VA Horror Story Policies Continue: Dick's In Charge.

Several weeks ago I posted about my experience when trying to transfer a patient to the VA.  It was so horrible I created an Xtranormal video titled Hospitalist vs VA doctor patient transfer.   Dick is definitely in charge.  Now, here's another VA horror story on ridiculous policies that prevent our military men and women from receiving the care they were promised.  

A 58 year old retired army man with no alternative payer source except VA insurance presents to Happy's hospital from a small town community hospital, as a direct ambulance admission, with pneumonia and delirium.  Upon arrival, we realized this gentleman's only payer source was VA insurance.  After determining  that this man was clinically stable for ambulance transfer to the VA 75 miles away, a facility that could provide the care this man needed, we made contact with the veteran's hospital.

The VA refused to accept the patient because he was too confused to consent for  transfer to the VA.  Too confused to agree to transfer.   That's what they said.   What fascinates me here is the ease for which this confused gentleman made it to my hospital three hours earlier and yet, the immense  difficulties we encounter when trying to get him to the place he needs to be.  While we provide service, the VA gives us Dick. 

 This is not a rare occurrence.  This is the daily reality.  For the policy folks who believe the VA represents excellence, I would recommend you never try to get yourself admitted to a VA hospital.  By VA standards, you're too confused to consent to transfer. 

Which, when you think about it, is actually backwards.  The only people who would agree to transfer to the VA are the people who must, in one way or another, have a certain element of confusion.  Heck,  I trained at a VA for three years.  I wouldn't let a VA hospital touch me with a one hundred foot poll.  Not because the doctors are bad.  They aren't.  The VA doctors are your community doctors in the real world.   I can't speak for all the nurses.  Some of them have no business being employed.  Some of  them do a horrible job of faking employment.   Some of them are despicable.  But it's  much more than that.  It's the embarrassing hospital culture that starts at the top and permeates through every lazy and entitled bureaucrat  right down to the parking lot security guard.  

Here's the VA culture in a nutshell.  

• Nobody cares about anything, 
• All problems are there for somebody else to ignore.
• Everybody is too busy doing nothing to get anything done.  
• Too many paid holidays.  It's obnoxious. 

If you can stand working in that environment, sign up for a local VA job.  Perhaps Dick needs a partner in crime. 

Funny Patient Quotes? This One Is a Doozy!

Sometimes patients say the funniest things.  As a medical profession, we are around the lingo day in and day out.  It's easy to lose the perspective of a lay person.  That means funny patient quotes are bound to happen.

In fact, I  had a funny patient quote just the other day.  It was an older lady admitted with abdominal pain and severe constipation who had remarkable results with just a couple suppositories.  

Happy:  How do you feel today? 
Woman:  I feel fantastic.  I want you to send me home with a couple dozen of them depositories.

It took every ounce of strength in my body not to start laughing out loud.  But she got a heck of a smile out of me.    I couldn't help but see images of Ben Bernanke  dumping wheelbarrows full of freshly minted cash into his vault  as she tried to tell me about the rest of her night.  

She lost me at depositories.  It's like a cancer patient who doesn't hear a word you say after you drop the C world.    I didn't hear a word she said after the whole depository thing.    All I could do was smile and laugh inside.  It made my day.    I suppose she figured I was just really happy that she pooped.

I didn't have the heart to correct her.  It was just too cute.

Best Doctor's Day Celebration Sign For 2011 (Picture)

Thanks to all the nurses on all the floors for their kind Happy Doctor's Day thoughts on this  March 30th, 2011 celebration of Doctors.

The winner for my unannounced best  Happy's  Happy Doctor's day sign goes to the cardiac floor for this creative poster.  And a thank you to all the other floors for all the wonderful chocolates and snacks that were placed wide open in the nurses station, filled with all the life threatening and disgusting biological fluids that placed my life at great harm (at least according to the folks at OSHA who have lost all sense of reality).

Happy Doctor's Day 2011

I guess that means the coffee police have officially disbanded and the hospital rules for no food or drink at nurses station no longer apply. Hallelujah! Now that's a reason to celebrate  Doctor's Day for 2011!

For more about Doctor's Day read about:

• The origins of Doctor's Day.
• Doctor's Day breakfast and lunch (pictures) from 2010.

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.

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 definition view

Death Perspectives From Different Medical Physician Specialties.

Everyone has their own perspectives about life and death, often based on life experiences and their worldly views. Doctors are no different, except to say that doctors deal with life and death every day of their lives. For medical doctors, death perspectives are more likely to be defined by their disease specialty.

