Save On Electricity Bills: Just One Simple Common Sense Suggestion

What a crazy winter this has been. The cold snap is sure to have many folks asking themselves how to save on electricity bills or rising natural gas bills.

Compared with last year, natural gas prices are much lower (in fact they were at record lows just a few months ago), which has allowed those homes heated with natural gas to escape the brunt of rising energy costs.  However, the same cannot be said for the electricity bills coming due.  Do you want to save money on your electricity bill?  Read about what not to do if you live in Orlando.

Many at Happy's hospital got  snowed in on Christmas.  We are used to the cold winters and occasional blizzards.  In the south however, things are different.   Atlanta snow turned drivers into maniacs.  Even Orlando got a massive two week freeze that killed their fish, their coral and many of their endangered manatees.  

I just returned yesterday from a refreshing four night stay in Orlando.  The Orlando Sentinel newspaper reported about skyrocketing electricity bills due to the record breaking cold snap that had customers using almost double the amount of electricity they normally use.  Many locals found themselves wondering how they could save money on their electric bills.  Sonja Smith, a hairstylist  found herself scrambling to cover a $514 electric bill caused by the early January cold wave, more than double her previous record  electric bill. 

Some customers called it ridiculous.  The region's power companies understood and were willing to work with customers to set up billing arrangements.  Many customers wonder why their electricity bills went so high.  It's simple market forces at work.  When you have a record number of people using electricity, the costs of obtaining that energy becomes greater.  Thus is the nature of supply and demand.  It's one of the main reasons why the supply of primary care doctors are shriveling up, despite the increasing demand (false government RVU economics)

One 79 year old lady in Orlando wondered if her meter was read correctly after receiving a $726 monthly electric bill, far higher than the $300 she usually pays in extreme conditions.  Why was this lady's electric bill so high and how could she save money on her electricity bills?  Well, for starters, she admits to setting her thermostat as high as 77 degrees to keep herself warm in the brisk cold  Orlando winter.

Seventy-seven degrees?  Are you kidding me?  It's no wonder she paid $700 for her electric bill.  Perhaps if she wants to save on her electricity bills, she needs to stop turning her home into a sauna and set the thermostat at a temperature that isn't going to bankrupt her.

Mrs Happy and I struggled with bitter cold temperatures late last year which were fixed by the simple magic of a replacement furnace filter.   We have our thermostat set at a comfortable 70 degrees.   It's perfect.  I don't even want to think what my gas bill would be if turned the temperature up to 77 degrees.

If you want to save on electricity bills, I have just one suggestion:  Don't set your thermostat to 77 degrees.  If you live in Orlando, put on a sweater and brave the 70 degree weather in your home.   Or better yet, turn it down to 65 degrees.   It's no wonder why some people are paying sky high electricity bills.  They forgot to use common sense.

How To Initiate Coumadin Dosing or Warfarin Dosing And Is Anticoagulation Therapy Considered A High Level Risk For Medical Decision Making In A 99233 Hospital Follow Up Visit?

A reader asked me this question:

In a follow-up progress note (soap note) for a hospitalized patient, if things are relatively stable with them BUT we have more than enough Physical Exam "bullets," and enough data points / diagnoses that we're watching.. does routine monitoring of the patient's PT INR testing (Coumadin dosing or warfarin dosing) or anticoagulation therapy  qualify for the Medicare National Banks' criteria for the High Risk category of medical decision making, such as:

"Drugs requiring intensive monitoring for toxicity"

Here is my response (I'm not a certified coding expert with regards anticoagulation therapy so read this with that warning in mind.  However I've been doing this for years and I could justify my answer till the cows come home to any judge or jury that would question my coding authority from my position as an expert in hospitalist medicine):

The reader is referring to the billing of a high level hospital follow up code 99233.  I absolutely consider anticoagulation therapy (coumadin dosing or warfarin dosing)  to be a high risk process requiring intensive monitoring.   I would definitely consider ordering a daily protime or INR (International Normalized Ratio) as a form of intensive monitoring for toxicity.   Intensive is a realitve word.  I have never seen it defined.  Weekly checks?  Monthly checks?  I have no idea what the government wants.  Surely a daily INR would be considered intensive for a drug that can kill you if not prescribed with caution in sick hospitalized patients with multiple comorbidities.

Everyday I'm doing anticoagulation therapy patients who's INR has accelerated out of control due to  the coumadin dosing or warfarin dosing interaction with Levaquin or Bactrim or amiodarone or Fluconazole. These patients are certainly at high risk of complications from their disease process.

Everyday I'm adjusting my coumadin dose up or down trying to decide when it's safe to stop the full dose Lovenox or venous embolism prophylaxis dose of Arixtra being used for anticoagulant therapy.  I see hospitalists and subspecialists everyday ordering bolus doses of coumadin.  Published research suggests a bolus coumadin dosing does not improve outcomes but does increase the risk of bleeding complications by statistically significant amounts.  

How do I initiate coumadin dosing  or warfarin dosing as my anticoagulation therapy?  After seven years of seeing the horrors of excess anticoagulation therapy on my hospitalized patients as well as my hospital admission patients with their spontaneous subdural hematomas and massive diverticular bleeds,  I have adopted a highly conservative approach  based on  sound evidence  and clinical experience when initiating this rat poison who's mechanism of action  as a vitamin K antagonist interrupts the synthesis of clotting factors II, VII, IX, and X.

How do I initiate coumadin dosing? The standard starting dose I use is 6 mg for everyone under the age of 50.  As far as I know, there is no randomized clinical trial that uses an age based scale for initiating coumadin dosing.   All I have is seven years of experience treating thousands of patients.  Here is my age based scale for coumadin dosing and warfarin dosing:

Less than 50 years old:  6 mg

Less than 65 years old 5 mg

Less than 70 years old 4 mg

Less than 75 years old 3.5 mg

Less than 80 years old 3 mg

Less than 85 years old 2.5 mg

Less than 90 years old 2 mg

Over 90 years old, I'm not starting it without a compelling reason.  

I do not know the data or if there even is any data on prescribing short term or long term anticoagulation therapy in the 90+ year old population.  Before I entered my medical school education, I worked as a lab technician for a year at a phase three clinical trial company.  Prior to that in fact, I was a patient in a trial as an undergraduate college student.  I  quit that study because of the incredible amount of pain I experienced with 20 or more blood draws a day from the same site for over a week. And they didn't have a vein light to help the technicians.  And I didn't need the money that badly.   

It was very clear to me.  The only people being studied were young healthy nonsmokers.  That's how these drugs clear their clinical trials.  There were no 90 year olds getting tested on the pharmacokinetics of warfarin dosing in their age group.   All we have are clinical experience and post marketing data.  That's as good as it's going to get.  And my experience says coumadin dosing in a patient over 90 years old is a recipe for disaster.  So I choose not to use it at all, if at all possible, even if the guidelines say I should.  Because my experience says the guidelines were not made for the 90 year old body with twelve medical problems.   Instead,  if the patient had an immobilizing orthpaedic fracture or intervention of their lower extremities I would recommend a prolonged course of subcutaneous Lovenox or Arixtra for their anticoagulation therapy

After age, I next review the patients medication profile.  Many medications will interact with warfarin dosing through the cytochrome P450 enzyme system.  While recent genetic tests (the Amplichip CYP450 costs $500 and most insurance companies won't pay for it)  have become available to check for individual patient response to warfarin dosing metabolism, they are not clinically useful as they are not widely available with quick turn around in a cost effective manner.  In other words, by the time I get my patient's genetic coumadin profile, they will already be therapeutic from my clinically determined coumadin dose.  

