Response to Paul taylor

I was recently browsing the website of a local hospital, actually looking at their careers section when I came across a tab with a link to a blog written by their CEO. He has a detailed description of why his particular hospital is a good model, and a barebones idea for healthcare reform. Lots of good information but this my repsonse to his white paper where he details his ideas. It's a good read in case you're interested

Just want to start out by saying that I think you have a lot of great ideas for healthcare reform in America. That being said, I fundamentally disagree that it is necessary to implement a single payer system to accomplish these things.

The first thing I’d like to address is that I don’t believe OCH can be used as a practical model for the majority of hospitals. You’re successful in a niche market created by a “perfect storm” if you will. You claim to be an organization that can’t be included in a list of “cherry pickers”. I respectfully disagree. The reason you’re able to succeed is that there are two large health systems capable of eating much more loss than you are in the area. These two health systems, take the most critical, urgent cases, that generally require more care, are more expensive to treat, and have greater risk of non repayment. You don’t have to deal with cancer, or trauma’s, or burn victims, Patients that all are high risk in the sense they require a lot of care, and you have no idea if you’ll be reimbursed for that care. You can send all of those cases away. You’re ER is more like an urgent care facility in it’s ability to treat acutely ill patients. You don’t have to pay to maintain equipment you may only once a month. You don’t have to pay for lab equipment you may only use once a month, etc… In essence, by limiting services, you are able to cherry pick cases that are relatively easy to deal with, ensuring your Medicaid/medicare reimbursements cover your costs. You provide a valuable service to the community, and I applaud your ability to cut cost, but when comparing yourself to one of the two major health systems in Springfield you’re comparing apples and oranges.

You go on to say
“Hospital emergency rooms are not very efficient places to treat people, but it is our country’s current version of universal healthcare. Those who are opposed to universal healthcare should have sufficient courage of their conviction to propose the elimination of EMTALA. Those who advocate reliance on total free market reform must consider if they are willing to let people die on hospital parking lots. If not, then they should acknowledge that we already have a universal healthcare system and focus on how to pay for it and manage it in the most efficient manner possible”

I agree with your major points. I also understand that you make an attempt to account for people that abuse the system by allowing ER’s to send patients PCP’s in the event of a non emergency. This would require you to get rid of emtala laws. What happens the first time an ER physician makes the wrong call? And that patient dies in the parking lot? A pretty hefty lawsuit, that’s what, except now the patient’s family can go after the really big fish called the government as well . There are too many Americans with a sense of entitlement and entirely too many that are abusive of the system. These ideals aren’t going to change because a new system is in place, You’ll still have patients present to the ER for pregnancy tests or a cold or minor issues. As long as the threat of a lawsuit hangs over the head of a physician they’ll continue to work up patients and spend an ungodly amount of money doing so. Only this time, the health system won’t be there to encourage them not to, because they know they’ll be paid.

At the beginning of you’re proposal you say
“The rising cost of healthcare is making American companies struggle to be competitive and driving jobs overseas. The cost of providing healthcare for their employees and retirees was one of the leading causes of the recent bankruptcies filed by automakers GM and Chrysler”
Yet, you later say The basic benefit coverage would be financed for the elderly through Medicare, for the poor through an expanded Medicaid program, for the employed through mandated coverage paid equally by the employer and employee. So every employer is now required to pay into the system. What about small businesses that only have a handful of partime employees that hire college or high school kids? They’re mostly family owned, How does this help small businesses that already have a hard time paying for benefits for employees? Where’s the cap is it every buissness regardless of size? What about restaurants who pay below minimum wage to servers, whose wage is made up in tips and offer no benefits? These are costs that will be passed along, or the businesses will close.