Here are a few examples of  death perspectives from the different medical specialties

If you're a pulmonologist, nobody dies without first getting a bronchoscopy.

If you're a cardiologist, nobody dies without first getting a heart catheterization.

If you're a nephrologist, nobody dies without first getting a run of dialysis.

If you're an oncologist, nobody dies without first getting a course of chemotherapy.

If you're a neurologist, nobody dies without first getting an EEG and an MRI.

If you're a gastroenterologist, nobody dies without first getting a colonoscopy.

If you're a rheumatologist, nobody dies from lupus, because the answer is never lupus. 

If you're an infectious disease doctor, nobody dies without first getting a course of doxycycline.

If you're a family practice physician, nobody dies without getting a consult.

If you're an internist, nobody dies without first admitting the patient to the hospitalist.

If you're a dermatologist, nobody dies. Period. 

What's the moral of the story?  If you want to live forever,  get a dermatologist as your primary care physician. 

Nursing Hazing vs Medical Hazing vs Fraternity Hazing.

Nursing student hazing

Happy:  How much oxygen is the patient breathing in.

Student Nurse:  She's not on any oxygen.

Happy:  No Oxygen!  What is she breathing in?

Preceptor RN:  Just ignore Happy.  Tell him to pick on someone his own size.

Med student hazing.

Attending:  Does the patient have a temperature?

Med Student:  No.

Attending:  No temperature?   Are...you... sure?

Med Student:  Yes.

Attending:  Then you're telling me my patient is at absolute zero.  Did you order a warming blanket?

Med Student:  I thought you meant did they have a fever.

Attending:  Ah.  Remember to always pay attention to the details, because details will make the patient sink or swim.  

Fraternity hazing.
Never mind...

Organized Tax Documents Complete. Oh, The Pain.

Here is a picture of my organized tax documents.  It only took me two full days of  tedious back breaking work combing over my tax preparation disaster and turning it into these neatly organized files filled with doctor  income on the right, itemized deductions on the left  and a pile of  tax related blog papers in the middle. 

Now if I could just stay organized throughout the year, this wouldn't be so painful.  

Woman, Eva Fisher, Robs a Bank To Pay For Her Denture Bill: Ordered To Eat 3-5 Years of Free Food and Receive Free Dental Care.

A reader sent me these  links about this woman, Eva Fisher, who robbed a bank in August, 2010.  Not much of a headline, until you realize that she was caught at a CVS Pharmacy after already making it to an  Affordable Dentures store to pay off her $500 denture bill.

She pleaded guilty to this charge, after previously receiving probation for a 2005 bank robbery.  What was her sentence this time?  Three to five years of free food and dental care in the slammer. 

I wonder if the bank confiscated her dentures and sold them at auction.  I'm almost sure they  did after taking a peek at this lady's mug shot.  It doesn't matter though.  As a prisoner, she could probably get another pair or two of dentures for free.  

Something tells me she got the last toothless laugh out of this one.  Here's to the men and women of law enforcement for taking a bit out of crime. 

Hospital Construction: Obamacare's Obamazone (Picture)

I snapped this picture showing mass confusion at Happy's hospital the other day.  I've seen a lot of construction at Happy's hospital over the years. Entire floors and units springing up out of nowhere.  But this is crazy.  Is there gold behind them there doors?  Or is this just a picture of hospital construction,  Obamacare style?  Does this represent the danger we are heading toward with unfunded mandates and irrational economics?

And which is it?  Is this an exit?  Is this an emergency exit?  Is this not an exit at all?  Are we stuck with no way out?  So many questions being asked.  No answers to be found.  Only more confusion. 

KEEP OUT! NO TRESPASSING!  CAUTION!  STOP!  These  are the warning signs of what is to come.

I couldn't have said it better myself.   You are now entering Obamazone. Put your hard hat on folks.  The boulders are everywhere.

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.

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 definition view

Signing Medical Durable Goods Requests: Oops, Sorry About That.

As you know, I've been going through a massive pile of disorganized papers for tax preparation purposes.  In the process I found a one year old pile of work papers that I intended to organize.  I apparently forgot about them.  What were they?  They were mostly unsigned medical necessity durable goods requests.   Things that need to be signed and returned to the durable goods supplier in order for them to get paid by the Medicare National Bank.

I'm sure they eventually got signed after several re-faxed requests.  Oops.  Sorry about that.  More uncompensated work that nobody pays for.    How does Medicare, Medicaid and every private insurance company get away with this practice of  consuming physician time and resources without paying for it?    Why haven't physicians, as a matter of default, started charging for every piece of paper that comes through their office?  I know some offices have started to charge for phone calls, emails, disability and FMLA forms.

