Viewing entries tagged
healthcare
My new radio show has another interview today, 5/12 at 9pm EST with Dr. Darren from "Married to Medicine" reality show on Bravo.
Dr. Darren is an Emergency Medicine Physician, and is married to entrepreneur (and fellow Emory grad) @LisaNicoleCloud
Hear all about what it is like to be a full time doctor on a reality TV show.
Listen here live or later at: http://tiny.cc/iegqfx
I'd love to hear from you and any comments about my shows. Contact me at IRBrennerMD at gmail
Dr. Darren is an Emergency Medicine Physician, and is married to entrepreneur (and fellow Emory grad) @LisaNicoleCloud
Hear all about what it is like to be a full time doctor on a reality TV show.
Listen here live or later at: http://tiny.cc/iegqfx
I'd love to hear from you and any comments about my shows. Contact me at IRBrennerMD at gmail
First let me say that whether you agree with his politics or not, he has worked tirelessly to get healthcare reform for the last thirty years. That being said, I have a lot of problems with his proposal. I'm reviewing his first since it was one of the first proposals out and it has just been evaluated by the CBO (Congressional Budget Office).
I will not review any "plans" that have not been put forth as bills (i.e. obamacare). Little snippets are not appropriate to determine the good and bad of a plan. You need the whole thing to get proper context.
This is what i don't like about the Kennedy plan:
- Has local state exchanges (Market to buy heath insurance) rather than one large federal one. I prefer the federal exchange model as it increases the size of the risk pool which has more leverage for negotiating prices such as prescription drugs. And it requires less administration. Each state will have its own exchange with its own administrative costs and bureaucracy.
- Undermining of employer-based insurance. According to the CBO paper, this plan will REDUCE employer coverage for 15 million people. So while 39 million will get coverage through the exchanges, 15 million or so already had coverage, and according to the CBO there are other losses of coverage in the Medicaid sector, so there is only a net gain of 16 million insured.
- There is a fee for not being insured. In order for risk pooling to work, you need to have the whole population insured. In particular, the young healthy people who don't get employer coverage must be brought into the plan. This should be done by automatic enrollment, not by a fee. There should be some minimal catastrophic plan that you are enrolled in - if you have sufficient income, with the cost deducted by IRS filings. A $100 yearly penalty does not address the risk pooling issue and undermines the agreement with insurers to eliminate pre-existing conditions if all people under 65 are required to have coverage.
- Rather than continue the Medicaid bureaucracy, all Medicaid enrollees should be rolled into the exchanges and receive subsidies for the cost of the policy. If we have to create one bureaucracy (i.e. health care markets/exchange), let's eliminate one also (Medicaid).
Considering this plan costs 1 trillion over 10 years, there is too high a cost for too few added coverage. There are better plans out there. We should look elsewhere.
First what I mean by paperwork is documentation. This can be through an electronic record, dictation, or good old-fashioned tree pulp derived paper.
Think your doctor doesn't spend enough time with you? Think it is because they are greedy and trying to see too much in too short a time? How about this as a reason - It is because physicians are drowning in required paperwork and have to jump through pre-authorization hoops by insurers. As an ER doc, I thankfully don't have to do the latter, but I spend about 2 hours of my 12 hour shift dictating. Until my throat is sore - especially when you see 30 patients and have to dictate on all of them.
First, check out this article "Physicians Spend 3 Weeks per Year on Insurer Paperwork." What was even more shocking was that Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. There are 52 weeks in a year, and while I understand clerical staff doing administrative work, nurses spend HALF of their time doing non-nursing work. Wow.
And this costs 31 billion dollars each year. I'll say this again, non-medical-care administrative time costs 31 billion dollars a year. In health care insurance-speak, that means 8 million more people could have had good health insurance (at $5K/year).
If I did not have to dictate, I could see six more patients per shift, or spend more time with the ones I have. Conversely, I recognize the need for good documentation for the benefit of the patient; not to mention for medicolegal reasons.
I remember I did an administrative month in my medical training, where I sat in on a meeting where they were discussing "How to increase nurse satisfaction" as morale was low. They put boxes around the ER asking for suggestions. In the same breath they talked about how they needed something tracked and said the nurses should do it and would now make the nurses fill out ANOTHER form as part of the discharge process. I raised my hand and suggested that if they want to increase morale, tell the nurses they have to fill out one less form; not give them one more. Needless to say, nobody "got it" and continued with their plans.
Healthcare providers went into the profession (for the most part) to deliver healthcare. But increasingly, we do so much that has nothing to do with providing healthcare. Which is why many physicians are going to all-cash practices - without insurance plans (includes Medicare/Medicaid) hassles to deal with, they can spend more time with more patients at a lower cost to patients.
