CYA and Healthcare Reform

September 27, 2009

Ok, so I know that I haven’t written a post for some time now and you are about to understand why. About one month ago, my dad called me to tell me that his primary care doctor had instructed him to go to the ER immediately because his routine EKG showed a change from last year. She had in fact stressed him out to the point of probably giving him a heart attack with her behavior which included wanting to call 911 to take him directly to the ER from the clinic.

Was he having symptoms (chest pain, shortness of breath, diaphoresis, decreased exercise tolerance)? No. In fact, he felt totally normal. Was he having ST elevation or depression on his EKG (findings typical of heart attack or diminished blood flow to the heart respectively)? No. He had “nonspecific t-wave changes”. Were his vital signs concerning? No. His blood pressure was 128/72, heart rate was 88. So why call 911? Because the primary care physician wanted to practice CYA (cover your arse) medicine.

For some reading this post, the term CYA medicine might be something of a novelty. Certainly one never sees Dr. House, MD or Dr. Cox from “Scrubs”, or even Dr. Green and Carter from “ER” practicing this type of medicine. What exactly is this type of medical practice?

It basically involves the most limited degree of mental commitment possible in a medical encounter, where you are asking yourself only one question, “How can this patient hurt me later?”.  Based on the medical provider’s answer to that question, they then proceed accordingly. It doesn’t matter how much this will cost the patient – insured or not. It doesn’t matter how many needless tests you have to order at the patients physical, financial and emotional expense. It also doesn’t really matter if the patient agrees with you or not, especially if they are insured – because you can always threaten them with an AMA (against medical advice) discharge where their visit will not be covered by their insurance. They are your prisoner so you can strategize your defense from a medical malpractice lawsuit.

As an ER physician myself, I cannot always blame providers who practice medicine this way. I don’t believe that anyone graduates residency intending to practice medicine this way. Its after someone comes after you for something only God could have forseen that you get gun-shy. At the end, it becomes a vicious cycle of abuse from both ends.

This is the biggest problem with Healthcare reform – the hidden nooks that politicians can’t see the way we, as healthcare providers, see them from within. There are too many groups mining in the medical gold mine – malpractice lawyers, insurance companies, drug companies, etc. – and they each have powerful lobbies to back their interests. The purity and simplicity of the doctor-patient relationship with all that it used to contain of trust, friendship, understanding and forgiveness has been plundered and I personally am not sure we can return to that after having let in the greedy pirates mentioned above.

So, back to my dad. He asked me to come with him to the ER – in my car and not the ambulance – to make sure they didn’t rape him there with unnecessary tests and procedures. He had me stand behind the ER provider who was practicing CYA and give him thumbs up or down depending on whether I agreed with the management or not. They of course told him that he could die if he wasn’t admitted for “further testing”, but he did just fine at home until his next follow-up appointment.


Healthcare Administrator Salaries and the French Fireplace

June 5, 2009

stress salary

A few days ago, I had the great pleasure to visit some good friends from the hospital for lunch. They are good, hard-working people; salt of the earth. It bothered me how hard they work and how they seem to get so little back for their work, and I mentioned that to them. It led us into an interesting conversation about how much the admin people are making at our local community hospital – I think I hurt my jaw when it hit the floor.

I am not naive when it comes to the outrageous salaries that health-care administrators (CEO’s, CFO’s, COO’s and all the other acronyms they make up to take more money for nothing) seek to justify to themselves, but most people tend to think of these overblown salaries as belonging to Wall Street types in big cities; not your run of the mill smaller town.

So, I was quite surprised to learn that the CEO at our hospital pays himself close to a half million dollars per year. All while cutting nursing hours, chastising docs about overtime hours and outright terminating other direct patient care personnel positions for “cost savings”. The CFO also gets a healthy paycheck, closer to a quarter million though. He once told the hospital staff that they always have to go for the best in patient care, kind of like when he couldn’t decide on importing an $80,000 fireplace from France or buying an American one for under 10 grand. He decided that he should go for the “best” and went ahead and imported the French one in the end. He probably should have ordered a mail-order brain and conscience while he was at it.