Why charge for the phone call but not the Medicaid preauthorization request? When did the physician's office become the verifier and enforcer of patient benefits.  And not only that, but why are they expected to  tackle the job for free.

Perhaps the best way to handle the situation is simply to schedule an appointment every time any request for anything comes through the office.  The doctor and patient could fill out the paper work or make the phone call together, with the patient present.  If the patient is upset that making an appointment to come in so the doctor can sign the verification form for their walker a waste of their time, then they will have a pretty good sense on how frustrating the whole process is for physician offices and have an excellent incentive to contact their Senators or bombard their employer and insurance company with angry letters.   Perhaps they will understand more clearly how bad it has become.  Having patients come in for a scheduled appointment does two things:

1. It turns uncompensated work into compensated work.
2. It helps the patient understand what's necessary to provide care for them in the third party insurance model.  

Either patients  don't care, or they don't understand how bad the paper pushing has gotten.   Making them come in fixes both.  

Dog Surfing the Internet (Picture)

It's not just people who  waste their day away reading blogs and surfing the Internet.  I present to you a picture of a dog surfing the Internet.  I caught Cooper, our seven year old Italian greyhound, surfing the Internet with Mrs Happy the other day.  

You'd better be careful Cooper.   Too much surfing the Internet and you might just become the fattest dog ever.  Here he is helping Mrs Happy fill the baby room with goodies.  And before you know it, he might even have his own blog. 

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel, and their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Dogs Meet Baby Crib For the First Time (Video): Italian Greyhounds Jumping For Joy!

We're at 33 weeks and counting for baby Zachary.  We got the baby crib up the other day.  Here, Marty and Cooper, our two seven year old Italian greyhound dogs, meet the baby crib for the first time. You can find them jumping for joy in this video.  You'll even find, Marty, the white Iggy, making his bed inside the crib near the end. 

When I found Marty seven years ago, he was the runt of the litter.  He was the last one.  And the lady had him sleeping in a baby crib.  I wonder if this brings  back memories for him.

Watch our dogs meet the baby crib for the first time.  You might even laugh.

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Pregnant Belly with Dogs (Italian Greyhounds) Pictures. Precious.

Here's a few pictures I caught of Marty and Cooper sleeping next to Mrs Happy's 33 week pregnant belly yesterday. Precious.  I think Cooper and baby Zachary are exchanging heart beats while Marty gives us the stink eye.

For more Marty and Cooper action, you can catch them at their YouTube channel, and their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Tax Preparation (Picture). Chaos In A Sea Of Organization

Blogging might be a bit light for the near future. Mrs Happy and I are preparing baby Zachary's kennel, I mean castle.  Plus I'm trying to get all my papers together for the accountant, who probably hasn't slept more than a couple hours a night in months.  Perhaps the federal government needs to intervene and mandate sleep requirements for all accountants during tax preparation time in order  to protect we, the people, from deadly financial mistakes caused by sleep deprived accountants.

Here's a picture of my tax preparation efforts. Somewhere along the way I got confused and thought chaos in a sea of organization was the goal.  Boy did I get that one wrong.  But I suppose, when you owe the IRS a bunch of money, there's no hurry.  Take your time Happy.  You still have three weeks to earn 0.4% interest on their money. 

Let's be honest.  When the jokers continue to spend 1.5 trillion dollars a year more than they have, what difference will a few dollars from a physician blogger make?  Or maybe I'm wrong.  Perhaps if I had paid my bill a few months earlier this  whole government shutdown debate could have been avoided. 

Maybe this year, I'll be a little better year round about that whole tax preparation thing.  Then again, probably not.

Doctors Writing Stuff In The Chart That Didn't Happen and Telling Things To Patients That Aren't True: I'm a Nurse. What Should I Do?

A reader asked me some compelling questions about witnessed fraud and the pain and suffering that's tearing her up inside:

Dear Dr. Happy,

I'm going to get right to the point:

I work with an oncologist who repreatedly writes progress notes on the pt's paper chart without having assessed the patient.  I work with another oncologist who gives chemo to dying patients. I'm told by her patients that she says they need it. Recently, one of her patients came to the ER directly from the onc office for SOB experienced while receiving a prolonged chemo infusion. She has widely metastatic non-small cell lung cancer (every organ you can imagine) with excruciating pain.    After a two week intubated stay in the ICU, on four pressors, with an albumin of 0.8, she was discharged to a nursing home unable to do anything.    On the last hospital day, the oncologist wrote a note that the patient "looks great and will be ready for another round of chemo soon".   Looks great?  Greater than what? The family is adamant about 'doing everything' because her oncologist said she was doing better!  This lady can't even move.  