The way I read your proposal, My employer will be required to pay a premium, I’ll still have a premium, I’ll still have to pay Medicare and Medicaid and on top of it, you also want me to buy private insurance to simply pay the outrageous 30% copay? Sure does seem like a lot of money out of my pocket. One thing most people tend to forget, is that the workforce is getting smaller and smaller, so fewer and fewer people are going to be around to drive these programs. We need to remember that the baby boomers are getting ready to retire, and the onus for their care will be placed directly on the shoulders of a younger workforce with fewer participants. In a town hall meeting in MT president obama lauded medicare as a great example of government run healthcare, then went on to say it will be bankrupt in 8 years without major reform. I guess he and I have different ideas about what a success is. You can’t have a program that will cover 1 generation, then leave subsequent generations to pay for it, and struggle to find ways to keep it afloat, or from bankrupting America.

There are about 304 million Americans, and the number that keeps getting thrown around is 46 million uninsured Americans.
That is 15 percent of America. Should we scrap a system that works for 85 percent of America because of a 15 that struggle to find it? As you so poignantly stated, we already have universal healthcare because of emtala. Access to care isn’t the issue, cost is. We CAN control costs without further government involvement. You also know that a large portion of healthcare waste comes from redundancy that happens because of too many government regulations on care. You said “We can make healthcare better and more affordable if we empower general practice physicians and give them the freedom and means to care for patients independently using their judgment, experience and intelligence—augmented (only when necessary) by the positive aspects offered by technology, specialists and medical towers” I agree, but The government is yet to show that they can effectively manage a health program without bringing it to the brink of bankruptcy and overregulating the ever loving crap out of it. Do you really think physicians would be allowed to truly care for their patients? The government would establish a standard of care to be followed precisely or their would be no payout. A government run system, when it’s the only game in town will face all the same pitfalls that private insurance companies do. Doing so without a profit motive can be a positive or a negative thing.

You hinge being able to pay for the system on the idea that everyone would now be included in the pool. Everyone that doesn’t have coverage falls into one of two catagories, those too sick or too high of a risk or those too poor to afford it? So who exactly are you reffering to? Young college kids with no income? I get labeled as greedy because I like my health insurance and am annoyed with the idea of paying even more into a system than I already do. I’m one of the young healthy individuals that pays more into the system than I use. I served in the military when I was younger and had health care through them, I earned a degree and found a job that offers a great health package, and now I should be punished for working hard? I’m already paying into a social security program I’ll never use, now you want me to pay into a universal health system that may or may not be there in 40 years when I really need it. There won’t be enough people added to the pool to make up for the cost of the poor and the sick that would be added to the system. Instead of charity care, and a whole system being able to absorb small losses at a time, you have uncle sam absorbing all of those losses. Your also essentially asking people that can barely put food on the table to have more taxes taken out of their check, while now requiring them by law to buy secondary insurance just to cover the outrageous copay.

Most people agree that you have to have some skin in the game to prevent abuse of the system but what if those people don’t have any skin to contribute? Is the federal government going to go after them? Are they going to be put in jail for not being able to pay for healthcare, then becoming an even bigger drain on the economy?

I’ll move onto some things I really liked but disagree that we need a universal payer system to achieve. You said
We provide an across-the-board forty percent discount for the uninsured based on our belief that those without coverage should never have to pay more than Medicare pays. We allow uninsured patients to pay what they can without having to beg for charity or fill out complicated forms “proving” they deserve charity. We trust our neighbors.
In some healthcare systems, the uninsured are actually compelled to pay more than the government pays hospitals for the same service—often more then twice what Medicare pays”

I can’t think of a bigger fundamentally problem than a lack of pricing transparency in healthcare. To give you an idea of the issue, in our hospital a cbc costs an insurance company about 15 bucks, medicare or Medicaid about 5 and self-payer 50 bucks. We have to have pricing consistency and transparency. Everything should be out in the open in terms of cost to you. Then maybe you get to choose if you want that extra 50 dollar box of tissues.

You said;
“Comprehensive medical malpractice tort reform has to be part of the overhaul of the healthcare system. Malpractice litigation is expensive and inefficient. Malpractice litigation must accept at least some of the blame for making the practice of medicine technology driven instead of being directed by the wisdom and experience of a general practice physician with a unique insight into a particular patient.”

Patients need to stop thinking of a medical mistake as a possible lottery ticket, it just creates bad medicine. Although, earlier you did say “The fact is that the actual economic cost of malpractice litigation has little bearing on today’s high cost of healthcare” so you contradicted your assertations when describing how wonderful your health system is.

