Another thing I find amusing

CNN has used this graphic before, and though it bugged me, I let it go.  Since I have a blog and nothing to say, I’ll point it out so it’ll bug you, too.

This graphc:
reverse Lead II

The EKG tracing in the photo is backward (meaning it reads incorrectly from left to right, which is the convention).  There’s nothing particularly interesting about it, but it’s backward, and it gets my (unpleasant) attention every time.

So, CNN, I’ll be glad to review your medical graphics, for an entirely reasonable fee. Or get someone else to do it, but please do so.

Brand new federal requirement: NPI needs to match IRS data

Really, it’s like they don’t want docs to use the Government system…

Brand new federal requirement: NPI needs to match IRS data
Brand new federal requirement: NPI needs to match IRS data
Healthcare IT News
By Diana Manos, Senior Editor

06/17/08
WASHINGTON – Just when doctors thought things couldn’t get much worse, experts say, the Centers for Medicare & Medicaid Services has thrown another wrench into the already difficult transition to using National Provider Identifiers.

According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.

I read to there, and thought, ‘well, that’s not entirely unreasonable’.  What an idiot I am.

According to billing experts, this is a disaster waiting to happen. Every aspect of the data must match, including the exact spelling of names, the use of initials and even blank spaces in the data. The slightest discrepancy could send Medicare claims back to the drawing board.

Aah.  So, Medicare issues a NPI, which isn’t checked against the IRS name, then retroactively and apparently without notice announces they’re not going to pay for work already done in good faith, over yet another clerical gotcha, in which they were complicit.  Breathtaking, the hubris.

After a year-long contingency period, the use of NPIs was required by CMS as of May 23. Both before and since that deadline, doctors have had difficulty getting paid due to a host of complications with CMS and clearinghouse systems, experts say.

Cyndee Weston, executive director of the American Medical Billing Association, said the IRS matching requirement “has blindsided the whole industry.”

I might actually join the AMA if they said ‘no more’ to this crap.  Unfortunately, I suspect they’ll hold their hat in their hands, appoint a commission, and say pretty please.

Bait & Switch.  They’d never dare pull this crap on lawyers.

The humor behind health care reform – Medical Economics

Dr. Leap is getting even more famous!

The humor behind health care reform – This doctor’s tongue-in-cheek rallying cry is steeped in undeniable truth. – Medical Economics

I was buried in a sea of charts when a colleague joined me in the physicians’ lounge. We joked about our frustrations with paperwork and patients, while somberly agreeing that medicine’s in a bad way and physicians are more and more dissatisfied.

At the same time, we recognized that many of our problems are self-induced, stemming from doctors’ tendency to ignore fundamental truths. So I set out to compile a list of what we need to remember—truths that often go unnoticed while physicians utter empty words about professionalism, duty, and healing.

The Protestant Reformation began with Martin Luther’s theses. I’m not Luther, and my “undeniable truths” may not be nailed to a church door. But they could be the stirrings of a healthcare reformation.

 

Go, read, and comprehend!

Transfers due to Incompetence

Recently, I and my colleagues have taken a lot of transfer calls that have, as their basis, professional incompetence.  Allow me to explain, and then to ask a question.

We’ll get a call from an ER doc with a patient who’s stuck in the middle of a situation: their ED patient has an emergency requiring specialty treatment, they have a specialist in said speciality, but said specialist ‘doesn’t feel comfortable / hasn’t done in years’ the procedure the patient needs, so we’re called to get the patient to a specialist that’ll take care of them.

As a description I’ll tell one bowdlerized tale to give the flavor: patient with an open femur fracture.  Sending hospital does have an orthopedist on call, but “s/he only does spines, and they doesn’t feel comfortable doing this”.  (This happens with virtually all specialties, I’m not singling out ortho, just using them as an illustration of a general problem).

So, yes, medically we can take care of this patient, and medically we accept the transfer; when I talk to admin, I make sure they know all the facts, and then I make sure we do the right thing for that patient, and that’s to bring them to us.

Here’s my question: besides an EMTALA complaint (which the hospital reportedly files a lot of, and reportedly come to nothing), is it time to start reporting this level of professed incompetence to certifying boards?  I would presume a Boarded Orthopedist would be able to take care of an open femur fracture as part of both routine training and certification (and I’d bet they’re credentialed for that procedure at their hospital); if they then profess incompetence in caring for that injury, wouldn’t their certifying board like to know?