This is wrong.  It happens often.  I feel terrible and I'm really distressed. I'm just a nurse. 

Do you think I should report what I know to hospital administration?  Should I file a report with a medical ethics organization?  Or should I keep my mouth shut and hence keep my job?  Or should I look the other way and be grateful I have a job?  This is distressing and I can't sleep - - I just feel so miserable.   I need a level-headed, pragmatic opinion.  Can you tell me where I could get one of those?  Thanks very very much. Sorry to bother you, but I had to start somewhere.

You bring up several points worth talking about.  First of all, I too have had nurses tell me they have seen physicians write follow up progress  notes, complete with a history and physical exam, and never enter the patients room. 

It disgusts me too.  To know there are colleagues I work with   that don't have enough  integrity to document truth in a chart makes me livid.  I don't know what the right option here is.  It's a difficult situation.   You could take your concerns to the medical staff offices at the hospital.   If your hospital has any integrity at all they would  not take your concerns lightly.

There is a possibility you could get "fired", as happened to those nurses in Texas who filed a complaint against a physician,  then got fired, then sued and fought back and as far I I know, won their case.

If the patients are Medicare or have private insurance, both insurance programs have processes in place for filing fraud complaints.  You could go directly to them.  If your employer is the oncologist you're  more likely than not to be let go.  Certainly, you could carry on your crusade as an unemployed nurse.  If your employer is the hospital, bringing up concerns about fraud is something they should want to hear about.  And if they sanction you for your truthful actions, it's time to get a lawyer.   Or you could always tell the doctor up front that what she documented is not what you witnessed and explain your concerns about fraud.  Perhaps she believes nobody is watching and she may just surprise you.  

Now, as far as your concerns about end of life ethical issues, unfortunately, we live in a health care buffet where not only do patients have an all access pass to FREE=MORE, but doctors do as well.  As physicians, our only limitation is what we say it is.  It's unfortunate, but when you have  physicians who

1. Lack perspective
2. Lack integrity
3. Lack common sense
4. Lack compassion

They have the ability to offer patients everything, all the time, whether it has medical necessity or not.  I have to ask, Where are all the other doctors?   The best pressure on doctors to behave are other doctors.   Why have they not stepped up and confronted this oncologist with a more rational picture of reality and their concerns about pain and suffering the patient is needlessly experiencing.  

My experience, as a hosptialist, is that medical inertia is a powerful force.  Once the wheels of doing something, anything, get moving, it's hard nearly impossible to change directions.  What you need is a rational family and a rational physician communicating about dying with dignity.  

What your hospital needs is a palliative care team.  I've heard it said before that the ICU team is the most expensive palliative care program out there.  I've heard the same said of oncologists, cardiologists and nephrologists. Even many hospitalists lack persepective.      A real palliative care team is invaluable.   They can and should be asked to enter into the discussion of dying patients to help define the past, present and future goals of the patient and family.  

What your hospital  needs is a team that can help bring an objective truth in to the equation.  What the family hears is not reality.  What this oncologist is telling them is not reality.  Both are living in some sort of fantasy world, or Hell, depending on how you look at it.  Both parties need  redirection.  

I wouldn't get into the middle of such squabbles.  It's not a battle I think you can win on behalf of your patients.  You know they are suffering, but the medical opinion of the oncologist will always trump your opinion as a nurse, no matter how right or wrong they are.  

What you need are folks on your side, helping you help your patients by overwhelming your patient with an alternative opinion the truth. It's all about truthful communication.  You won't win this battle alone.  

Then it's up to the doctor to stop ordering the pain and suffering, it's up to the insurance companies to stop paying for it and it's up to the patients and their families to accept the reality of the situation.  As long as everyone is fully informed, the chips will fall where they should, most of the time and dying with dignity becomes a reality.  

Perhaps some readers have an opinion on what this distressed nurse should do about the documentation fraud she is seeing committed and the pain and suffering she feels is being handed without telling patients the truthful reality of their situation. 

On a side note, you can watch my video hospitalist vs oncologist for a delightful look at cancer care.  

Walking Pet Balloons at the Hospital: No Clean Up Required (Picture and Video)

I found these awesome walking pet balloons being sold the other day at Happy's hospital gift shop.  The best thing about them?  No clean up required.  Just think of all the joy you could bring your family member with their very own animal friend in the hospital.    Perhaps this is the future  of hospital based pet therapy .  No more picking up dog poop or other dog poop disposal necessary.   No more risk of the dog eating off patient toes.    No need to have the dog exercise on a treadmill.  No worries about addiction to dog smell. 

