piano staircase, the crazy water slide stunt,  a gazillion birds dancing, a whole hospital dancing for breast cancer,  or when homeopathy meets the emergency department.

Crazy Blogger or Dedicated Blogger?

That my friends is either a crazy blogger or a  dedicated blogger.  Is he the next  Robert Scoble?

Why Is The AARP Strongly Behind Reform When Most Seniors Aren't?

It seems a bit strange, doesn't it?

AARP 

Until you read what the AARP stands to gain from the "kickbacks" being legislated into law.

I just have to ask the question: Why?

Dr Gupta Gets The Swine Flu

He went to Afghanistan and all he brought back was the swine  H1N1flu.

A true blogger indeed.  One of my partners showed up at work the other day with a face mask on.  It turns out her kids had H1N1 and she wasn't feeling too good.  She was told as long as she lacked fever, she was OK to work.  What do you think?  Would you want your doctor taking care of you if they had the flu?  How about the common cold?  Should doctors stay home from work when they aren't feeling good?

Doctors who are self employed, who's daily income depends on seeing patients and collecting their fee for service  payments  will work until their death bed.  Plus, for many, it's engrained in their work ethic.  When doctors don't show up to work, their  office staff still gets paid. Do they put their patients and others around them  at risk?  With common sense protections, I doubt it.  The face mask protects those around them. And hand washing is always a given whether you are sick or not.

On the lighter side, check out this funny swine flu picture. 

Topical Viagra May Prove To Be Stiff Competition

Topical Viagra is just what the world needs.

Tests on rats have shown that the drugs are effective in nine out of 10 cases.

Topical Viagra on rats?  I'd love to see that research protocol.

Does Health Care Legislation Require Doctors To Pay A Fee To Join Medicare or Medicaid?

Under proposed rules coming through the Senate's new plan, doctors may be required to pay a fee. Page 185

Read On

Worst Page Ever Made By A Nurse

Worst page ever made by a nurse.  

Nurse:  "Dr, your patient screened positive for sepsis."
Doctor:  "That's what they're here for."
Nurse: "I'm supposed to call all positive sepsis screens."
Doctor:  Feeling like crying uncontrollably.

What happened to treating nurses like professionals and allowing them the professional latitude to stop wasting everyone's time with the worst pages ever and instead allow them to use their thinking skills for instituting common sense patient care? Just because a protocol says to call every positive sepsis screen does not mean we have to treat nurses like robots. It's a shame that nurses have been reduced to paper pushers and pill dispensers at the hands of a legal driven fear of civil liability and we're left with a system where every night I get the worst page ever made by a nurse.

Is Practicing Healthy Lifestyles Instinctually Hard?

Dr D seems to be saying it is

The only instinct going on here is the lack of motivation in the pocket book.  If you make the issues of personal choice and lifestyle about personal wealth, the masses will respond. Smoke up and pay double or quit and reap the benefits.

I could care less about what JimBob down the street does with his own body. He can smoke till his lungs are content. But treating him the same as a someone who makes a conscious decision not to light up that cigarette and then telling the smoker they will pay the same in premiums as a nonsmoker is a recipe for moral hazard disaster. When you incentivize bad behavior, you get bad behavior. When you incentivize Cheeto eating, Oprah watching couch potato lifestyles, and tell the masses they will pay the same for their health care whether they engage in personal sacrifice or not, you are giving them the golden ticket to the Willy Wonka Healthcare Factory. The finance issue in this country is not about health insurance. It's about health. If you can reduce diabetes, heart disease, stroke and cancer by 80% you solve the health care finance problem.

You want to make it worse? Let's start insuring couch potato, Cheeto eating, Oprah watching smokers and charge them the same whether they engage in personal health care sacrifice for the common economic good or not.

The issue here is about funding a moral hazard that has no boundaries.  The entitled masses believe they  have a right to their health care and health care insurance.  But they cannot also accept that they have an obligation to limit their consumption of these community resources through lifestyle choice. That's because FREE=MORE prevails.  Those that argue for social solidarity choose to ignore the individual's responsibility to society for accepting society's resources as their own.

The reason socialism will always fail is because it's easier to be fed than to hunt.  When we have everyone feeding, and nobody hunting, we get famine.  Perhaps that's exactly what our country needs to turn a nation of feeders into hunters again.