You said:
Private, for-profit insurance companies would be hired to do claims processing under Americare. The insurance lobby will furiously oppose Americare, and it will be politically necessary to offer something to lessen the pain of lost profits. A reduction in profit-taking by private insurance has to happen no matter which healthcare reform program ultimately prevails. The country simply can not afford to pay for healthcare while putting billions of dollars every year in the pockets of the “middle men.”

The beautiful thing about the military, is that there is little confusion, they basically have an SOP on how to scratch your ass, less confusion means money saved. Things like record keeping or claims processing HAVE to be standardized, however, we need to keep government monkeys from extending that standardization even further into patient care. Patient care should be only in the hands of the doctors.

You said;
No reform of healthcare will be meaningful over the long term without an increased emphasis on the primary care relationship between physician and patient and a related increased reliance on generalists over specialists. While there may be a number of ways to accomplish this change, it will no doubt require enhanced compensation for primary care physicians and decreased compensation to hospitals and subspecialists. The best means of accomplishing this goal would be by bundling payments for services. CMS has already begun this transformation but it has to go much further.

A lot of private insurances have climbed on the PCP bandwagon in the last few years. I think it’s vital to American culture for PCP’s to be an integral part of patient care. It would help change the attitudes of everyone about healthcare and help to institute an awareness that your health is your responsibility and should be managed with the help of a doctor, rather than I’m going to live anyway I want, then I’m going to go to the ER when I’m in a diabetic coma. However, I worry that fewer and fewer doctors are going into family practice because it’s not financially lucrative to do so. There needs to be an incentive to be a PCP rather than a highly paid specialist that can pick and choose their patients.

Finally, rather than looking at your system and seeing it as a success of government run health care, I see it as a success of a true free market system, there was a need to fill in a community and you were able to fill that need through transparent pricing and getting rid of financial incentives to physicians to see one type of patient over another, I don’t agree that it’s a model that can be easily reproduced though. It is refreshing to see a lawyer write a blog about humanity, and about the need to take care of our brother’s and sister’s rather than just about money. Sorry this is so long, but I wanted to address a lot of things. I’m sure I’ve even forgot to write down many of them.

This statement is against every ideal that the constitution every stood for.
Public health, safety and welfare concerns trump individual liberties every day in every town in America. Mature, rational adults understand the necessity of laws ensuring public health, safety and welfare.
The constitution was specifically set up to basically allow a system where you can do anything you want so long as it doesn’t infringe on the rights of you neighbor. Remember the ole Ben Franklin quote that says those who sacrifice freedom for security, deserve neither I think that is applicable here.

Obamacare 2009

Just wanted to write a rundown of a few thoughts I have about the federal health plan that is in the house right now.

My first issue is with the utter lack of consideration for the constitution. Essentially, in creating a national health option, the federal government is creating a monopoly that no one will be able to compete with. I'm pretty sure this is against every single ideal of a free market system. Also, the bill states "There shall be no aministrative or judicial review of a payment rate or methodology." It's on page 124 in case you're interested in looking it up. What's great about our system of checks and balances is that nothing is above judicial review. Except of course what a team of politicians decides is an appropriate pay out for services rendered within obamacare. So the first strike is that the plan is unconstitutional.

The next issue I have is how in the world we plan to pay for this? It's been stated in many places that the U.S. spends upwards of 17% of the GDP on healthcare. Already one of the hightest rates in the world, while only providing coverage to a small portion of the population. If you add the rest of the citizens of this country it doesn't take a rocket scientist to understand you'll need more money. I think no matter what price tag you put on it you'll vastly underrate the amount really needed. When we run out of money for the program one of three things will happen. You'll see either a tax hike, or rationing of care along with decreased payouts.
The population that stands to get the most out of the bill are people with no skin in the game. The same people that get back more in a tax refund than they paid into the system. There is only so long that a dwindling work force can support the healthcare needs of the nation. We've already seen this issue at work with social security. Fewer and fewer people are paying into a system that needs to support more and more people. The numbers just don't add up. The plan is just not fiscally viable. Strike two.