What effect does the cytochrome P450 enzyme system have on coumadin dosing metabolism?  Some common drugs  (quinolones such as Levaquin or levafloxacin, Cipro or ciprofolxacin, amiodarone, Bactrim, Diflucan or fluconazole,  Biaxin or clarithromycin, Flagyl or metronidazole) are inhibitors of the  P450 enzyme system (they make the patient require less coumadin dosing).  

Some common drugs (Tegretol or carbamazepine, Dilantin or phenytoin, phenobarbitol, rifampin and even tobacco) are stimulators of the P450 enzyme system (they make the patient require more warfarin dosing).  Once I have reviewed the patients age and medication profile, I make an approximate 30% adjustment in coumadin dosing (my own estimate)  when drug interactions are obvious.  I know of no published data other than clinical experience that can guide the clinician hospitalist towards dosing adjustment based on drug-drug interactions.

Once I have adjusted for age and drug interactions, I want to know what the patient's protein status is.  Coumadin is highly bound to albumin.  As you know, so is calcium, which is why a low calcium level is rarely critical if one had the education, motivation and inclination to calculate the  scientifically proven and physiologically accurate corrected calcium level to prevent unnecessary interruptions through meaningless data-through-telephone-transfer-protocols.  

  

 Because coumadin is bound to albumin, a low albumin level will mean that the patient requires less coumadin dosing for long term anticoagulation therapy(ICD V58.61) to get to the therapeutic INR of 2-3 for most conditions (atrial fibrillation, DVT prophylaxis, deep venous thrombosis or pulmonary embolism treatment, arterial thrombus of any kind) or  an INR 2.5-3.5 for mechanical valve anticoagulation therapy prophylaxis.  If the patient's albumin level is really low (less than 2.5)  I will cut my coumadin dose in half until I know how the patient responds to their initiating dose.  

That means for a healthy 40 year old on no medications I will start the coumadin  dosing at 6 mg a day with no bolus dosing.  For an 85 year old on amiodarone and an albumin level of 2, I may chose to start warfarin dosing at 1 mg a day until I know how the patient responds.

With all that said,  I reiterate that coumadin dosing is absolutely considered a high risk anticoagulation therapy requiring intensive monitoring for toxicity.  And with that said, it would qualify as part of the ridiculous CPT® rules our Medicare National Bank has put into place for us to follow.

The same could be said for heparin. If you consider frequent checking of your partial thromboplastin time (PTT) when adjusting your heparin drip to be important,  I would certainly consider coumadin dosing to be just as important.  I would even consider an intravenous or subcutaneous insulin scale to be justified as intensive drug monitoring  for the purposes of CPT® medical coding.  Glucose is the monitored parameter for toxicity and insulin is the drug.  Are you checking Dilantin levels as well?  That can get toxic real quick.  Heck, even adjusting the lasix dose based on the creatinine could be justified as a high risk medication requiring intensive monitoring for toxicity (creatinine and potassium levels).

Coumadin dosing and anticoagulation therapy is one of the major coding tools I use when I accurately document my work performed in order to justify a high level complexity visit in a post operative orthopaedic surgical patient for which I am co-managing their anticoagulation therapy and other chronic diseases.  

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

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Head On Over to Grand Rounds This Week

It's the LOL edition.

How Do You Clear A Snow Path For Dogs In Rochester, New York?

We have dogs that hate the cold weather, but we have to help our Italian greyhounds survive the snow. I hand scooped the trails for Marty and Cooper in our back yard when the Christmas 2009 winter snow storm hit.  But I don't live in Rochester, NY.  They average over 100 inches of snow a year.  How do you clear a snow path for dogs in Rochester?  Here's how.  With a snowblower.

Hypotension Causes: Three Cases Of Severe Hypotension and Their Dramatic Response To Treatment

Hypotension causes physicians to pause.  I get paged everyday about nonsensical issues that can wait for my daily rounds.  But hypotension is different.  Hypotension causes physicians to react quickly.  What are the most common admitting causes of hypotension in my hospitalist practice?   Infection and volume depletion would have to have to lead the way.

The most common  hypotension causing infections encountered by hospitalists are probably pneumonias and urinary tract infections.  When bacteria from either process enter the blood stream, they can cause an inflammatory chain reaction leading to hypotension, hemodynamic collapse and eventual rapid death.   When dealing with sepsis and shock, time is critical.  Minutes can mean the difference between life and death.  That's why if you suspect septic shock in your differential diagnosis, your first two goals should always be

1. Volume resuscitation fast
   
2. Antibiotic administration fast
   

The nationwide Surviving Sepsis campaign has lead the charge for educating doctors and nurses about the importance of early intervention in this deadly disease process.  Everyday I see patients that have been woefully under rescued from their deadly sepsis cycle.  Their hypotension causes them to experience a delay in organ resuscitation.  It's all about time and it's all about volume.   That's what saves lives.

Many protocols have been developed to assist physicians in the management of severe hypotension. Some treatments are well established.  Some are controversial, such as steroid use in sepsis.  One theory  says hypotension causes a relative adrenal insufficiency in patients unable to produce enough mineralocorticoids to maintain their blood pressure.  This is the theory behind giving steroids to patients with sepsis.  The thoughts on steroids seem to change with every passing year.

I define hypotension as a blood pressure that is low enough to cause end organ harm to a patient.  Most of the time, as a matter of default, we are trained to accept a systolic blood pressure (the top number) of less than 90 mmHg or a mean arterial pressure of less than 65 mmHg as hypotensive.  But, this is not always the case.   For some folks hypotension causes problems at higher numbers (acute ischemic stroke patients need higher pressures) and for others hypotension causes problems only at much lower numbers (cirrhosis patients can tolerate much lower blood pressures).  The key for me is whether the hypotension causes organ failure.

Case #1 and  #2:  Hypotension causes me to view steroids with respect.

Both patients complained of  a few days of generalized weakness, malaise and viral like symptoms.   Both patients were terribly sick upon arrival to the hospital. Both presented to the emergency room with critical levels of hypotension causing hemodynamic collapse.  Both patients got a central line.  Both patients began aggressive fluid resuscitation.  Both patients had critically low central venous pressures.   Both patients failed to respond to aggressive fluid resuscitation.  Both patients were initiated on intravenous blood pressure support medication.  Both patients weren't getting better.