Cardioversion of Atrial Fibrillation: The Wild Unsynchronized Version

My First Unsynchronized Cardioversion of Atrial Fibrillation:

He started out like most other patients admitted to the hospital. An active smoker with active shortness of breath came for acute exacerbation of his chronic underlying progressive multiorgan disease, The admitting diagnosis was the internist trifecta: COPD exacerbation, CHF exacerbation and pneumonia. Of course, there are some patients in whom you just can't tell. Their heart, their kidneys and their lungs prevent an accurate diagnosis. So you put them on steroids for their COPD and hope their CHF doesn't get worse. You put them on diuretics for their CHF and you hope their kidneys don't get worse. You give them antibiotics for their pneumonia, because, well, everyone in the hospital deserves a course of antibiotics. That's why we have hospitals.

Read On

I have Osteosporosis (or is it Osteosperosis)

One of my favorite patient verbal misspellings is "I have osteosporosis" (Also commonly misspelled as osteosperosis.   This sounds like a fungal infection.  In case you're wondering, the correct spelling of osteosperosis and osteosporosis is o-s-t-e-o-p-e-r-o-s-i-s.    And just in case you are wondering, about my other favorite patient verbal misspellings, it's prostate, not prostrate.  Consider that my public service announcement for the day.  What is it with the S's and the R's with misspelling medical terminology such as osteosperosis or osteosporosis or prostrate.

Cognitive Therapy For Puppies

Funny stuff. I don't know how I missed this one. Especially with the little Iggy in there.  See other funny dog cartoons about dogs. Read about pet therapy dogs here.

Why Do Doctors Order Blood Gases?

Blood gases can be a doctors best friend.  So why do doctors order blood gases?  To be a great internist you have to be great at blood gas interpretation. And you have to be able to do it quickly and efficiently. You have to understand what all the numbers mean and you have to get a good clinical sense of how to interpret them and how to change management based on their result. And you have to be able to do it without pulling out your formula books. In six years as a hospitalist. I have never calculated what the compensatory responses should be. I just know.

Read On

Is It Safe To Eat Chili Left Out Overnight?

I ate chili the other day that sat out overnight. Mrs Happy wouldn't go near the food. She told me she'd wait to see if I got sick before giving it a shot. I guess I took one for the team.

Would you eat it?

How Much Does A Military Hospitalist Position Pay?

So I'm minding my own business when out of no where some guy calls me asking if I knew anyone interested in working a four month military hospitalist posiition at a military base for the Department of Defense. How much does a miliatry hospitalist position pay these days?  Around $120 an hour as a DoD employee or almost $150 an hour as a self employed contract worker.

I politely declined the offer. Although it got me wondering. What's it like to work for the DoD? Would I get top secret clearance to take care of the aliens in Roswell? Would I get to sneak a peak at Obama's smoking infested lungs? Would I get to hop a ride in a military transport plane for a vacation to Hawaii?

I just get the feeling I'm losing out on the opportunity of a lifetime...

Physician Risk Managment Expectations Applied To Investment Advisers?

You ever wonder what life would be like if physician risk management expectations were applied to the investment adviser community.  I have blogged extensively about why standard of care is an irresponsible measure of the threshold for determining negligence in medical care.  Imagine for a moment what capitalism would be like if your physician risk management expectations were applied to your investment adviser, who was sued every time your investment value went down. Imagine what life would be like if  your adviser  risked civil liability every time a bad outcome occurred. What if no laws were broken? What if an after the fact determination of negligence was based on a bad outcome?  What would physician risk management expectations do to the investment community?  It would destroy them. 

Read On

Continuity of Care Is A Poor Prognostic Sign For Hospitalist Medicine

You're probably wondering how continuity of care could ever be a bad thing.  Well, if you're a hospitalist, continuity of care indicates you are a frequent flier to the hospital.  That is a bad prognostic sign.  