Some suggestions include single-payer systems, as one payer means less bureaucracies to maneuver through. Whatever the system, politicians need to acknowledge that if they want higher quality care, they need to pay physicians for providing care, and minimize administrative duties for them and their staff (less staff would cost less too).
Regarding documentation, computerization has offered a solution that has pros and cons. I have used a few history/physical and order entry systems and have found, for me - a computer literate 75wpm typer - it saves time and is more legible. Many systems are overly complex and take too long for simple documentation i.e. it should not take 10 minutes to document an ankle fracture. I like these systems where I take a laptop in the room and document while in the room, order tests in the room, and before I leave, the nurses/techs are already there initiating my orders. I have to document and order stuff, why not do it in front of the patient where they can get more face-time and it doesn't interfere with the flow of the physician-patient interaction?
However, there are a number of problems: 1) Laptops used everyday have degradation of battery life and don't last more than a few hours, to say nothing of a whole shift. 2) Physicians who are not as computer literate will find the process frustrating as it takes longer for them to document. 3) Templates do not have good medicolegal documentation and make a poor narrative. 4) Free-form typing takes a long time, even with macro use. 5) Actually uses more paper than a paper system. 6) Major issues when computers are "down."
We have a number of hurdles to getting higher quality, higher efficiency, lower cost health care. Administrative costs are one of them.
Think your doctor doesn't spend enough time with you? Think it is because they are greedy and trying to see too much in too short a time? How about this as a reason - It is because physicians are drowning in required paperwork and have to jump through pre-authorization hoops by insurers. As an ER doc, I thankfully don't have to do the latter, but I spend about 2 hours of my 12 hour shift dictating. Until my throat is sore - especially when you see 30 patients and have to dictate on all of them.
First, check out this article "Physicians Spend 3 Weeks per Year on Insurer Paperwork." What was even more shocking was that Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. There are 52 weeks in a year, and while I understand clerical staff doing administrative work, nurses spend HALF of their time doing non-nursing work. Wow.
And this costs 31 billion dollars each year. I'll say this again, non-medical-care administrative time costs 31 billion dollars a year. In health care insurance-speak, that means 8 million more people could have had good health insurance (at $5K/year).
If I did not have to dictate, I could see six more patients per shift, or spend more time with the ones I have. Conversely, I recognize the need for good documentation for the benefit of the patient; not to mention for medicolegal reasons.
I remember I did an administrative month in my medical training, where I sat in on a meeting where they were discussing "How to increase nurse satisfaction" as morale was low. They put boxes around the ER asking for suggestions. In the same breath they talked about how they needed something tracked and said the nurses should do it and would now make the nurses fill out ANOTHER form as part of the discharge process. I raised my hand and suggested that if they want to increase morale, tell the nurses they have to fill out one less form; not give them one more. Needless to say, nobody "got it" and continued with their plans.
Healthcare providers went into the profession (for the most part) to deliver healthcare. But increasingly, we do so much that has nothing to do with providing healthcare. Which is why many physicians are going to all-cash practices - without insurance plans (includes Medicare/Medicaid) hassles to deal with, they can spend more time with more patients at a lower cost to patients.
Some suggestions include single-payer systems, as one payer means less bureaucracies to maneuver through. Whatever the system, politicians need to acknowledge that if they want higher quality care, they need to pay physicians for providing care, and minimize administrative duties for them and their staff (less staff would cost less too).
Regarding documentation, computerization has offered a solution that has pros and cons. I have used a few history/physical and order entry systems and have found, for me - a computer literate 75wpm typer - it saves time and is more legible. Many systems are overly complex and take too long for simple documentation i.e. it should not take 10 minutes to document an ankle fracture. I like these systems where I take a laptop in the room and document while in the room, order tests in the room, and before I leave, the nurses/techs are already there initiating my orders. I have to document and order stuff, why not do it in front of the patient where they can get more face-time and it doesn't interfere with the flow of the physician-patient interaction?
However, there are a number of problems: 1) Laptops used everyday have degradation of battery life and don't last more than a few hours, to say nothing of a whole shift. 2) Physicians who are not as computer literate will find the process frustrating as it takes longer for them to document. 3) Templates do not have good medicolegal documentation and make a poor narrative. 4) Free-form typing takes a long time, even with macro use. 5) Actually uses more paper than a paper system. 6) Major issues when computers are "down."
We have a number of hurdles to getting higher quality, higher efficiency, lower cost health care. Administrative costs are one of them.
I read this the other day:
Sen. Hutchinson touts value-based healthcare insurance coverage. In an op-ed in the Houston Chronicle (5/28), Sen. Kay Bailey Hutchinson (R-TX) wrote that rising healthcare costs "threaten the competitiveness of businesses in Texas and across the country and place an added burden on families who are struggling to make ends meet. Furthermore, our state and the federal government cannot indefinitely sustain the soaring cost of entitlement programs, like Medicare and Medicaid, which have helped ensure low-income and elderly Americans receive care...One of the most promising new concepts in health care delivery is Value Based Insurance Design, which offers the potential to simultaneously improve health care quality while reducing costs." This concept "embraces the simple yet transformative idea that cost barriers should be removed for 'high-value' prescriptions and treatments. A medicine or procedure is deemed high-value when evidence shows that we can maximize the health benefits to patients compared to dollars spent."