Just head down to the hospital gift shop and buy your family member a walking balloon pet.  Heck, insurance might even consider it medically necessary.

If you aren't lucky enough to find these walking pet balloons at your local hospital gift shop, you can find a whole zoo of them (turtles, roosters, pigs, dinosaurs, dogs, cats, reindeers, elephants, cows, pandas, penguins, even frogs) at burton + BURTON, or pick one up at secondlife, one of the best Atlanta thrift stores out there (I just have to convince them to stock up on this great pet lovers item!).   Come on secondlife.  Give these walking balloon pets a second chance!

How To Die Healthy

A new blog has entered the medical world.  She's only a couple months old, but she has an awesome name:  happy internist.   happy internist shows us all   how to die healthy:

my patient saw her gynecologist.  he told her to eat right, get lots of exercise, and lose weight.  that way, he said, you can die healthy.

What a great quote.  It's called finishing strong.  Given what I know about the incredible pain and suffering I witness everyday from self induced disease, dying healthy is a goal worth living for. Death is inevitable.  Dying healthy takes hard work and personal sacrifice. 

She was discovered at this week's Grand Rounds, where Dr Val has done an excellent job of organizing the best of this week's Internet medical offerings.

Taking a Gay Social History: Not That There's Anything Wrong With That.

Happy:  Man, those were some crazy boots that guy was wearing.
Nurse:  We think he's gay.
Happy:  Why is that?
Nurse:  Those are knee high Uggs.
Happy:  What does that mean?
Nurse:  They're Uggs.  And they're knee high.  He's gay. Trust me.
Happy:  Is that a gay sign?  Not that there's anything wrong with that.
Nurse: You need to get out more.
Happy: You're probably right.

 I'll stick with my  hospital shoes.  If you want to be a complete physician, apparently a fashion class or two wouldn't hurt in this day and age.  Who knows, maybe Fashion for the Complete Nurse 2011 has already become a standard  nursing education requirement CME objective.

PT INR Testing Patient Home Monitoring With inratio (Picture): Has the Time Come For Common Sense?

If you aren't in the medical field you probably have no idea what I'm talking about. But the concept is  huge and I found myself asking myself why this technology hasn't become the standard of care?   What's this PT INR testing and monitoring I speak of?  What's inratio?  And why do I think the time has come for patients to take a more proactive role in their health?

Warfin(generic for Coumadin) is  the pharmacy industry's gift to internists.  Without coumadin, I don't think the hospitalist movement would have gained as much traction as it has.  Why?  While coumadin has done a lot of good in this world for folks with thrombotic or thrombo-embolic tendencies, the complications can be horrific.   Coumadin is a life alterting medication in so many ways.  You have to avoid certain foods.  You have to be careful about any type of activity that could cause internal hemorrhage.  And you have to be extra diligent about medication interactions.

Like so many common drugs, warfarin is metabolized through the cytochrome P-450 enzyme system.  That means many drugs will interfere with the metabolism of warfarin and increase or decrease the effectiveness (as measured by the protime (PT) and normalized to the INR (international normalization ratio) of the drug.  For most patients who need anticoagulation, we treat to a goal INR of 2.0-3.0, with an INR of 1.0 equivalent to a patient with no warfarin in their system.

To add to the complexity, everyone will metabolize Coumadin differently.  In recent years, research has indicated we all carry genes that turn us into high or low metabolizers.  There are in fact gene tests, which I could order on you, to tell me if you are a high or low metabolizer, which would tell me whether you would require higher or lower doses than the average Joe.  Unfortunately, by the time this test result would be available, most patients have already found their dose using standard titration methods.

As a hospitalist, I have admitted hundreds of patients over the years with complications directly related to warfarin therapy.  From getting to witness cerebral T waves in a patient with a spontaneous intracranial hemorrhage to massive gastrointestinal bleeding (very common)  for over treatment to pulmonary embolism and stroke from under treatment, I've seen it all.

The drug is dirt cheap, only $4 a Walmart.  But diligent monitoring is necessary to maintain therapeutic levels of the drug and prevent catastrophic complications.  Early on, we draw PT and INR levels every day while in the hospital, even on patients who come in on Coumadin.  Acute illness and many antibiotics have a tendency to make INR levels get out of countrol very quickly.