Who says hospitalist medicine lacks continuity? If anything, what we see as hospitalists are a broad and continuing spectrum of acute and chronic disease in our failing elderly. When I give my dementia lectures to the sons and daughters of their father with  end stage Alzheimer's dementia loved ones I explain it like this:

Read On

Internal Medicine Doctor

What is an internist you ask?   An internist is someone you go to when you don't have any idea what's going on.   An internist is a doctor who is devoted to not only understanding what is going on, but what else is going on through the expanded differential diagnosis.  An internist is someone who makes the esoteric diagnosis you only hear about in medical school.  An internist is a master of multitasking a mountain of data and internalizing and processing the possibilities and probabilities.

An internist is who you go to when everyone else has failed you. Now we can only hope the current medical economic climate prevents internists from dying a quick and painful death.

What Is Medicare Code 44: Inpatient vs Observation Rules Clearly Explained

What is the Medicare Code 44 and why is it so important?  Read on for detailed explanations on how to define Inpatient vs Observation hospitalization across a variety of situations.  With the Medicare  recovery audit contractors moving full speed ahead, they will be searching to recovery billions of dollars of inappropriately paid claims. Their efforts will mostly be directed toward hospital billing practices not physician CPT® medical coding. One they will be looking carefully at is whether the inpatient status or observation status was paid appropriately.  And that's where Code 44 becomes applicable.

It comes as no surprise that hospitals every where are solidifying the rules. I present to you several scenarios and what happens behind the scenes for your hospital to get paid by the Medicare National Bank.

When you get admitted to a hospital, your physician has a choice: admit you as an inpatient or as an observation stay. The implications are mostly in how much your deductibles will be, whether you will have to pay for your own medications while in the hospital (you do as observation status) and whether you need three midnights in the hospital to qualify for your skilled nursing benefits.

Medicare has a giant book of criteria that must be met for you to qualify for inpatient stay. Did you know ordering fluids at 100 cc/hour would help qualify you for inpatient under the "intensity of hospital services" component, but ordering fluids at 75 cc/hour would not? I learned that a few weeks ago. How am I ever supposed to know that? And why is it up to a physician to decide whether you are inpatient or observation. These are Medicare rules. It should not matter what I write. If they qualify for inpatient, they should be inpatient. If they don't, they should be observation status.

But under the current rules, I the physician get to write what status I want my patient. So what happens if I get it wrong? Read through these scenarios to see what goes on behind the scenes in order for your hospital to get paid.

Scenario 1: Admit observation and qualifies for inpatient the next day

The doctor writes the order to admit observation status on Sunday. The observation status is correct on Sunday. On Monday, the care management team identifies that inpatient criteria are now met on Monday. What needs to happen?

• Care management obtains an inpatient order from the physician on Monday
• The patients status is changed on Monday to inpatient
• The observation day on Sunday will be rolled into the hospital admission for DRG payment purposes
• The counting of inpatient midnights begins Monday night
• Patient will not be charged for their outpatient medications on Sunday

For physicians, they bill their observation admission codes (99218, 99219, 99220) on Sunday. On Monday, they could bill a full History and physical examination (99221, 99222, 99223) if they did the work to support it. I usually just bill an inpatient follow up code (99231-99233). I can only assume that Medicare will still pay the physician for both their Observation admission on Sunday and their inpatient admission (if they wish to do one) on Monday.

Scenario 2: Admit observation but meets inpatient criteria

The doctor writes an order to admit observation status on Sunday. On Monday, care management realizes that inpatient criteria was met on Sunday. What needs to happen?

• The physician needs to write an order to change to inpatient status on Monday. The physician cannot back date the order to Sunday EVEN THOUGH the criteria was met.
• Change the status to inpatient effective on Monday.
• The observation charges for Sunday will be rolled into the inpatient DRG, so no money is really lost by the hospital.
• However, counting of inpatient midnights won't begin until Monday, EVEN THOUGH the criteria was met on Sunday. This could impact the three midnight requirement for skilled nursing benefits.
• The patient will not be charged for their medications during their observation stay on Sunday

In this situation the physician bills their observation admission stay on Sunday (99218-99220). They could bill another full H&P on Monday if they did the work to support it. Otherwise they bill follow up hospital codes (99231, 99232, 99233) on Sunday.