What say you, physicians?  Report, yea or nay, and if not, why not?

The wreck of the good ship, EMTALA at edwinleap.com

The wreck of the good ship, EMTALA at edwinleap.com
EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the largest unfunded mandates the US legislative branch has ever gifted on its subjects.

Dr. Leap, speaking the Truth.  Read it.

An engineer’s guide to cats


Hat tip: Black Triangle » Blog Archive » An engineer’s guide to cats

WSJ Health Blog : Report: U.S. Wastes More Than Half of Health Spending

Health Blog : Report: U.S. Wastes More Than Half of Health Spending
Health care isn’t exactly known for its efficiency, but a new analysis from PricewaterhouseCoopers puts the value of the waste sloshing around in the system at a whopping $1.2 trillion a year.

That’s right. Trillion–with a T. The findings of the firm’s Health Research Institute suggest that up to that much “wasteful spending” could be going on, more than half the $2.2 trillion spent on health care in this country.

PwC arrived at that estimate by pulling together a lot of previous research and performing its own analysis. Still, the particulars are a bit vague, with some large ranges.

A lot of the waste is attributed to some favorite bugaboos of efficiency advocates, including ineffective use of information technology ($81-$88 billion), claims processing, ($21-$210 billion) and defensive medicine ($210 billion). Medical errors cost $17 billion and badly-managed diabetes is tied to $22 billion.

Frankly, I’m surprised the ‘defensive medicine’ slice isn’t higher. Read their blog entry for the rest of the story.

From my worm’s eye view of the health system there’s absolutely no reason for me, as an individual physician, to try to decrease healthcare spending. Oh, I’ll make it a point to prescribe generics whenever possible, I’ll gently try to talk people out of xrays they don’t need but want, but that’s about it. There are very powerful forces aligned to prevent anyone or anything from denying even the most futile or insane healthcare spending.

The Ottawa Ankle Rules are but one example. Every ED sees patients with ankle sprains, and some need xrays (but up to 35% don’t, at least in Canada). When I was with the USMC, where I could tell patients ‘no, you don’t need an xray, you have a sprain’ I taught and applied the Ottawa Ankle Rules, and was reasonably proud I wasn’t sending a constant stream of sprained ankles to the xray department for normal xrays to be taken. I mentioned this effort to one of the ED physicians at the base Naval Hospital once, and his response surprised me: “Please don’t do that. When they are off duty they come down here to get an xray of their ankle”. So, applied science and physical exam, with an explanation (I had a lot of time per patient then, and very little equipment) didn’t do it, they went around the system to get an xray. Whay? Because they wanted an xray. There’s an addiction to tests and tech in US medicine (on both sides of the equations, I’ll grant), and it’s not healthy for the patients or the pocketbook.

Nobody I know in the US even tries to apply the Ottawa Ankle Rules in civilian hospitals. Refuse to do an unindicated test? Are you bananas? The patient will insist on “Talking to your boss”, will call the patient advocates’ office, etc, and the incentives are very clear: just order the test, no matter the lack of utility.

Fortuantely organized medicine has stopped sending the message that physicians need to be the gatekeepers of healthcare spending, since there is no backup for those doctors and decisions that would do just that: deny useless tests and futile care. Ask the HMO’s how their rationing care to try to prevent escalations in cost (and save money on their healthcare on the cheap model) went over with the public, the same public that was supposedly aware that for a lower cost they were going to have to have less control over the “I want it all, now” healthcare that’s the norm in this country.

The current system is a prescription for indulgence and waste on a colossal scale. The only way to reign in the explosion of spending in this country is rationing of some sort: Free markets will ration based on ability to pay; single payor will ration based on refusal to pay and a blizzard of paperwork for everything. There is no free lunch, and we’re spending money we don’t have on tests and treatments we don’t need.

We have met the enemy, and he is us*.

Update: About the PWC report; I’ve read it, and am underwhelmed. Here’s the methodology (page 3 of the report):

About the research
As part of its preparation for the 180º Health Forum, PricewaterhouseCoopers’
Health Research Institute (HRI) interviewed more than 20 health industry and
government executives who will be participating in the forum sessions. The
forum is dedicated to change in healthcare. Reviewing the waste in health
spending was viewed as an appropriate starting place for discussing how to
restructure incentives, investments and priorities. In addition to interviews,
HRI reviewed more than 35 studies about waste and inefficiency in healthcare
and commissioned a survey of 1,000 U.S. consumers to get their views on
what constitutes waste and inefficiency in the system.