What happened?  Why was the aggressive volume resuscitation  not helping in either patient?  In the first case A CT scan of the abdomen confirmed the presence of bilateral adrenal hemorrhage. The presence of bilateral adrenal hemorrhage in meningococcal sepsis patients is known as Waterhouse-Friderichsen syndrome.  My patient did now have meningococcal sepsis.  They had spontaneous bilateral hemorrhage into their adrenal glands from the anticoagulant warfarin.  I don't think I will ever see that again.  But this case will forever be ingrained in my psyche.  Bilateral adrenal hemorrhage causing hypotension causing hemodynamic collapse.  I was amazed at this patients response to steroids.  Within 15 minutes of steroid administration,  this incredible adrenal crisis hypotensive causing  death spiral was completely reversed.  The patient fully recovered almost immediately and all critical parameters had returned to normal.  If your patient does not respond to fluids, give them steroids (hydrocortisone 100mg IV followed by 50mg IV Q6 hours).  You just might save their life.

What about my second patient?  Well, they didn't have bilateral adrenal hemorrhage, but they did have primary adrenal failure with subsequent hypotension causing hemodynamic collapse.  I did a cosyntropin stimulation test on them (drew a baseline serum cortisol then administered 0.25 mg of cosyntropin to stimulate the adrenal glands, drew a 30 minute and then a 60 minute post infusion serum cortisol).  The test is rarely abnormal.  If you're stressed your baseline cortisol should be high and giving a drug to stimulate your adrenal glands should make your cortisol levels go even higher.  In this case both the baseline level and the stimulated levels were low (below 10).  This is pretty diagnostic of an adrenal crises.  In this case, it was probably a viral or perhaps an autoimmune failure of the adrenal glands.   Who knows why.    Both patients responded immediately to intravenous steroids.  That is the clue to adrenal crisis.  When hypotension causes a hemodynamic collapse that reverses almost immediately with IV steroids, you know your adrenal glands have failed you.

Case #3 Hypotension causes me to cover my bases.

The last case was a crazy one.  One day you're normal.  The next day you're in the intensive care unit with a central line, a central venous pressure monitor and an IV pole with five or sex life saving medications hanging by the way.  When you show up in the ER with a systolic blood pressure of 50 with 20 of dopamine hung in the field, you know things are bad.  What could possibly make a grown adult go from normal to a hyptotension causing disease process ready to take your life?  In this case, it turned out to be a reaction to an over the counter medication being used to treat a garden variety headache.

How about that.  A severe allergic reaction, which spared the respiratory and skin centers,  but created a beast of a hypotension causing hemodynamic collapse on the order of severity I had never seen before.  After some steroids, H2 blockers, subQ epi and a ton of fluids, my patient went from near death in the ICU to walking home the next day.  Amazing.

For the vast majority of my patients in the hospital, hypotension causes a brief delay in their recovery process.  They usually respond well to fluids and antibiotics.  They usually got dried out by their diuretics  and they usually recover nicely with broad specturm antibiotics. Their hypotension causes them no long term consequences.  But sometimes, we must change the game plan when our fluids and antibiotics don't work.  We must think of other causes.

These three cases show the power of the human body's own regulatory network of hormones and the consequences that occur when they fail you.   When your adrenal glands stop working the subsequent hypotension causes a life ending complication  unless steroids are administered.  When your body rejects a medication  the hypotension causing chain reaction can kill you.  Just remember, all hypotension is not caused by infection or volume.  If your patient fails to respond to standard therapies, it's time to go back to the drawing board. 

Pet Therapy Dog Service Will Be The Future Driver Of Hospital Revenue And Hospitalist Value

Meet Visa, Happy's hospital pet therapy dog.  I saw Visa roaming the halls (without a leash) the other day and snapped his picture.  Hopefully the Joint Commission and Humane Society don't shut us down.  This dog is cleaner than many folks I come in contact with who emit the nauseating aroma  of tobacco smoke and stale body odor.  As you can see, he is a bit camera shy.  Mrs Happy and I have Marty and Cooper, our two Italian greyhounds.   Their love tanks are always full.
 

I think they would make the perfect pet therapy dogs.  Marty gives huggles and kisses.  I'm not kidding.  If you tell him "hugs and kisses"  he will walk onto your chest, wrap his skinny little paws around your neck and press his neck into your chin.  He'll give you a hug and then smack you a wet kiss. He just loves giving hugs and kisses.  What patient wouldn't want Marty as their pet therapy dog jumping on their sternal incision and navigating around their chest tubes?

I say go for it.  If Marty and Visa can make you feel better as a patient and help the hospital get higher hospital  survey satisfaction results, it's time we get a pet therapy dog on every floor. It's also  time for hospitals to start looking for alternative sources of revenue.  Pet therapy dogs offer the perfect growth opportunity for hospitals struggling under the weight of declining payments and increasing patient entitlement.  Much like primary care and their movement into concierge medicine, it's time for hospitals to start thinking outside the box.  Pet therapy is the perfect revenue source.

I envision pet therapy dog time as just one option of many to be offered to patients on a daily basis.  For an additional fee, the patient will have a host of services to pick from.  Whether it's  pet therapy dogs and hair stylists on one day or pedicurists and  massage specialists on the other, the menu of fee carrying hospital amenities  is limited only by the imagination.

If  the patient can pick their food menu everyday why not offer them amenities above and beyond what their Medicare and Blue Cross is paying for.  I envision the future of hospital medicine being funded by the rich and well off who demand a higher level of service in their hospitel.  Unless they can find alternative sources of revenue, hospitals will suffer as Medicare goes bankrupt.   It will be a race to the bottom, unless hospitals can generate income above and beyond what insurance will pay for actual health care.

The time has come to build hospital kennels and invest in pet therapy dogs.   Who's going to pay for the right to see Visa?  You know who you are.  The ones with the summer home in Hawaii and  a 40 feet fifth wheel parked in your 12 stall garage.  You want the comforts of home.  You want Fido there to comfort your ills. Well,  it's time you help support the economic collapse coming to a hospital near you.  It's time to pony up some extra cash to pay for that pet therapy dog to grace your presence. It's time you paid to get your hair done and your back massaged.  It's time you paid to get your nails done.  You are the future revenue source of hospitals everywhere. 

Who is going to manage these pet therapy dogs in the hospital?   Who is going to be your hair stylist?  Who's going to do your nails and give you your massage?   Why hospitalists of course.  I see training and managing of pet therapy dogs among the other amenities as just another in a series of value added benefit hospitalists will bring to the future of hospital based medicine.

Pet therapy is just one of many revenue sources for  hospitalists  to entertain as they enter this future of  hospitalist based medicine.  You won't hear about any of this at the Society of Hospital Medicine international convention this year in Washington, DC.  Nope.  You heard it here first.

Quality care?  Evidence based medicine?  Nah.  None of that matters.  The future of hospital medicine isn't about quality or evidence driven medical care.  It's about keeping patients happy.  Rich patients. Rich patients with money.  Rich patients who will keep our hospitals solvent for the rest of us common folk.  That's the future of hospital based medicine.  Without rich patients, hospitals won't survive what's coming our way.

In-patient pet therapy dogs are  the  future  source of revenue for hospitals struggling to stay alive in a Medicare system that's broke.  It's this type of thinking outside the box that will save future hospitals from the greatest asset  collapse the world has never seen.  As a hospitalist I plan on staying ahead of the curve.  I'm getting my dog handling permits in line today.   I recommend others do the same.