The problem I see with this scenario is that Medicare, is reneging on their stated obligations. If the patient meets criteria for inpatient on Sunday by their rules, they should start paying for inpatient on Sunday. They should start counting midnights on Sunday night. And the physician should be allowed to change their billing to an inpatient admission H&P on Sunday. Whether a patient is observation or admission should have nothing to do with a physician order and everything to do with whether the criteria for inpatient are met. Whether a patient meets inpatient criteria or not depends on a giant book, hundreds of pages, that no physician could possibly know the answers to.

Did you know if a patient came into the hospital with a diagnosis of acute renal failure with a creatinine of 6, used a vein light for IV access and  and was placed on IV fluids at 75cc/hour, they would not qualify for inpatient? As I stated above, the fluids must run at 100cc/hour or greater to qualify for inpatient status. I have discussed inpatient vs observation many times with my care management folks. That's what they do for a living. You can't possibly expect physicians to know the correct status on admission.

One solution is to make every patient inpatient from admission and let the care managers sort it out. The real loser here is the patient who increases their risk of hospital acquired complications, and the hospital which spends valuable hospital resources so the patient can get their necessary unnecessary third midnight to qualify for a skilled nursing bed at the local nursing home. That Medicare would allow the rules under this scenarios to exist is blatant stupidity. To believe that patients don't spend an extra night in the hospital to qualify for their skilled nursing benefits is ignorance.

Scenario 3: Admit inpatient but only meets observation

The doctor writes an order for inpatient on Sunday. On Monday care management realizes that inpatient criteria was not met on Sunday. What needs to happen?

• The physician needs to write an order to change to observation status on Monday.
• The observation order cannot be back dated to Sunday EVEN THOUGH they only met observation criteria on Sunday
• Submit a Medicare Code 44 status
• The claim will be rolled together and inpatient rates will not be paid on Sunday

For physicians, I'm not sure how this would get paid. I can only assume that I would change my inpatient code (99221-99223) from Sunday to an observation admission code (99218-99220), since the inpatient status on Sunday will be rolled into the Observation status. If I submit an inpatient code for Sunday and the hospital does not, I will definitely not get paid for Sunday. I have no idea if the hospital will get paid for Sunday. I suspect that by submitting the Code 44, they will.

One of Medicare's benefits involves 100 days a calendar year of skilled nursing benefits at a nursing home. But for Medicare to pay for it, the patient must have been hospitalized for three midnights within the last 30 days. In the above situations, if a patient is admitted observation status but qualified for inpatient, Medicare is saying they will not recognize the midnights where the patient was listed as observation, even though a retrospective analysis indicates the patient qualified for inpatient. The solution is to write inpatient admission status for EVERYONE and then let the care management team sort it out.

Or perhaps I should simply start writing an order for "admission status per care management recommendations". And let them sort it out. Deciding whether a patient is inpatient or observation should not be a physician's responsibility. It is what ever it is and me writing an order one way or another doesn't change that.

Why Medicare is making it harder than it has to be is beyond me. If the patient meets inpatient criteria, they are in patient. If the patient doesn't, they don't. And it shouldn't matter what the physician orders. But since it does, you get more bureaucracy and layers of paper work that does nothing but add cost to the hospital's bottom line and raises all our premiums in one way or another.

You can see much more for free in my free lectures on medical billing and coding.

How To Bill Prolonged Service Codes In The Hospital (CPT® E&M Codes 99356 and 99357) With Threshold Times

There are three ways to pay for time in Evaluation & Management (E&M)  codes for inpatient care.  Prolonged service codes 99356 and 99357 are one of them.

1. Critical care.
2. Counseling services for admits, consults and follow up notes.
3. Prolonged Service Codes

I'm going to explain #3 for you today. Prolonged service codes are supposed to pay for time spent on patient care beyond the "bundled" payment of current E&M codes. If you spend 10 minutes or 35 minutes on a level three hospital follow up CPT® code (99233), you will get paid the same. The AMA, which owns the CPT® codes, has defined their usage. Their definitions are generally accepted by CMS for payment purposes. Except for the prolonged service codes.

A major change happened in the 2009 CPT® book. The AMA used to define prolonged service codes as only face-to-face time beyond the threshold time defined in the CPT® codes. With the 2009 CPT® book the physician can now count any time spent on the patient care, including all unit/floor time spent.

However, CMS has not yet changed their rules. They still claim that prolonged service codes must be face-to-face.