Sen. Hutchinson touts value-based healthcare insurance coverage. In an op-ed in the Houston Chronicle (5/28), Sen. Kay Bailey Hutchinson (R-TX) wrote that rising healthcare costs "threaten the competitiveness of businesses in Texas and across the country and place an added burden on families who are struggling to make ends meet. Furthermore, our state and the federal government cannot indefinitely sustain the soaring cost of entitlement programs, like Medicare and Medicaid, which have helped ensure low-income and elderly Americans receive care...One of the most promising new concepts in health care delivery is Value Based Insurance Design, which offers the potential to simultaneously improve health care quality while reducing costs." This concept "embraces the simple yet transformative idea that cost barriers should be removed for 'high-value' prescriptions and treatments. A medicine or procedure is deemed high-value when evidence shows that we can maximize the health benefits to patients compared to dollars spent."
Why is this "transformative?" I've always wondered why treatments weren't covered for necessary medicines etc...that would keep people healthy and out of the hospital (which costs a lot more). Hepatitis vaccine isn't covered, but hepatitis treatment is. Stuff like that. So "value-based" healthcare basically says that a medicine or procedure has a huge benefit relative to dollars spent.
While I agree this should be done, I ask, why is this idea transformative? It is simple common sense. I guess not so common in the political arena.
Of course, I have noted potential for problems in the wording. What do they mean by "maximize?" I would use the definition: The value of a procedure or medicine is maximal if were that done, a higher cost medicine or procedure or admission to hospital will no longer be required.
I have some additions and clarifications to my previous post.
To the above tips I add:
7) Find out which hospital closest to you has 24 hour cardiac catheterization capabilities. If you have a heart attack, you do not want to go to a hospital that is going to have to transfer you for this critical life-saving procedure. Time is muscle!
8) Pick a hospital with a pre-code team. What is a pre-code team? Usually when a patient "codes" i.e. heart stops or stops breathing, or both, a "code blue" is called where all available physicians who are part of the responding code team converge on the patient, with nurses, and respiratory therapists as part of the team (in many hospitals this is simply the ER doc running like a mad-man or mad-woman to the code). A pre-code team assess patients that are getting sicker BEFORE they code. And prevents them from coding in the first place. Not many hospitals have this. I would select one that does.
Clarifications:
When asking if a there are hospitalists, you need to specify, "Do you have hospitalist in-hospital at night?" (some hospitalists take call from home - odd, I know, but that's why you need to specify).
While academic centers have residents taking care of you at night, you might be wary, but compared to not having anyone there at night, it is preferable. Though I would ideally want a hospital with intensivists (ICU specialists that are there 24 hours) and a pre-code team. And second to that would be having hospitalists overnight. An Academic center would be my third choice. In certain situations, academic centers may be superior - especially for unusual diseases, transplants, and state-of-the-art medical care.
**note**
I would like to thank minako for her suggestion for #7 above. An obvious omission on my part, I'm sure it will not be the last. I welcome your comments and suggestions.
To the above tips I add:
7) Find out which hospital closest to you has 24 hour cardiac catheterization capabilities. If you have a heart attack, you do not want to go to a hospital that is going to have to transfer you for this critical life-saving procedure. Time is muscle!
8) Pick a hospital with a pre-code team. What is a pre-code team? Usually when a patient "codes" i.e. heart stops or stops breathing, or both, a "code blue" is called where all available physicians who are part of the responding code team converge on the patient, with nurses, and respiratory therapists as part of the team (in many hospitals this is simply the ER doc running like a mad-man or mad-woman to the code). A pre-code team assess patients that are getting sicker BEFORE they code. And prevents them from coding in the first place. Not many hospitals have this. I would select one that does.
Clarifications:
When asking if a there are hospitalists, you need to specify, "Do you have hospitalist in-hospital at night?" (some hospitalists take call from home - odd, I know, but that's why you need to specify).
While academic centers have residents taking care of you at night, you might be wary, but compared to not having anyone there at night, it is preferable. Though I would ideally want a hospital with intensivists (ICU specialists that are there 24 hours) and a pre-code team. And second to that would be having hospitalists overnight. An Academic center would be my third choice. In certain situations, academic centers may be superior - especially for unusual diseases, transplants, and state-of-the-art medical care.
**note**
I would like to thank minako for her suggestion for #7 above. An obvious omission on my part, I'm sure it will not be the last. I welcome your comments and suggestions.