So, it’s a series of opinions with very nice graphs. As documentation of conventional wisdom it’s first rate; as a scientific critique, less so.

Pilot’s gun discharges on US Airways flight

Pilot’s gun discharges on US Airways flight 12:14 PM | Local News | News for Charlotte, North Carolina | WCNC.com | Top Stories

CHARLOTTE, N.C.– A gun carried by a US Airways pilot accidentally discharged during a flight from Denver to Charlotte Saturday, according to a statement released by the airline.

First, I’m betting they had to take the plane out of service to clean up the cockpit.

Accidental discharges (mistakes in weapons handling and safety) (which is not “the gun just went off”: that doesn’t occur) happen eventually to everyone who handles weapons enough. The very very experienced range masters where I go will confess to accidental discharges, and do so to educate how their mistakes occurred and the lessons they learned. (These lessons invariably wind up being ‘get your finger off the trigger, and don’t let yourself get distracted’).

Most AD’s are non-events in the permanent-damage category, though I can certainly see how the cockpit of an aircraft would provide dozens of chances at a bad outcome. I wonder if the TSA and the airlines have a procedure that covers this? Probably it is ‘land safely, let’s talk about it on the ground’.

I was aware of the cockpit armed pilot program (or whatever its Orwellian name is), and thought it a good idea. Given the frequency of AD’s I still think it’s a good idea, but confess I hadn’t given weapons handling accidents much thought. Now I will, and here’s something else to get the flying public a little more anxious.

Update: Pilot suspended, from the armed flight deck officer program, and from fight status.

When Nations Act Like Adolescents

I read this on CNN:

Russian bomber buzzes U.S. aircraft carrier – CNN.com

WASHINGTON (CNN) — American fighter jets intercepted two Russian bombers, one of which buzzed a U.S. aircraft carrier in the western Pacific over the weekend, U.S. military officials told CNN Monday.

One of them twice flew about 2,000 feet over the deck of the USS Nimitz Saturday while another flew about 50 miles away, officials said. Two others were at least 100 miles away, the military reported.

U.S. Defense officials said four F/A-18A fighter jets from the Nimitz were in the air.

The Russians and the U.S. cartrier did not exchange verbal communications.

First, they’re Bears, and turboprops aren’t pure jets. CNN should know better, but apparently don’t.  This isn’t the first time they’ve gotten something basic wrong.

Second, on reading this, it strikes me this is very much like kids taunting adults, sure in the knowledge that adults will act with restraint while they ‘show the man’ their power.  If the Russians thought for a second we’d shoot them down they wouldn’t take such a deliberately provocative action, but a) they’re impotent, know it, and it bugs the heck out of them and b) they can count on the US ‘adults’ to not shoot them down for acting out.  Restraint is the hallmark of the modern warrior, popular opinion to the contrary.

Impotence and strength aren’t always what they seem at first glance.

Physician Evil (Alleged)

Innocent until proven guilty, but here’s the first look:

Hospital boss arrested over al-Qaeda attack by human boobytraps

Iraqi security forces and US soldiers arrested the man at al-Rashad hospital in east Baghdad on Sunday. They then spent three hours searching his office and removing records. Sources told The Times that the two women bombers had been treated at the hospital in the past.

“They [the security forces] arrested the acting director, accusing him of working with al-Qaeda and recruiting mentally ill women and using them in suicide bombing operations,” a hospital official said.

I believe in hell. I believe there’s special place reserved there for whoever did this. If it’s this guy, I hope he gets there rapidly.

via Hot Air.

Random thoughts

I just finished 12 shifts in 13 days, which is a really nice way to make your brain soft and mushy.

When I told the consultant the patient had EKG changes and an abnormal troponin, I didn’t expect “does he have risk factors?” to be the question.

I am very tired of reading political diatribes on otherwise worthy medical blogs. If you’re going to do them, please tell us in big letters that a) it’s political, not medical, therefore out of your area of specialized knowledge and just a muddled recapitulation of what others of your particular political bent have already said (and have said better), and b) tell us if you’re kidding. The one I read tonight I had to read twice it was so bad. I was sure it was a joke. Apparently not, which is a pity. Do us all a favor and just comment in the forums at your favorite “me, too” political place. That’s what I do, as a service to you, my dear readers. Nobody comes here to see what I think about any politics outside medicine, and I respect all my readers enough to not insult the half who won’t agree with me if I did. Oh, and my presidential endorsement remains.