So it appears we are in a quandary. You can submit your prolonged service bill based on the AMA's CPT® rules, and yet CMS may not pay, because they haven't changed their application of the rules.

Oh yeah, and some non Medicare insurers don't recognize these codes either.

So how do you bill a prolonged service code (and hope it gets paid?)

These codes kick in after the threshold times have been exhausted for the original E&M code. What are the threshold times for hospital admission, follow up and consultation codes? Here they are:

99221 (low level admit) 30 minutes

99222 (mid level admit) 50 minutes

99223 (high level admit) 70 minutes

99231 (low level hospital follow up) 15 minutes

99232 (mid level hospital follow up) 25 minutes

99233 (high level hospital follow up) 35 minutes

99251 (lowest level hospital consult) 20 minutes

99252 (second lowest hospital consult) 40 minutes

99253 (mid level hospital consult) 55 minutes

99254 (second highest hospital consult) 80 minutes

99255 (highest level hospital consult) 110 minutes

What does that all mean? It means before you can even consider doing CPT® medical coding for a prolonged service code, these threshold times for each specific CPT® code must be met, and documented. So lets assume you actually spent 110 minutes on a consult (something I think has never been done in the history of modern medicine). How would you go about billing for your extra time?

CPT® 99356 (inpatient prolonged service codes)

1. You must spend up to 60 minutes (minimum of 30 minutes) of additional time past the above threshold times to bill this code.
2. You must document the total time spent during the face-to-fact portion of the encounter, and the additional unit or floor time in an additional note or one cumulative note.
3. In my state 99356 is worth about 1.7 work RVUs or $60 for the work portion.

CPT® 99357 (inpatient additional prolonged service codes)

1. Once you have met the threshold for 99356 (60 minutes) you can bill a 99357 for every additional 30 minutes (minimum of 15 minutes).
2. You must again document total time spent during the face-to-face portion of the encounter, and the additional unit or floor time.
3. In my state a 99357 is worth 1.7 work RVUs, or about $60

Here is a real life example of how to bill these codes. Lets say you spent 30 minutes working on a hospitalized patient with multiple medical problems. Let's say your documentation supports a high level code 99233. In the chart above, the threshold time is defined as 35 minutes.

Let's say you are asked to come back later in the day to evaluate a change in status. The status may not rise to critical care. Let's say you spend another 40 minutes talking with a family personality that takes up all your time, evaluating the data, speaking with the respiratory therapists reevaluating the data of the day and discussing with other subspecialists on the case.

You will have spent 30 + 40=70 minutes on the patient's care. To bill a prolonged service code you have to spend at least 30 minutes past the defined threshold time. In this case, for a 99233 that is 35 minutes + 30 minutes= 65 minutes. The AMA says it doesn't have to be face-to-face. CMS says it does. So you can bill prolonged service code 99356 and hope it gets paid.

Let's say five hours later you are asked to reevaluate the patient's condition. You go back up and spend another 20 minutes on their care. The day's total is now 30+40+20 = 90 minutes. In order to bill an additional prolonged service code (99357) you have to consume the 35 minute threshold time for 99233, spend another 60 minutes for 99356, and spend at least 15 minutes additional time for the 99357. That would mean you need to spend at least 110 minutes. In this case, you spend 30+40+20 = 90 minutes. You do not qualify for an additional billing of 99357.

However, if your hospitalist partner, who comes on for you spends an additional 30 minutes that night, a total time of 30+40+20+30=120 minutes would meet the threshold for billing an additional 99357.

I can't think of any circumstance where I would spend 75 minutes past the threshold time for any CPT® code in order to bill a 99357. If I'm spending that much time, it's because the patient is really sick and a critical care code would suffice.

I can however, think of many times where a 99356 could be billed. Usually the threshold time can be met when you have difficult patients who then have families that require lots of time. And in these situations, I think, using the prolonged service codes make sense.

As a side note, notice the value placed on these prolonged service codes. For a 99356, spending up to 60 additional minutes of care on a patient is worth only 1.7 work RVUs, or $60 for your education and experience. $60 an hour. Even if you met the minimum 30 minutes, the value of your education and experience is $120 an hour. This is the time value that has been decided as fair by the RUC, a committee controlled by procedural and surgical subspecialists that makes default recommendations to Congress on physician pricing.