Good Home Grown Hospitalist Humor

Dr Happy:  Hey Dr Cardiologist I have a 99 year old man with critical aortic stenosis and...
Dr Cardiologist:  He's not a 100 hundred yet huh...

That's just some good home grown hospitalist humor.

The Power Of Love: Going To Dialysis Hell and Back

The power of love is alive and well. Huey Lewis & the News said it well in his Back to the Future hit single The Power of Love.  Love can make one man weep and another man sing.  The power of love can  cloud the minds of rational men and women.  The power of love can drive irrational medical decisions.  The power of love can even drive men and women to experience great pain, suffering and self sacrifice to prevent the only companion they've ever had from experiencing the agony of lonely heartache.

As physicians, we often forget about the powerful forces that drive a patient to act.  We are trained to look at data with an objective mind. We are trained to make decisions based on probabilities. We are trained to discuss outcomes based on objective data and clinical experience.  If we find ourselves emotionally attached with our patients, our ability to remain neutral, for them,  in the face of their adversity, could cause us to act irrationally as well.  The power of love works both ways.

While this may be viewed by many as uncaring, it is in fact necessary to remain emotionally neutral for the practice of sound evidence driven medicine. We need physicians that can cry for their patients, not with them. 

Patients are often viewed as a disease that can or cannot be cured.  Patients are often viewed as a compilation of symptoms that can or cannot be managed.  Patients rarely present to the hospital with a DRG.  They don't come to the ER saying "I have an empyema".  They say, "I'm coughing and short of breath".  They want their symptoms to go away.

For many patients, money is a powerful motivator in their pursuit of health care decisions.  "How much is my copay?  How much is my deductible?  Does my insurance cover it?  My insurance is covering everything.  I want you to to all my outpatient testing I had scheduled for next week while I'm in the hospital.  While you're at it, can I also get my pap smear done as well?" For many patients, money is the motivating  factor on how they make decisions on their health care.

However, the power of love is alive and well.  Families make irrational decisioins all the time when faced the the finality of death.   Advanced directives are reversed everyday when children and spouses have to face the acute nature of a dying loved one.  In my seven years of hospitalist medicine, I have rarely seen the power of love play out right in front of my eyes as it did for my elderly couple.   The power of love is real.   The power of love definitely drives patient decisions, whether those decisions are based on sound medical principles or even a firm grasp of reality.  Perhaps the power of love is a driving force of denial, driving a hope that everything will be OK.

I had the pleasure of taking care of Gertrude, a 94 year old farmer's wife, stricken with end stage age.   Gertrude is the wonderful farmer's wife of Fred, her 97 year old knight in shining armor.    The two of them have 12 children, four of which have already passed on, 26 grand children and 12 great grandchildren.  The power of love in their relationship is incredible.

You see, not only does Gertrude have the advanced stages of life, she has end stage kidney disease (ESRD).  Gertrude needs dialysis to survive.  If you don't know anything about your kidneys, know this, if your kidneys don't work well enough to filter a low calcium level, or  critical lab values, toxins and fluids, you end up swollen and dying of a quick and painless deadly heart arrhythmia or peacefully in your coma like state.

Instead of accepting the limits of mortality with grace, the power of love has driven Gertrude to test the limits of suffering most humans couldn't bear to witness.  Gertrude wants dialysis.  She's willing to go to Hell and back, suffering through the weakness, the immobility, the nausea and dizziness, the infections, the sepsis and the pneumonias.  She's willing to go through it all for the power of love.  Gertrude doesn't care how much suffering she will endure by starting dialysis at the end stages of her life.  She doesn't care how much it costs for her or her country.  She doesn't care about any of that.

The only thing on her mind is the power of her love for Fred.

"I can't stand to watch Fred suffer.  I can't stand to watch him watch me die, knowing how much pain that causes him.  I'm willing to go to Hell and back to keep Fred from suffering and watching me die."

The power of Fred's love for his wife is just as strong.

"I want you to do dialysis on Gertrude.  Even if it means I have just one extra day of life with my Gertrude, I want you to do it."

I have to admit, this is a very unusual circumstance. By the time most of my patients have entered their 90s, they have already lost their spouse.  They have already accepted their own mortality.  Most of the time, they and their family, are willing to accept the probability of dying with age.  Most of the time the discussion of kidney replacement therapy wouldn't even be considered.

At one point, palliative care had been discussed.  In fact, palliative care had been initiated.  Until Fred's suffering became to much for Gertrude to watch.  The power of love had taken over.  Gertrude changed her mind.    Palliative programs allow patients to die with dignity.  Unfortunately, in this fantasy world of American health care we all participate in, saying no is not an option.  Should 94 year olds  with end stage renal disease even be offered dialysis.  Should patients with end stage life be offered all the technological amenities of modern medicine?

When the Medicare National Bank was started almost half a century ago, none of the politicians could have predicted the economic implications we find ourselves in today.  Medicare is broke and it's not getting any better.  None in Washington expected this social health program to pay for dialysis to  temporarily  delay the death  of our 94 year olds.  None of it was planned for.  None of it is being paid for.  Not then and certainly not now.  The question of appropriate medical therapy is not even on the radar of today's health care discussion.  Not yet at least.  It will be.  Someday.  It has to.

The power of love does not care about probabilities.  The power of love does not care about patient expectations and mortality figures.  The power of love does not care about how much kidney dialysis is going to cost others.  The power of love only cares about Gertrude and Fred.  That's how they have chosen to make their informed consent.  That's the resource they have chosen to guide them through their mortality.

It's romantic.  Almost 75 years of life with one partner.  That's a tribute to their love.  But love doesn't make rational decisions.  Love doesn't pay the bills.  There is no statistical p value for the outcomes of love.  There is only the power of love.

I'm glad that this situation is rare, at least in my practice.  Most of the ninety plus patients I take care of  have already faced the death of their life long partner.  Most have already accepted their own mortality with grace.  Most do not make these irrational decisions based on love.  Most do not pursue and demand therapies which will cause them great pain and suffering for the love of those around them.  Most are ready die with grace. 

But when the power of love is alive and well, all bets are off. 

How Do I Know My Cancer Is Bad?

You know your cancer is bad when, upon autopsy, the pathologist reports:

Multifocal tumor thromboemboli in right and left lung.

That's when you know your cancer is bad.

CPT® Medical Coding Done Right Can Save Your Practice And Help You Thrive Economically

If you want to make a living in today's environment as a nonprocedural oriented physician you must master CPT® medical coding to maximize your revenue in the  undervalued relative value unit system of cognitive medicine.

Medicare recently eliminated consult codes for both in-patient and outpatient E&M medicine.  What this means is that all physicians performing consultative services in the hospital (at least for Medicare patients) will now bill the hospital admission codes (99221, 99222, 99223) instead of the consult codes (99251, 99252, 99253, 99254, 99255).

If the patient is not a Medicare patient, physicians can still submit consult codes to the non-Medicare  insurance company as most are still paying them.  Just imagine how complicated that gets as a physician, trying to decide which code to submit for  which patient based on which insurance they have.  As a group Happy and his partners have decided to continue with business as usual.  We will submit our consult codes as if none of our patients have Medicare and we will let our billing company figure it out.