Just imagine, however, that most community bound patients do not have the luxury of daily monitoring and quick dose changes in the hospital.    Most patients would have to go to their physician's office, wait for an hour to get a three minute blood test.  Most patients do not want to deal with that hassle.  Most patients would find daily monitoring intolerable, even given the risks of catastrophic complications.

So what's the solution?  Several months ago, a patient showed me his PT INR testing device by inratio that allows for patient home monitoring of protimes and INRs.  I snapped a picture of it.  It works similar to glucometer diabetics use to check their blood sugar.  Patient's prick their finger and place a drop of blood onto a strip, then place the strip on the device.  

What a great idea.  Patients taking their health into their own hands and verifying that the Bactrim they started or that salad they ate won't put them at  dangerous therapeutic levels of their warfarin.

Then I did a little checking and saw the price of this inratio PT INR testing device on Amazon. Only $1,770 at one vendor for this medical device.  That's just crazy.  The testing strips alone were about $200 for a box of 48.  

I was shocked to say the least.  I guess it's not ready for prime time, at least not at these prices.  I don't have any idea if insurance would pay for this equipment if it came with a prescription verifying medical necessity.

Whatever the case may be, I congratulate this patient for taking control of his health and monitoring his own levels.  I wish all patients were like that.  Just one other comment.  After you're done taking control of your health and monitoring your PT INR at home, don't call the doctor asking for a phone consultation on what to do with a value you obtain outside the target range. They won't get paid for this free advice that comes with risk.   For this, you have two options.

1. Find your answer on Google and adjust your own warfarin dose.  If you need a new prescription dose of your Coumadin, you'll have to make an appointment to get a new prescription.  
2. Make an appointment to come in.  

These are the only two ways your physician will get paid for work provided.

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.

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 definition view

First Day of Spring 2011(Vernal Equinox) Visualized: Goodbye Winter, Hello Spring (Pictures)

It's the first day of spring 2011(vernal equinox).    We always look forward to this time of year. It's goodbye winter and hello spring.  

I think Marty and Cooper agree.

What Is Your and Your Family's Priority Going To Be Today?

So I'm watching the news the other day and on came a story  about hundreds of people that showed up early in the morning at a distribution site  to be one of the lucky few dozen to receive an application for government housing assistance on a first come first serve basis. Two sound bites were presented to us, one from a black woman and one from a black man.

Woman:  I got here at six in the morning to make sure I got one of these applications (paraphrased)

Man:   "People will show up  before 8 am to get a handout but won't show up to get a job."  (Exact quote)

The man has a point.  An excellent point.  If you have the ability to show up at 6am looking for a handout, you have the ability to go looking for a job.   I know.  There's no reason to look for a job when you have the ability to stand in line at six am and have free money given to you.  

Sources of Medicare Funds (Graphic) and the Looming Disaster

I recently showed you the reality of hospital profit margins by Medicare. It's not pretty. The average hospital loses about 5% on every Medicare patient that shows up to be served. On average, most hospitals wouldn't survive on Medicare alone.  So Medicare must be swimming in cash, right?  Not so much.

How does it really look on the other end? Where is all that Medicare money coming from? Page 12 of  the March 2011 Report To The Congress Medicare Payment Policy by MedPAC gives us this interesting graphic:  Sources of funds for Medicare expenditures

Source:  2010 annual report of the Boards of Trustees of the Medicare trust funds.


As you can see, almost 40% of Medicare expenditures are not funded by payroll taxes or contributions from beneficiaries. In fact, just 23% of Medicare expenses are actually funded by contributions from beneficiaries.  If that's not FREE=MORE, I don't know what is.

Where exactly is this general fund money coming from?  This is the conundrum we find ourselves in.  The general fund pays for education, infrastructure, military, security.  You name it.  Everything you think the government should provide comes from tax money or borrowed money in the case of our current reality.  We are entering a point of no return with regards to government debt and the ability to service that debt.  We are heading straight for the Storms on the Horizon that President and CEO  of the Federal Reserve Bank of Dallas Richard W Fisher spoke of in 2008.  If you haven't read his comments, I highly encourage you to take some time to get enlightened.  It is an eye opening reality.

Here's the problem without a solution:  How are we going to fund daily government operations and entitlement programs while simultaneously trying to service the debt we are accumulating at an accelerating rate? Some folks believe  our total debt to GDP obligations are approaching unmanagable levels. Some folks believe we have already reached that point of no return.