Imagine for a moment if the orthopaedic surgeons or the cardiologists placed, on a time based axis, a value of $60-120 an hour on the value of their services.

They would all quit. Which is exactly what is happening to primary care. You get what you pay for.

You can see much more in my free lectures on medical billing and coding.

Vent Speak?

So I asked my patient's ICU nurse if my vent/trach patient speaks.

"Yes, but you have to be able to speak vent to understand him", she says.

Is this something you nurses learn in nursing school?

ADDENDUM:  Perhaps some day the MARTI interpreter system will have a vent speak or trachonese translator available as well.  

Free Chantix Help And Quit Smoking Advice: I'll Show You How.

Here's the best quit smoking advice ever:  If you are poor and you need help to quit smoking, there are programs available to help you do the right thing including getting Chantix for free. There is no longer an excuse for not being able to afford the medications. Chantix, a drug that works in about 44% of people who use it, helps ease the cravings of nicotine addiction, without simply replacing one nicotine delivery system for another.  My best quit smoking advice:  Just Do It.  Our government is broke and there will come a time when you are going to be told no.

One option is Chantix.  It recently earned some black box warnings for causing aggression, wild and vivid dreams and the potential for suicidal ideations. But if you can look past those warnings and give it a try, it is available by prescription. However, if you need help because you're poor, you need not look any further. You might be able to get your Chantix for free.  

You can go to  needymeds.org to look for help with numerous medication programs available. In the case of free Chantix, click here for the specifics.

I suppose you're wondering if you qualify. You have to

• Make equal to or less than 200% of the Federal Poverty Level, adjusted for family size.
  
• Reside in the US

You can still get assistance with your copay even if you have insurance. What are you waiting for? Get out there and quit smoking

By the way, this is how you help the poor. You don't raise taxes and force government run bureaucracy onto the American tax payer and create entitled mentalities for generations to come.

UPDATE:  Chantix lawsuits, here we come.  

How Dads Should Be (Nice Baseball Video)

How dads should be.  How many dads out there would have yelled at their two year old?

Defensive Medicine Is A Myth, And The Texas Medical Association Speaks Out

A med mal lawyer speaks out against tort reform and the mythical beast of defensive medicine on his blog. And the Texas Medical Association responds.

 

I heard a local med mal lawyer drag a doctor through court because a drug addicted crack head got a blood clot after refusing to let the doctor remove a central line that the good doctor insisted must come out. The patient didn't want to be stuck for lab.

This lawyer was then overheard, during a poker game (yes folks, a poker game) with other distinguished lawyers (and a physician, unknown to the rest) bragging about just needing to find a handful of jurors sympathetic to the client's plight and cashing in on the hatred for those greedy doctors.

Ah yes, and defensive medicine doesn't exist. And lawyers are looking out for the interest of justice. As long as state bar associations allow rogue lawyers to reek havoc on innocent doctors, there will always be doctors ordering MRIs CT scans (MRIs are not the test of choice for trauma) on your child to be absolutely sure they don't have an intracranial hematoma when they bump their head on a door knob.

If you don't want your child getting an MRICT scan (MRIs are not the test of choice in trauma) just to be sure so a physician can protect themselves against a failure to diagnose lawsuit, your state bar associations should get together and decide not to sue physicians who don't order an MRI CT scan (CT scans are the test of choice in trauma) in children who bump their head and then have a bad outcome. Or disbar these lawyers.

It really is that simple.

How Important Is Medical Malpractice Reform To Obama?

1 trillion dollars for health insurance reform.

25 million dollars for malpractice demonstration projects.

The Power Of Perspective

I guess we have to order a bunch of MRIs to spend that trillion dollars.

Hospitalized Patient With Fleas

Nurse: "What would you like to do?"

Happy: "Can we get him a flea collar?"

In ten years, I've never had a patient with fleas. How do you get rid of fleas? Any suggestions out there on what to do? Should I have called for a stat I.D. consult?  I thought I was the only flea in the hospital. 

Why Is Food and Drink Prohibited At The Nurse's Station And Other Hospital Work Areas?