As a side note to this whole coding mess, PQRI, the CMS pay for performance initiative   for 2010 has now become a logistical disaster.  Two of our reporting initiatives were only reportable under consultative or discharge codes  but not admit codes.  Now that Medicare consult codes have gone away, my understanding is that these PQRI codes will now be submitted under admit codes as well.  None of our systemic processes we had in place to maximize success with PQRI accounted for this sudden shift in reporting processes.  My concern is that many of Happy's partners will lose out on their 85% reporting requirement because they do not understand how to play the game as I do.

But none of this madness compares to the blatant self sacrifice and destruction I heard a physician consultant tell me the other day.  I'm going to say it again.  If you want to survive in the cognitive fee for service game called evaluation and management (E&M), you must master CPT® medical coding and be your own expert on every patient,  every time.  If you are concerned about getting audited, you must understand that CPT® medical coding is about following the rules.  If you document appropriately, you should bill appropriately.    If you want to get paid for the work you do, you must learn how the CPT® medical coding game works, regardless of where you fall on the bell curve.

After asking the physician what they have been doing for the last two weeks now that consult codes have been eliminated, the response was simply to "bill a level two admit instead of a level four consult for just about everyone".

I was stunned, shocked and floored by this response.

Happy:  You do realize that if you are billing a level four consult or a level two admit on your patients, just about every single one of them will qualify for a level five consult or a level three admit.  Doc, you are throwing away tens of thousands of dollars a year because you don't understand CPT® medical coding"

After I went through a brief  impromptu lecture on  how to bill CPT® 99232, the following conversation ensued:

Subspecialist:  "Happy, maybe you do know what you're talking about"
Happy:  Yes doc, I do, and you are throwing thousands  of dollars out your Lexus every day."

Let me run you through the mathematics of CPT® medical coding and how it relates to annualized revenue potential lost because you choose to bill a mid level CPT® code instead of  billing for the work you actually did (and may or may not have documented)

The AMA has a website where you can plug in your state and CPT® code and it will tell you how much you will get paid for ever CPT® code you can possibly bill.  In Happy's state, here are my payments:

CPT® Medical Billing Codes
99222 Mid level hospital admit code:  $115
99223 High level hospital admit code:  $170
99232 Mid level hospital follow up code: $60
99233 High level hospital follow up code: $90

How does that play out in a group practice? First of all, because of the way the E&M rules are set up, if you are doing the work of a mid level admission, you can almost always get credit for a high level admission.  That's just the way the E&M rules are set up.  What does that mean for the average clinician?  It means you should almost never be billing mid level (99222) admission codes, because if you document appropriately, you will qualify for the a high level CPT® medical billing code 99223.

I went back and reviewed my 2008 admission data.  In 2008 I billed 313 high level admissions (99223) and two mid level admissions (99222).  That's because I know how to document and billing a level two admit when you do the work of a level three admit is not only irrational,  it's no better than overbilling and is itself considered a form of reporting Medicare fraud. Unfortunately for you, you'll never find a Medicare audit complaining that you under bill your CPT® medical coding.

What was my distribution of level two hospital follow up codes (99232) to high level hospital follow up codes (99233) in 2008?  Of approximately 1,400 inpatient hospital follow up codes I billed in 2008, the distribution was right about 50% for each.  The jump from a mid level  hospital follow up to a high level hospital follow up requires a little more documentation than it does for the admit codes, but doing so helps you get paid for the work you are performing.

What does this mean on an annualized revenue basis?  Let's run some numbers for my good E&M subspecialist friend I referenced above.

CPT® Medical Coding Scenario #1

1. Three consults a day being billed at midlevel (99222) and 10 follow up visits a day being billed 80% midlevel (99232) and 20% high level (99233)
2. Converting this to all high level admissions (99223) and a 50% distribution for follow ups

On an annualized basis an office with these types of numbers seeing a 100% Medicare population, seeing patients 365 days a year could generate hospital revenue of (3*$115 + 8*$60 + 2*$90)*365 = $366,825 .  What could that revenue look like if CPT® medical coding was done appropriately?  This office could generate  (3*$170 + 5*$60 + 5*$90)*365 = $459,900.  That is a difference of $93,075  (25% )for doing nothing more than approaching CPT® medical coding with the attitude of confidence and experience.

CPT® Medical Coding Scenario #2

1. Six consults a day being billed at midlevel (99222) and 15 follow up visits a day being billed at 80% (99232) and 20% high level (99233)
2. Converting this to all high level admissions (99223) and a 50% distribution for follow ups

Here are your revenue numbers:

• Before CPT® medical coding optimization:  (6*$115 + 12*$60 + 3*$90)*365=$613,200
• After CPT® medical coding otpimization (6*$170 + 7*$60 + 8*$90)*365= $788,400

If this office could get its doctors to optimize their CPT® medical coding under this simple but highly plausible scenario, they could realize an additional $175,200 a year in additional revenue, a 28% increase.

CPT® Medical Coding Scenario #3

1. 10 consults a day being billed at a mid level (99222) and 20 follow up visits with a 80/20 distribution between mid level and high level codes
2. Converting this to all high level admissions codes (99223) and a 50/50 distribution for mid and high level follow up codes

Here are your revenue numbers:

• Before CPT® Medical Coding optimization: (10*$115 + 16*$60 + 4*$90)*365= $901,550
• After CPT® Medical Coding optimization : (10*$170 + 10*$60 + 10*$90)*365= $1.168,000

If the doctors in this scenario were able to learn corect CPT® medical coding and apply it to real world situations, they could increase their revenue by $266,450 a year, or 30%.

That's how much money doctors leave on the table when they allow their fear and ignorance of CPT® medical coding to guide them in their lack of daily documentation.  With continued pressure to reduce costs and ever declining payments to doctors on an inflation and rising overhead cost basis, having the skills to guide CPT® medical coding is necessary to not only surivive, but to thrive.  Many doctors have implemented fancy EMR comparison systems to help them maximize revenue.

What ever it takes, as a physician, you have a right to get paid for the work you perform.  You can see much more for free in my lectures on medical billing and coding.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high def view

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

Can Food Be Health Care?

The theme of this week's grand rounds has a food them and focus.  Go check it out.

Television Executives To Late Night Television Watching Americans: Screw You And Oh Yeah, We Have $40 Million Dollars To Give Away To Conan O'Brien

In a bold move by television executives to screw every American who watches late night television, reports have surfaced that Conan O'Brien will get $40 million dollars to walk away from his Late Night talk show and stop bad mouthing his NBC network.  $40 million dollars for walking away.

Read On

Vein Light Technology And IV Access In The Hospital: A Detailed Look

So I'm doing a hospital admission on a 78 year old man the other day with bad COPD  and chronic systolic heart failure.  As I'm doing my history and physical  the nurse pulls out a Vein Light. I was amazed  but not surprised that such a technology existed.  Every year that passes, hospitalized patients seem to get sicker and sicker.