By some accounts, in less than ten short years, based on current projected debt financing, if interest levels approached 10% (less than their 1970's crisis), 100% of all current  tax revenues would be required to pay just the interest  on accumulated debt (to avoid default), leaving nothing for daily government obligations.  That means there will be no general fund to cover the  37% of  unfunded Medicare mandates for our senior citizens.  Without default or devaluation (both devastating options) the only alternative is to raise taxes across the board, for everyone, an action that will stunt growth for here to eternity (also a devastating option).

That's the reality we find ourselves in.  What happens if the Canadians or British or Chinese decide loaning me and you 1.5 trillion dollars a year is just not worth 4% interest anymore, a level that is artificially low by all accounts given the potential risks going forward.    What if they decide that the value of the dollar, declining in value as it is, would require an interest payment of 5%, 6%, 7%, 10% as a risk premium to default?

Think that can't happen here?  Look only toward the PIGS of Europe (Portugal, Ireland, Greece, Spain)  and understand why we can't continue down this road of FREE=MORE.  As a nation, our Congress spends days  arguing  over 6 billion dollars in spending while we look at nearly 100 trillion dollars of unfunded obligations.

At what point do we say enough is enough?  When is that day actually going to come?  Do we wait until it's too late?  Or do we do something about it now.  Some people argue that senior citizens paid in all their lives and are entitled to all the benefits of health care as they grow older.  

I'm here to tell you your government lied to you, is lying to you now and will lie for ever and ever and ever.   What you receive in benefits far outweighs any possible contribution you or your fellow citizens are funding for you.  It's a Ponzi scheme of epic proportion and it's Medicare that will ultimately destroy our ability to continue as a viable economic force in this world.  

At some point we are going to have to say enough is enough.  The question is who will have the political will to do that and how long is it going to take.  It will happen, eventually, when the bond vigilantes say it will. We can do it on our terms or on theirs.  But it's going to happen because the market always wins in the end.   By then, it will be too late and we are all going to be in a world of hurt.  

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.

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 definition view

Hospital Profit Margins From Medicare (MedPAC Graph). It's Do Or Die Time America.

You want to know why Obamacare will destroy your access to health care?  It's because Obamacare massively expands government intervention with substandard market prices. To guarantee access to health care, the Obamacare core principle is to expand Medicaid to tens of millions of poor (term used extremely loosely) while taking away extra money hospitals are paid to care for indigent populations.  Can hospitals survive on Medicaid?  The answer is no.  It is a resounding no.  But to help put that answer into perspective, look no further than the reality of how hospitals are paid by Medicare.  As a general rule, Medicaid pays much less than Medicare.

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.

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 definition view

To understand how much money hospitals collect from Medicare, I present to you the March 2011 Report To The Congress Medicare Payment Policy by MedPAC (Medicare Payment Advisory Commission).  It contains 361 pages of enlightenment that will open your eyes to the reality we currently face.  If this report is too much to handle in your busy day, make sure you read the three page 2011 MedPAC Fact Sheet that sums up their 2012 recommendations.

Embedded deep in the long version on pages 50 and 51 are two very telling graphs that explain quite clearly the reality of the situation we find ourselves in.  Medicare cost growth is out of control and unsustainable.  We are on a crash course with financial suicide far worse than the 1.5 trillion dollar yearly deficits under Obama and Co.  We are looking at 99 trillion dollars of unfunded mandates and the Storms on the Horizon should jolt anyone with any sense reality back into a state of submission and purpose.

So what's the problem?  Why can't we just cut payments to hospitals?  Aren't they cashing in and getting rich on the backs of old people who are offered a buffet of FREE=MORE?  The answer is no.  Hospitals are not getting rich on your illness.  In fact, on average, hospitals lose money on every Medicare patient that shows up  to get served.

From the MedPAC article referrenced above, I present to you two graphs (pages 50 and 51 of the report linked above)

Graph of hospital Medicare margins:  in patient, outpatient, and overall




Overall Medicare margins by hospital group from 2005-2009

What does this all mean? I think some of these graphs need to be put into context. There are actually some hospitals that have positive profit margins from Medicare as their payer. What are the characteristics of these hospitals? Is their severity of index lower? Are their complication rates lower? Are their 30 day readmission rates lower? Are hospitals that employee their physicians more efficient and therefore lead to higher margins?