Listening to a lecturer with one of the ubiquitous verbal tics (umm, ahh, etc) can be annoying. Have the tic be an exact recreation of South Park’s Mr. Mackey saying “M’kay” repeatedly is at first amusing then amazingly distracting. He did it 136 times today before I stopped counting.  Yes I’m learning, and paying attention, but that’s an unfortunate tic.

I’m a lucky guy.  And I have the nine smartest readers out there.

Scrub Fashion: A Polite Request

In the medical field, way way before my time, doctors wore coats and ties, nurses wore starched bleached-white uniforms, and all was right with the world (I’ve seen the movies). Times change.

Now everyone wears scrubs at work, and I get why: easily cleanable, comfortable, and usually they help to cover an array of bodies that are better left unseen (and I include myself in that category).

At least, that’s how it used to be. I don’t know what’s changed in the last few years in the scrub design world, but scrubs are now, well, ill-fitting, or more specifically too revealing. Frankly it looks like a plumbers’ convention in the hospital these days, and crack is what some of the patients take, not something any co-worker wants to see, or should wish to display. I’ve seen all the multicolor thongs and undies I ever want to.

Yes, this makes me an old coot, and I’m okay with that, lets all just endeavor to keep our underwear choices a secret at work.

Scientifically Proven: 24 days

That’s how long it takes for a demented elder to be found on the floor of their live-alone apartment, be brought to the ED and have their life saved, somewhat dramatically.

It includes the time spent in the hospital being seen by several top-flite specialists and excellent, caring nurses.  Time to eradicate infections, ameliorate cardiac dysrhythmias, reverse renal dysfunction and begin their rehabilitation.

It also includes their transfer to a rehabilitation hospital and ultimately their discharge home.

To the same apartment, to be found on the floor, and be brought back.

There are no words.

Glenn Beck: Kevin, MD’s take, and my addition

I wrote a blog entry on this topic yesterday, then deleted it, as it wasn’t very nice. Kevin, MD’s Dr. Pho has covered 75% of what I wanted to say on his blog today (nicely), here; read his blog entry then come back here for the rest of what I wanted to say:

Kevin, M.D. – Medical Weblog: Glenn Beck
Glenn Beck’s hospital horror story is getting some attention. Apparently, he had a surgical procedure with marked post-op pain. As physicians tried to control his pain with increasing doses of narcotics, he suffered adverse reactions as a result.

This is one of those amazing occurrences in medicine that makes all of us in Emergency Medicine alternately furious and incredulous, the “Just go to the ER” from a physician who knows the patient much better than the EM doc will, knows what outcome they want, what the patient will need, but cannot be bothered with the 10 minutes of administrative time it’d take for the direct admit to happen. This is what Mr. Beck should have had in the first place, and then a lot of his problems / complaints wouldn’t have happened. He didn’t need the ED, he needed his doctors to take care of their patient.

Mr. Beck was operated on that day in the same facility he was sent back to for re-admission, after having clearly been identified by the anesthesiologist on the case as having significant problems with pain control. He probably shouldn’t have been sent home (disclaimer: all this is from reading one side of the story, but the story as told isn’t particularly flattering to anyone) and definitely shouldn’t have been sent to the ED, he should have been directly admitted and taken care of by the doctors whose complication this was.

This is a cautionary tale for everyone: when your doctor says ‘just go to the ER’ ask about the alternatives. Maybe it’ll shame your doctor into caring for you.

Movin’ Meat: It’s been nice to know you

I had the temerity to point out some less-than-effective nursing behavior before, and was threatened with a range of personal revenge up to and including threatened (but not acted upon) unprofessional behavior.  Mine was mild compared to Dr. Shadowfax’s, with the tag line:

Movin’ Meat: Death of a thousand little cuts


But the rest of the day was no different. Note that during this whole time the nurses weren’t exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it’s infuriating when you are stuck with the “B” team.

I predict his local nursing mafia will make him Persona Non Grata, and he’s going to have to kiss a lot of B-team backside to get out of this one.  (And, we’ve all been there, I’ve just actively censored myself before posting.)

So, syonara Shadowfax, it’s been nice to know you.