As our elderly march ungracefully towards their delayed and unexpected death, the quality of their heart, lungs, kidneys and yes, even their veins seem to deteriorate exponentially.  It's just not that easy these days to get stable IV access in hospitalized patients.

Not a day goes by where I'm not being called by a floor nurse to tell me they can't find any veins or the patient's IV access is unstable, or they need a central line.  I've been working as a hospitalist at Happy's hospital for seven years and these calls are always some of the most frustrating, especially when they come from my partner's patients.  But this is the first time I have ever heard of the vein light.

Why not use a vein light, I say.  A few years back, the Site Rite was introduced to assist doctors with central venous lines.  This is an ultrasound assistive device the physician can use to directly visualize the patient's jugular vein.  I tried it three for four times several years ago and gave up.  I found it difficult to manipulate while trying to place the catheter  and I haven't used it since, mostly because I only put in subclavian lines.

If doctors can have ultrasound guidance for the central lines, why shouldn't nurses have a vein light to find their patient's vein as well.  If it keeps the nurse from calling me at all hours of the day or night to tell me they can't find a vein or can't get IV access,  I say get one for every nurse in the hospital.

IV access in the hospital is one of the most basic (and important) parts of the patient experience.  It can also be one of the most frustrating for doctors and nurses alike when stable IV access becomes a problem.  One of my biggest pet peeves as a hospitalist is having a partner of mine check out to me an unstable patient with nothing more than a 22 gauge for IV access.

I also hate it when the physician assistant or nurse practitioner in small town America sends me a septic patient with hypotension on dopamine administered through a 38 gauge butterfly IV as they role into the ICU.  If you are going to to work in the emergency department  you have to be able to stabilize the  patient appropriately.  If that was your mother you shipped away by amubulance, you would expect them to have  a central line or large-bore IV access at the least.    Anything less is inexcusable.

What is a large bore IV?  It is an IV with an 18 gauge or larger lumen.  The smaller the number the larger the lumen.   You want large lumens for IV access in unstable patients so you can administer fluids, medications and blood products very quickly.

Why do you need intravenous access in the hospital?  If you're sick enough to be in the hospital, you are sick enough to require IV access.  If you should crash and burn in the middle of the night and you have no IV access, you're going to wish you hadn't demanded the nurse remove your IV.  IV access is a basic safety measure in the hospital.  If you code, the nurses must have a way to administer your epinephrine. 

I think every nurse in the hospital should be given a vein light as a patient safety initiative to guarantee IV access.  Unfortunately, I know that is not feasible.   Why?  Because this vein light, nothing more than a glorified studfinder, costs almost $500.  That is amazing.  Would you pay $500 for a stud finder in the name of patient comfort?   I can assure you that you won't find a vein light  in Egypt.  And you wont find vein lights in the future of American medicine as hospitals struggle to survive under the weight of a bankrupt Medicare National Bank.

What is the order of hierarchy when it comes to establishing IV access in the hospital?

1. The Emergency Room Nurse.  Most patients get admitted through Happy's ER or through a small town hospital ER.  It's the ER nurses job to establish adequate IV access.  Frequently, I am asked to admit unstable patients with 32 gauge IVs placed by the triage nurse, covering for Susy who's on lunch break.  A 32 gauge IV does not constitute stable IV access for a hospitalized patient.  Instead, all ED nurses should be trained in placing double lumen peripepheral IVs.  I asked an ED nurse why all nurses don't place them.  It seems like this combination 18+20 guage IV would solve a lot of the IV access problems I encounter in the hospital and it could save many patients from getting PICC line complications.  I was told that these IVs intimidate a lot of nurses.  Interesting to say the least.  By the way, I didn't see any vein lights floating around in the ER.  Maybe it's time to introduce them.
   
2. The Floor Nurse.  If the patient is admitted from the ER, they should already have adequate IV access established by the time they hit the floor.  If the patient comes from a small town ER or hospital  they should already have adequate IV access as well. Often times, however, they don't.  These hospitals aren't splurging on $500 vein lights, I can assure you of that.     Sometimes the patient arrives as a direct admit from the doctor's clinic at which point they won't have any IV access at all .   Some floor nurses are better than others.  In fact some floor nurses are a lot better than others.  I'm sure many nurses would agree.  I know a few nurses who never miss.  They are the go-to-guys and gals when it comes to needing IV access.  If a floor nurse can't get an IV and they've tried "multiple times", I'm glad they now have a $500 studfinder vein light to help them.
3. The ICU Nurse.  Once the floor nurse has exhausted his or her skills and the vein light has failed them, the next person to call is the ICU nurse.  ICU nurses can get IV access 90% of the time a floor nurse fails.  Most of the time, adequate IV access can be achieved by these  nurses who specialize in taking care of really bad protoplasm.  Sometimes they  even  resort to placing external jugular lines    
   
4. The Flight Nurse.  If the ICU nurse can't get the peripheral IV access, and the jugular fails,  even after they've tried the vein light, it's time to call in the flight nurse. These are the trauma nurses who fly around in helicopters and stabilize field traumas.   These are the folks who can stick just about any vein with a pulse. But you have to get lucky.  Often they aren't in house.  If they are, they can solve the problem 90% of the time an ICU nurse fails.  I'm not sure many flight nurses carry around the vein light though.  Something tells me it would be a badge of weakness for them.
5. The Nurse Anesthetist.  Happy's hospital has 24 hour access to anesthesia services.  However, the one person in house is often off doing a trauma case or putting in an epidural on a pregnant lady to earn their keep.  Occasionally, when all routes for peripheral IV access have been exhausted, I must write an order to "consult Anesthesiology" to place a peripheral IV. Once the emergency room nurse, floor nurse, ICU nurse and flight nurse have exhausted their capabilities, I can usually count on these folks to get the job done at 3 am.  I'm pretty sure the vein light is not a part of their hospital issued arsenal.  Something tells me the scrub nurses would laugh them out of the building.  If the nurse anesthetist can't get peripheral IV access, even with their $500 Vein Light, there isn't a soul in the world that's gonna get it at 3 am.
6. PICC Line Nurse.  My experience as a hospitalist is that patients need IV access 24 hours a day, not just Monday throught Friday from 8 am- 5pm and Saturdays until noon. That's why PICC Lines must be available 24 hours a day, if necessary.  I'm just glad they are.
   
7. Hospitalist.  I'm lucky # 7 on the road to IV access.  If all roads have been exhausted, it's time to place a central line.  For me, that means a subclavian approach (under your clavicle/collar bone).  I've done hundreds of them. In seven years I've given two patients a pneumothorax.  That's pretty dang good. My record from start to finish is twelve minutes. I like using the quadruple lumen catheters  for extra access.  I never place anything with less than three lumens.  Some of Happy's partners don't do central lines.  Some only place jugular lines.  It's really a matter of preference.  My preferance is the subclavian approach.  That's what I'm comfortable with.  I don't use ultrasound guidance mostly because I rarely have a problem obtaining access.  And if I do, it's time for someone else to try.  Who might that be?
8. Intensivist, Pulmonologist, Trauma Surgeon, Anesthesiologist, Interventional Radiology.  It's a head to head competition on who gets to try next.  It depends on what time of day it is, what hospital I'm at, where the patient is , and who's following the patient.  It comes down to an issue of urgency and convenience.  Who's the easist doctor to reach.  What happens if none of these doctors can get IV access?
   