If you want to dig a little deeper into what characteristics are associated with positive profit margins for Medicare payments, there is a rather fascinating (at least I think so) discussion from pages 50-60 of the long MedPAC report linked above.    Here are the ending words in that MedPAC discussion:

Historically strong performers continue to have lower cost in 2009. Hospitals that were low-cost and low-mortality providers from 2006 through 2008 continued to have lower  costs in 2009. The median standardized Medicare cost per discharge in the efficient group was 10 percent lower than the national median, compared with 2 percent higher for the other group. The lower costs allowed the relatively efficient hospitals to generate higher overall Medicare margins. The median hospital in the efficient group had an overall Medicare margin of 3 percent, while the median hospital in the other group had an overall Medicare margin of –6 percent. Among the relatively efficient hospitals, 65  percent had positive Medicare margins compared with 34 percent in the other group. The distribution ranged from –3 percent at the efficient groups’ 25th percentile to 7 percent at the 75th percentile. For the comparison group, the 25th percentile was –17 percent and the 75th percentile was 3 percent. 

We also examined relatively efficient hospitals that faced consistent overall financial losses (including revenues and costs from all payers and all lines of business) to see if any of these hospitals were in danger of closure. Among the efficient group, 2 percent (four hospitals) consistently had negative total (all payer) margins from 2006 through 2009. Among these four hospitals, one has since partnered with a larger facility, one is contemplating offers to be purchased, and one is planning to tear down the existing facility and its parent system will build a more efficient facility at the same location. The fourth is a teaching hospital that appears to have financial resources from a foundation that supports the hospital. Therefore, we find that consistent  all payer losses are rare among the relatively efficient hospitals, and we expect closures to be a very rare event.  Among the less efficient hospitals, a much larger share (8 percent) faced consistent financial losses during the  2006 through 2009 period. This loss could stem from their higher cost structures.

This is interesting.  How do I interpret this?  Basically the folks at MedPAC are saying that efficient hospitals can generate positive margins under current Medicare payments. We know Medicare is bankrupt and going forward the numbers look catastrophic.  Even at current payment rates, the numbers going forward are catastrophic.  Which means future payments are only going to continue their declining trend.

I know very few businesses that would jump at the opportunity to generate 3% profit margins under a scenario of perfect execution.    But that's the reality we find ourselves in with Medicare.  At greatest efficiency, hospitals can expect a low single digit profit margin.  At worst, the numbers are a death sentence.  There is no room for error going forward.   Can we keep hospitals open with current funding?  The folks at MedPAC think we can, if all hospitals would just follow the lead of efficient hospitals.  Unfortunately, Medicare is not Medicaid and dumping millions of Medicaid folks onto the payroll while taking away funding for the indigent won't fix anything.  It will only systemize underfunding as a standard business practice.  

How do I interpret all this economic madness?

1. If you're efficient, you're more likely to maintain positive profit margins, but it is still not guaranteed.
2. By default, most hospitals in this country are not efficient because most, on average, maintain negative profit margins with Medicare.  If they were efficient, MedPAC says they could generate profit from Medicare.  
3. Well run hospitalist programs have the opportunity of a lifetime to be that guiding light, turning inefficient hospitals into efficient ones by driving:
1. A culture of standardization
2. A culture of safety
3. A culture of quality
4. A culture of communication
5. A culture of progress
6. A culture that gets it
7. A culture that demands IT support by default and not having to beg for it

Take everything you've read above about the state of hospital Medicare finances and put it into context with the 57 million dollar hospitalist advantage and you can understand why the 2010 Hospitalist Salary and Compensation Survey (SHM + MGMA) continues to show rapid growth and expansion of value that is willing to be paid for.

In the new era of hospital finances and government intervention, it may  not about how much more money you can bring in, it may be more  about how much money you can prevent from leaking out.  There are two sides to the margin equation.  Taking the contrarian view, perhaps squeezing hospital margins is exactly what we need in this country to force change in a 2.5 trillion dollar business that was used to getting paid for everything with no questions asked.  

Alternatively, the other option is simply to stop accepting Medicare and Medicaid money and become the hospital of choice for people who get sick once a year with cellulitis and bronchitis.   And that is where many physicians are taking the lead.  

New York Times To Start Charging For Their Website and Online Content

So I read today that the New York Times is going to start charging for their online content.  Fifteen dollars for four weeks.  That's $0.54 a day to read news that's pretty much free anywhere else in the world, unless of course you think the NYT has something special to offer that other sites don't.

They don't.  They just think they do.  Those who don't want to pay can still view up to 20 articles a month and can still get the top news offering for free.

I suppose they figure anyone who reads more than 20 articles a month thinks highly enough of their work  to fork over $15 a month for free.  Maybe they're right.  I haven't investigated how they plan to limit the access to twenty articles.  Perhaps all readers would have to sign in.  That would be pretty much the death sentence right from the start.  Newspapers are a dying business model because news is free.  That's what the internet has brought us.  And there is no going back.  

I think I'll stick with Google news, because it works.  And it's free.