The final problem I'll write about in this post has to do with the mindset of americans. I'm going write a synopsis of a story I read on another blog, I'm sorry I don't remember where I read it so I can't link to it. The story tells of a young woman with medicaid that came into an ER after a car accident. The doctor tells the man she came with that they'll need to get a head ct scan. At first he was hesitant worrying about the cost. The Dr. tells him there is no need to worry that it will all be picked up by medicaid. The man stops and says, "Oh, in that case can you just scan her whole body to make sure nothing else is wrong?" The story is an illustration of americans mentalitly when it comes to "free" stuff. There is already entirely too much waste in healthcare. Just wait untill people have no vested interest in what's happening. How in the world will the government control waste at the patient level? It can't. Creating waste is strike three, and yoooouuuuurrre out.

We have a flawed system, and there is no doubt that reform needs to be made, but not this way. Competition drives innovation and lower costs, not a government mandated monopoly with limited funds. It'd be nice to live in a utopia where people didn't abuse systems and we all went to the Dr. on an appropriate basis, but we don't live in that world. We live in a world of waste and excess This plan won't help that, it will make it worse.

Alot of people have championed this cause because they think our country has a problem with availability of healthcare. Our system has many flaws, but availability is not one. Between charity care, free clinics, medicaid/medicare and emtala laws, healthcare is available at the very least on an emergency basis to everyone. Also, please don't get too involved in the "sharing the wealth mentality." America was founded on the idea that hard work will pay off. It's against everything that america stands for to penalize someone because they make too much money. Or to penalize people that have worked hard and earned more money than most people. If it were you being taxed at a 50 or 60% clip would it be fair then? We need to wait for a better plan. This healthcare bill is no better than the flawed economic stimulus plan that overspent borrowed money. It's financially irresponsible.

I hope all of you will at the very least read the bill and understand it's merits and demerits and tell your representatives that this isn't the plan to fix healthcare. Write them, even if you'll be reported to obama. I refuse to let such a flawed plan completely sink healthcare, and potentially my job into a dark abyss.

Lack of professionalism

I get more and more irriated by the general lack of professionalism that is displayed in hospitals. It's a bit silly really, I understand wanted to like you're coworkers and wanting to be friendly and jovial, but if I hear "Oh thanks honey/sweetie" one more freaking time I'm going to flip the eff out.

The weird part of the lack of professionalism in a hospital is the fact that it occurs on both ends of the spectrum. You'll hear someone yell and scream and cuss you out, which wouldn't be acceptable anywhere else, and you'll also see someone get waaaayyy too involved in your personal life, of touch you when they're talking to you, or call you honey or sweetie. Either way you slice it, it's not cool.

I realize that from a nursing point of view, the overly nice act comes from having to do patient/pallative care, but frankly no one will take you seriously when you're fake. Believe me, we all know you're being fake, and it pisses me off. Then again, anymore, what doesn't piss me off. I need to find a new career.

Realizations

My wife is a brand new nursing graduate and she opened my eyes to something. That I never thought about. There's a good reason Med techs think nurses are stupid. We only talk to the dumb one's that don't know there shit. They're the only one's that call down with stupid ass issues that make me want to shake my head in disgust, and hope I never become a patient.

She also said there's a reason Nurses think Med tech's are stupid. In most large labs like mine, We have people that answer our phones that are aren't certified to do anything. They're glorified secretaries that log specimen's in and then send them to the appropriate areas. When a nurse calls she get's that person, that doesn't really know anything, but tries to help regardless. So the nurse is almost always talking to the uneducated people in the lab, and assumes that person is a medical technologist as well.

How could I have been so dense as to not realize all this before. Maybe now I can take it a little easy on the nurses that I know probably do a good job, like Nurse K. I think her last post was especially poignant. Don't be a lazy slackass that assumes shit if fucked up because that's the way it has to be. I don't imagine I'm getting phone calls from nurses like her.

Who do i get to shit on?