9. Jesus.  If you are a patient and you have exhausted options one through eight and the nurses with their fancy vein lights and the doctors with their fancy ultrasound machines and the trauma surgeons with their fearless nothing can stop me now attitude can't get IV access, it's time to call Jesus. 

You're screwed.

UPDATE.  Or if  you  need to know how to find a difficult IV,  just grab one of these $6,000 vein locators.  The patient won't know what hit them.

Lost Generation Palindrome Video: Amazing You At 50 Contest Video

Check out this Lost Generation palindrome video in the You at 50 contest sponsored by the AARP.  This video apparently won second place.

I'm 36 years old, soon to be 37 years old.  Our country is spending 1.5 trillion dollars more a year than it takes in.  Our Medicare National Bank is cash flow negative and is for all intents and purposes, bankrupt.  Our government is buying off its constituents today and all but guaranteeing  that generations to come will pay heavily for the bribery of today.

In less than 14 years I'm going to be fifty years old.  That isn't that far off at all.  By then I could only hope that our population will haved wised up to the havoc Washington is creating on our prosperity.

The lost generation is going to be paying heavily for the blatant disregard for conservative fiscal policy by republicans and democrats alike.  They are all but guaranteeing a generational warfare in the years to come as the lost generation revolts against the inexcusable excesses and entitlements that have muddied the morality of today's politicians.

I can only hope the lost generation does not fall victim to the FREE=MORE mentality that the baby boomers will be expecting as they march ungracefully into that dark night.  I think the madness will implode long before I turn 50 if we as a nation choose free and more instead of sanity and stop the madness in Washington.

Watch the video now.

Eyeglass Frame Tattoo Video: That's Kind of Cool

Here's a crazy video of some guy that got eyeglass frames tattoo to his face.  Kind of cool if you ask me. I'm not sure his employers could realy complain, unless they complain about people who wear glasses.   While you're at it, check out the guy with the  eyeball tattoo.

My Top 50 Keywords of 2009

Dr Centor gave you a list of his top top 50 keywords which were used to find his site on search engines in 2009. Here you go doc. Here's my list of the top 50 keywords and the number of times my site was found through search engines using those keywords. 

Read On

Where Do All The Dead Bodies Go After Natural Disasters Such as the Earthquake in Haiti?

Where do all the dead bodies go after natural disasters such as earthquakes, tsunamis and hurricanes?  With potentially 100,000 lives lost from the recent earthquake in Haiti, I'm sure many of you are wondering the same thing.  I know I am.  CNN gives us a startling inside view  of where all those dead bodies are taken in the aftermath of massive death and destruction from natural disasters.    Wow.  How sad is that.  I had no idea it was so animalistic.

Do Doctors Ever Stop Bothering To Care About Patients?

Have you ever stopped bothering to care about a patient?  A doctor sent me his own personal account of the smoking Mr Jones:

Dear Happy.  I read your article on bouncing back with great interest, and was astonished by some of the vitriol it elicited.  I remember having one COPD dyspnea patient bounce back to me three times within a month at the VA when I was a medicine resident.  He would leave, not quit smoking for good and drink, and then come back and be readmitted to my service with exactly the same course each time.  It was like Groundhog Day.

Finally I had a little talk with him and said: "Mr. Jones, each time you come in, you're on death's door.  So I come down to the ER, stay up with you all night and save your life.  But you know, I'm really getting tired of having you come in after drinking and smoking and then working like a dog to save your life.  So let me tell you my quit smoking advice, the next time you do this there's a good chance that I'm not going to bother.  Why should I?  It doesn't seem to be doing either of us any good."

To my complete astonishment, he actually quit smoking and stayed quit for about a year.  Then he fell off the wagon, deteriorated too far before getting to the hospital and died.  I was frankly proud of him for the effort, but somehow suspect that I'd be shot in a drive-by if I ever told that story in public.

What do you think?  What is the patient responsibility for their own health when they are armed with the knowledge necessary to make the right decisions  and choose to ignore their own responsibility?

It appears in this situation that tough love is exactly what gave this man an extra year of life.  Should we as a nation sit by and accept the bankrupting of our nation at the hands of an unmotivated populace given guaranteed access to the fruits of other's labors without any personal sacrifice?  Should we allow the destruction of our country's solvency to be destined by COPDers who bounce back every month because they choose to smoke  and ignore their personal responsibility to society?  Should we not expect the population that benefits most from a system of FREE=MORE to pay exponentially higher prices for their right to to express their freedom on the sweat and sacrifice of others?

It's clear to me if as a nation we choose to excuse our citizens from the financial responsibility of their actions, we will get a nation of Mr Jones' who have no personal interest to help themselves or society. Only if we stop excusing Mr Jones from raping our nation's Treasury will we have the opportunity to make significant strides toward financial solvency.  

Either patients will have to start paying for the freedom to spend other people's money, or they will have to be excluded from the fixed pool of  resources available to help those who wish to help themselves.  As long as we pretend that we can provide unlimited resources to everyone and ignore the responsibility our citizens have to reduce their own consumption of their own health care resources, we are destined to meet a financial collapse of unimaginable pain.

In the hospital setting, I  would find it difficult to ignore the death knocking on Mr Jones' door.   I would stabilize and treat him like I do all COPDers who come in, smoking or not.  I would do everything I could, within reason, to stabilize his disease process, even if he smoked four packs a day.   That's the way the current health care system operates.  That's the system we practice in.

However, at some point or another, when all the money is gone and hospitals and emergency rooms start shutting down for good, Mr Jones will move to the bottom of The List  to make way for patients who offer self sacrifice in their disease process.  His care will be triaged.  His access will be denied.  In fact, if you think this is crazy, just such a suggestion made headline news in Britain  a year or two ago as their country's national health system continues to get buried under uncontrollable costs.

When our nation finally wakes up and realizes that  difficult economic health care decisions will have to be made  based on self sacrifice and choice, you can be assured that those who choose to do nothing for themselves will be sent to the bottom of The List. If you want to be in that Line, I suggest you continue your ungraceful march toward mortality by pretending that your actions today have no effect on your place in the Line to come.

Intensivist or Hospitalist: What Is the Difference?

A reader asked the question:

What is the difference between a hospitalist and an intensivist?

What is a hospitalist? Well reader, quite simply, a hospitalist is usually an internist (but can be a pediatrician or a family medicine doctor) that only works in the hospital and an intensivist is usually a pulmonologist with critical care training that works in the ICU (and usually the pulmonary office as well).

Hospitalists generally do not follow the patient outside the hospital.  They do not have clinics.  Many programs use the shift model of care.  That is, the hospitalist works defined daily shifts and checks out at the end of the shift to their partner who would then address any patient care issues that may arise while their partner is off service.

This is the model of choice in big hospitalist programs  that can support the funding of overnight, in-house physicians.  Hospitalists who just work overnight shifts are called nocturnists.  They generally command a higher rate of payment than doctors who work the day shift.  And hospitalists who don't work any nights should expect to be paid less than those who do.