Over the last several weeks I have received numerous emails dictating the enforcement of work place rules regarding eating and drinking in nursing areas and other areas with patient charts. It seems everyone, from the Chief of Staff to the CEO to the Head Nurse In Charge has been making it very clear that drinking in work areas won't be tolerated. I have at times been confronted by dutiful staff doing their jobs with a robust sense of confidence to enforce this potentially dangerous patient safety issue.

Or so I thought. Whilst speaking with one of Happy's friendly colleagues, I learned that the issue of food and drink in the work place has nothing to do with patient safety. Like my colleague stated so eloquently, if there is data that can be presented to me that shows my action of drinking coffee at the work stations would some how harm my patient, I will gladly stop immediately. Discussion finished.

But as I learned from my colleague, the issue of food and drink at the nurse's station or anywhere near patient charts has nothing to do with patient safety. In fact, the regulations are in place to protect ME from myself.

That's right, the coffee Nazis are cruising the halls with reckless abandonment searching for violators of the hospital wide coffee ban on rounds not because patients could be harmed, but because I could harm myself.  You see, it turns out my distinguished colleague was told these regulations were not CMS or JCAHO regulations, but rather OSHA regulations.

So I looked it up

Here are the actual OSHA regulations

1910.1030(d)(2)(ix)

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.

1910.141(g)(2)

Eating and drinking areas. No employee shall be allowed to consume food or beverages in a toilet room nor in any area exposed to a toxic material.

In other words this is not a patient safety issue, but rather an employee safety issue. The Joint Commission has no specific standard on the issue other than for hospitals to comply with OSHA regulations.

So with that in mind, I have two comments regarding the issue:

1. As a private practice physician who is not employed by the hospital, I would suggest that these OSHA rules do not apply to me and therefore the hospital risks no retribution for noncompliance from the accreditation arm of the Joint Commission, which is why I suspect the issue comes center stage for hospitals everywhere. If necessary, I will gladly sign a waiver to relinquish my rights to compensation should I ever contract a blood born pathogen or other communicable disease from drinking my coffee.
2. If the hospital believes this is a patient safety issue and wishes to make their regulations stronger than those of OSHA and apply them to ALL people in areas with patient pathogens, I will gladly relinquish my daily fluids when I am shown the data regarding patient harm AND the hospital also bans all patient guests from bringing food or drink into the patient's room. If this is a patient safety issue, it must apply to everyone should they wish to make their rules stronger than OSHA guidelines.
   

Until this is resolved with rational thought, perhaps over a round of coffee, I'm going to carry one of these around:

It always seems to work for patients.

What's Wrong With Using Standard Of Care As a Threshold For Negligence?

What's wrong with using standard of care as the threshold of medical negligence? I walked you through a case, point by point, as to how the failure to diagnose cannot be considered negligence and why the process of the differential diagnosis must be protected from the fear based legal system we operate in.

When the differential diagnosis became a legal driven process, we physicians lost our ability to offer cost effective, clinical driven medicine. We became front seat drivers in the world's largest Ponzi scheme known as the Medicare National Bank. A 99 trillion dollar black hole of defensive medicine.

What is it about the threshold of standard of care that makes it irrational? Why is that the standard for negligence? And what exactly is it? In six years of clinical hospitalist practice, three years of residency and four years of medical school, I have never taken a lecture, never seen a presentation, and never read a book about the mystical standard of care. In fact, I find myself grasping to comprehend exactly how to define its very existence.

I see a problem with what the standard has become. If everyone in my community orders a head CT for drunks with altered mental status, that represents an action by a responsible body of opinion. Does it mean it's the right opinion? It does not. When the body of opinion has been contaminated by a persistent and progress fear of litigation, the standard defies the evidence, and itself creates irrational bars of achievement that can never be sustained. The responsible body has itself become irresponsible.

If we are to be a science driven profession, we must be allowed to maintain our integrity, without the fear of legal retribution for failing to uphold the irresponsible responsible body of opinion. Our standards are no longer based on science. When everyone orders the CT scan in drunks with altered mental status, the standard itself has become unreasonable.

Yet the marked deviation of the standard of care from the science of care marches on.

I have argued that standard of care is a local phenomenon. It is what ever the local community of professionals says it is, as they are the responsible body of opinion. The standard for evaluating a pulmonary embolism in downtown Chicago is not the same as the standard in rural New Mexico as it is in the jungles of Africa.