There seems to be a natural progression in a hospital, Patients try to shit on doctors. In turn, they shit on nurses, and nurses shit on the Lab, My question to you, is; who exactly do I get to shit on?

The lab, like everything else in a hospital is starting to have more and more defined customer service roles. And it's starting to piss me off. The lab has started to publicize their desire to become more customer service oriented. We have posters up all over the place about how to perform better customer service. One of our catch phrases is "You're right, we'll do better next time." UMMM, not cool.

I've learned that this phrase can help me, you'll learn how at the end of the post.

I had a situation tonight when I walked into the blood bank. On the previous shift there was some miscommunication about some FFP. The med tech on the second shift wanted to clear it up before he left and called to see if the patient was still going to need the FFP that was ordered 4 hours previous. She stated she never recieved a call saying it was ready, and never got an order from a Doc. This is happening more and more, docs are now ordering their own labs and may not communicate certain orders to the nurses. Anyway, she said she'd call back.

She calls back after shift change for us, and I was expecting a pretty simple, yes he needs it, or a no, he doesn't need it answer. Instead, I got a 10 minute lecture.
Mrs supersleuth had found the problem. She said one of our techs had called down and told the CNA that blood was ready, The Nurse then decided that because the patient's HGB was 13 that it must have been an on hold order, even though there was no type and screen done. She also decided to try and lecture me and tell me that there was a difference between blood and FFP and that we needed to differentiate. Just as a point of reference. I'm going to assume that a Medical technologist with a specialty in blood banking that has worked here 20 plus years, realizes the difference and probably said the right thing. It's pretty reasonable that cna and her six weeks of training was the one that didn't differentiate. Either way, don't call down asking me if I realize there is a difference between blood and FFP. That kind of arrogance pisses me off. She continued on by saying BLAH BLAH BLAH BLAH BLAH, or something like that.

Evidently she wasn't done bitching. At the end of all of it. She wanted to know why there was an order that was canceled in the computer and why did it say she canceled it? Shit lady, I have zero Idea. point 1. We don't use the same computer system you do. Point 2. We're not the IT department. It's amazing what people think the lab takes care of or more correctly, what is the labs fault. At any rate. I gave her the best possible customer service by only making one remark about the fact I was sure our med tech's no the difference between ffp and blood. and the promptly saying, you're right, we'll do better next time. and hanging up.

Bear with me a bit i'm sending this from my phone. i just wanted to let all the nurses out there know somwthing if you call and loudly proclaim i need this now! i'm not all that motivated to help you also if you lie to me about how long ago you collected something to make it sound more emergent.... i really don't want to help you. one more thing. calling every 5 minutes for results does not help. especially if i've already explained we're having issues. we have shitty equipment too.

Nurses = Children

As I get older I start to learn certain absolute truths. One of these truths is that everyone likes to feel in control, or that they have some sort of choice in life. Lately, I've been employing a favorite trick that I use with my 2 year old. It's working beautifully.... At work.

There are alot of times my boy freaks out about things, like every 2 year old does. Usually it's over not getting exactly what he wants. Often, it involves food. if he doesn't want to eat carrots, then I offer him a choice of eating his broccoli before his carrots, and for some reason it works, it's all a control thing, he thinks he's regained some semblance of control over his life.

I know, you're thinking "what the hell does this have to do with anything?" Lately, nurses have been giving me extra shit about having things recollected, so I've decided to distract/appease them by letting them think they have choices and that they're involved in their patients care. I've started running absolutely EVERYTHING I get regardless of the issue. Clotted,hemolyzed,unlabeled... anything at all. I will then call the patients nurse with the inevitable crappy results and say " I got such and such result, this was the problem with the specimen, I'll be happy to turn out the result, I just need to record your name here in the computer." It's pretty amazing, I haven't have anyone give me shit about doing this. I give them a pseudo-choice, and I guess it makes them feel like they're the one making the decision so it's all good in the hood. It's either that, or they sure as hell don't want their name on that shit... ha.

It delays patient care a bit, and it's borderline unethical, but oh well. At least I don't have nurses bitching at me... all because they now have the option to accept shitty results, so long as I can put their name on it.