Shift hospitalist programs can be expensive to fund, mainly because many hospitals  do not have the patient  volumes  to support dollar for dollar nocturnal care.    Most programs shoot for 40 hour work weeks as the standard  shift model.  You can view the latest hospitalist salaries  data here. 

Many smaller hospitalist programs use home call as their scheduling of choice.  In otherwords, the doctors take their pager home with them.  This is the way medicine has been practiced for decades.  This model allows fewer physicians to run a program while still having enough bodies to fill the needs of the program.  Unfortunately, I think some of the benefits  of in-house hospitalist medicine are lost with the home call model, specifically, the immediate bedside evaluation in patients with acute changes. Unfortunately, smaller programs just can't afford the cost of 24 hour a day in house physicians.

Some hospitals at larger referring centers will close their ICU.  What does this mean?  It means only critical care doctors and other subspecialists are allowed to practice medicine in the ICU.  I just filled out my recredential paperwork that gives me privileges at Happy's hospital. Intensive care  unit privileges are something that must be granted by the hospital credentialing committee.  If the hospital closes their ICU, they are basically granting  practicing privileges to some doctors and not to others.

Usually a closed ICU denies privileges to the primary care fields of internal medicine, pediatrics and family medicine.  This is why I hate the designation of internal medicine as primary care.  So much of what we internists are trained to do is complex, intense and critical. It's not primary care and it's not something that can be done, in full scope, by those without a medical degree. 

This is how my University medical center functioned  when I was a resident.  If a patient of mine required transfer to the ICU, I gave up care to the ICU team.  When they came back from the ICU, I would pick them up again onto my medicine service.

Why do hospitals close their ICU?  Perhaps there are concerns about the quality of care being offered by the pediatricians, internists and family medicine doctors.  I know a study a few years ago suggested better outcomes (I can't remember what was being measured) when hospitalists rounded in the ICU when compared with the intensivists.  If Happy's ICU ever turned into a closed system and denied my ability to care for ICU patients, I would quit.  Providing ICU care is part of the great satisfaction I have as a hospitalist.

How about the  intensivist?  Intensivists are usually internists who have gone on to specialize in a two year (or three year) pulmonary critical care fellowship.  The word intensivist is used to defined these doctors as their role in the ICU.  Usually, an intensivist is available for immediate consulation during a defined period of time.  Most hospitals, even large hospitals, cannot afford to have an in-house 24 hour a day  intensivist. As a result, most intensivists may have a set period of time, perhaps 7 am to 5 pm, as agreed on with the hospital, where they are in-house, doing multidisciplinary rounds with the nurses and respiratory therapists and pharmacists along with doing procedures and taking care of patients.

Happy's hospital has both a hospitalist program and an intensivist program.  In fact, we have two intensivist programs.  Both groups have privileges at both hospitals.  Happy's hospital system is awash in intensivists.  We have an excellent working relationship with our intensivists.  Happy's hospitalists will often admit the patient to the intensive care unit and  obtain a consultation with the intensivists if we think it is necessary.

I have heard over and over again that Happy's hospitalists have given back the lives of the pulmonary critical care doctors, doctors who used to come in at 3 am to admit simple pneumonias because the family medicine doctor didn't want to take the time to make an evaluation.  We offer a great service to the patients and the intensivists, and they reciprocate by helping us manage patients that need a higher level of expertise or procedures and other interventions we aren't trained to provide.

I am thrilled with the relationship I have with the intensivists at Happy's hospital.  They are always available, 24 hours a day to assist in the evaluation and management of critically ill patients.  Rarely will I ever  call them  in for  a middle of the night consult. However, I know if I need them they are available.

Often times both the intensivist and the hospitalist will round on ICU patients.  The intensivist will often  limit their evaluation and management to the pulmonary issues at hand.  Frequently, there are multiple subspecialists on the case in the ICU (renal, bloodless surgery, GI, pulmonary, cardiology, ID).  Sometimes, too many subspecailists are involved.  In these cases, the role of the hospitalist can be limited.

I try and avoid this scenario, as I know, and my experience tells me, that more doctors and more care will often have no good effect, and perhaps even a detrimental effect on the care patients are receiving. 

So there you have it. A hospitalist can do a lot of what an intensivist does in the ICU, but not all.  An intensivist generally does not do hospitalist work, because they have limited most of their practice to pulmonary and critical care issues.  While they could do some hospitalist work, I wouldn't want them evaluating an 89 year old with weakness  anymore than I would want me doing a bronchoscopy.

Television Health Statistics: Each Hour Increases Your Death Rate From Cardiovascular Disease By 18%

If you've spent anytime on The Happy Hospitalist in the last two years, you know I am a strong believer in lifestyle as the only solution to an economic disaster we find ourselves in.  One recently reported television health statistic confirms, once again, the strong correlation between lifestyle and early death.
 

I blogged previously about studies showing an 80% reduction in heart disease, strokes, cancer and diabetes by adhering to lifestyle choices proven to save lives.  America is a nation of couch potatoes.  Everyday I see families, doctors and nurses taking the elevator up on story to the next floor above.    What ever happened to using the stairs for a little self sacrifice?

The television health statistics in this country are alarming.  How many hours a week do Americans spend watching television? 1  How does 31 hours a week sound.  That's amazing.  I have one or two shows a week that I watch, if I'm lucky.

How does all that television affect your health?  Of course, if your sitting on a couch watching television, you aren't doing something physically active, and a sedentary lifestyle is a major risk factor for poor health.  

The new research out of Australia has helped to quantify these television health statistics for us.  The data is shocking to say the least.  The recent study published in the journal Circulation helped to clarify just how much television was affecting our health.

That is amazing.  Almost an 80% increase in cardiovascular death for the average American in this country can be attributed to their decision to lay their butt on a couch and veg out in front of the boob tube.  And that doesn't include the almost 50% increased risk of all cause death and 40% increased risk of cancer death from watching 31 hours of television a week.

It's data like this that should give every American, at least those whom are fiscally honest, a pause to contemplate exactly what the disaster we have brewing within the walls of our government health care debate really means to us.

The issue is not about access to insurance.  Access will mean nothing when the cost of health care inflation prices out all but the richest of Americans.  There isn't a government in the world that can support FREE=MORE universal health care.  They are all doomed to failure?  Why?  Because the people demand unlimited access to a resource that, by all intents and purposes, could be self rationed by a creating a running log for a little sweat a sacrifice.

We have a President who smokes trying to make deals with a Congress buying favors  while our  entitlement programs spiral massively out of control.

And through all this promise of government salvation, not a peep is heard about the personal responsibility we all have to keep ourselves fit and healthy.  The solution to our health care finance crises is not about spending another 3 trillion dollars to create access to insurance.  It's about holding all Americans accountable for how they choose to live their lives.

If you want to spend 31 hours a week watching television and increase your risk of cardiovascular death by 80%, by all means, be my guest.  When the money is gone and there are no hospitals and doctors left to care for you, don't expect anyone except the mortician to be there to help you.