A lawyer previously responded that the local community should not set the standard. They argued that the standard should be a national, or perhaps an international evidence based standard. If science is science, there is no reason to believe that evaluating a pulmonary embolism in the United States should be any different than it is in the jungles of Africa. The most important factor in medical decision making if often not the science but the way the science is practiced on a local level.

The standard of care in McAllen, Texas is not necessarily the same as the standard of care at the Mayo Clinic. Is the cost difference legally driven or is it money driven at the local level? I suspect the contribution from both is enormous. Some argue that we should practice as Mayo practices. Mayo may be cheaper, but it isn't cheap. I would argue that even under their payment model as a large salaried multispecialty organization with economies of scale, the ability to practice defensive medicine still thrives. Who says what costs $8,000 in McAllen but costs $5,000 at Mayo couldn't be done for $2,000 if the victory against defensive medicine was won? I suspect it could, if physicians weren't held to irrational standards by the unreasonable reasonable body of opinion.

If the standard in McAllen is to do a heart catheterization on everyone with chest pain, that is what the community has decided. If the standard of care at Mayo is to do a cardiac stress test, that is the standard at Mayo. If the standard in the African jungles is to do a history and physical, that is the standard in the African jungle? What is the right standard?

The right standard is the one that doesn't get you sued.

Now, are all three standards of care based on science? No. They are based on what the community of physicians has decided should be done. There will always be a large disconnect between evidence based medicine and clinical medicine. It is not reasonable to do a CT scan to evaluate a pulmonary embolism in the jungles of Africa if that is not the standard, even if the evidence suggests otherwise. Clinical factors should always drive the medical decision making.

Some have argued the standard of care should be founded in evidence based guidelines and not local practice expectations from responsible bodies of opinion. Rarely are guidelines clinically relevant in the hundreds of decision trees physicians make every day in their diagnostic processes. Guidelines are based on studies with limited populations of patients whose neatly defined age groups have packaged disease processes. The realities of clinical medicine make many guidelines unworkable and unreasonable.

My post here is an example of the limited value of guidelines in the differential diagnostic process. Not only are the guidelines often not relevant, they are often contaminated by medical societies and other big businesses with a money driven agenda and stealth conflicts of interest.

We must also remember that most guidelines are not based on science but rather based on expert opinion. All physicians are experts in their scope of practice and their opinions should therefore carry the same weight as the opinions expressed on academic based guidelines. Those that believe national standards should exist to drive standard of care practices across the vast clinical spectrum lack an understanding of what it means to be a physician.

Some lawyers wish to believe that having X, Y, and Z data points means doing A, B and C. Some wish to believe that failure to do so represents negligence as a responsible body of opinion would have done so.

I have never been introduced to this responsible body of opinion. I have no way of speaking for their recommendations. We have local culture driving decision making. We have limited national guidelines often corrupted by external influences. We have a legal system, who's negligence is based on responsible bodies of opinion, opinions which have been established by fear driven medicine.

So what exactly does it all mean? When I order a lab or a test or a procedure or an x-ray to make my clinical decision making, I don't sit there and think to myself, "What is the standard of care?"

I think to myself, "What is my expected action or reaction from doing this? What am I trying to accomplish?" I have never been introduced to this elusive responsible body of opinion. I have never been invited to a luncheon. This responsible body has never asked me out for a drink. I have never gone on a date with this body. I have navigated through ten years of clinical medicine and I have never once been formally introduced to this all knowing body of opinion.

By establishing the threshold of negligence as a vague responsible body of opinion, a concept which few physicians have studied, few physicians can quantify and few physicians trust, we have built exactly what the medical-legal-industrial complex has prepared for us: A high volume, high supply, high demand, high cost fear driven reality that we all pay for with out of control health care inflation.

If you think Mayo care is cheap, the time has come to consider that even the highest quality, lowest cost centers in this country could reduce their utilization of health care resources by 1/3, 1/2 or more if the fear of civil retribution for failure to diagnose was taken off the shoulders of passionate and devoted physicians from all fields of training and they were allowed the freedom to employ their differential diagnosis skills in a manner consistent with scientific inquiry and not a legal driven fear.

The longer we deny the fear, the quicker the end will be here.