This prompted me to look into the whole issue of the hospital administrator fleecing of America. I found many intriguing details that just nauseated me in general, but none better then the following concise post written by Dr. Ira Kirschenbaum on his Mad About Medicine blog. I will quote just one paragraph here for your benefit:

… the next time you want to argue with your Primary Care doctor’s front desk about a $5.00 co-pay, remember that he makes an average of $149,000 per year. On the other hand — using United Healthcare as an example — your insurance company paid their CEO — one man — [324 million dollars] over a recent five year period.

He then goes on to list 23 health-care CEO’s salaries – mostly those of insurance companies and drug manufacturers – and their published 2005 salary as well as 5-year combined income. The “poorest” guy in the bunch, James Tobin of Cardinal Health, made “only” $1.1 million in 2005, but he had a good 5-year period over-all, making $33.5 million (or just under $7 million/year). Poor James, what ever will he do to keep up with the Joneses?

Inevitably though, discussions like this lead to some people praising the wonders of capitalism and warning against the evil of “socialism”. At the end of the day though, it is balance and moderation which saves a society.

Our hospital will certainly go down, as it eventually must with these crotch stains at the helm. At that time, I seriously doubt that the hundreds of people out of the job will be giving a damn one way or the other about political ideologies as they join the masses screwed out of their job by corporate greed as they try to figure out how they will put food on the table.

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Swine Flu: Epidemic on Our Hands?

April 26, 2009
Duct Tape. Save Yourselves! The End is Near!

Duct Tape. Save Yourselves! The End is Near!

I’m almost glad that I will be having some time off in the coming days because with all of the insanity regarding the swine flu racing through Mexico City, and now in certain parts of the US. News reports thus far have done what they have become exceedingly good at in recent years – scaring people. Remember duct taping your windows in case of a nuclear strike? Probably about as effective as hiding under your desk (what they officially taught the last generation to do in case of a nuclear strike). So what do I expect will happen?

Starting soon – in a city near you – ER’s will start getting loads of visits from people suspecting they have swine flu (had our first one already today). What are the symptoms you might ask? Same as any other kind of flu – fever, cough, fatigue, body aches, nausea/vomiting, lack of appetite, etc.  Pretty vague right? But there must be a way to get tested right?

Yes, there is a test. Whew, you must be thinking! But, the test needs to be done at a public health lab. So, in other words, it might take a while to get results. But there must be something I can do right?

Sure, if you notice these vague symptoms and get to your doctor within 48 hours of the onset of your symptoms, then you can get antivirals. “What are antivirals?”, you may ask. They are very expensive medications produced in very limited quantities that have totally variable rates of success. What does that mean? It means good luck.  Beyond that, only two out of the four available class of antivirals “seem to be effective” per the CDC. So what happens then if you get to your pharmacy and they’re out of Tamiflu or Relenza (the two that “seem” to work)? If you can’t get it within the first 48 hours then its not worth taking. But you’re not dead yet.

The CDC recommends routine precautions to prevent the spread of infectious diseases: “wash your hands often, cover your nose and mouth when you cough or sneeze, avoid close contact with sick people. If you are sick, stay at home and limit contact with others”.  So, I’m following their advice and staying away from sick people by not working until this fear campaign takes a rest.

The thing that really bothers me though is scaring people over something when there aren’t reasonable options for reassurance.  The last thing I want to see is a run on ER’s and people who are minimally ill, but maximally worried, depleting whatever supplies of antiviral are available (even if doesn’t work so effictively) so that later waves of possibly sicker people will not be able to get treatment.

I also hate seeing people get worried over something which in many cases is no different than getting Influenza. Influenze kills lots of people every year – approximately 36,000 deaths and more than 200,000 hospitalizations are directly associated with influenza every year in America according to the Journal of the American Medical Association. I’m not sure about you, but I don’t change my lifestyle or schedule because of Influenza. Do we really need to change our lives because of the Swine Flu?


Drug Seekers: Part 1 – Origins

April 14, 2009

pill-bottleOne of my attendings in residency taught me a great lesson which I faithfully try to apply to all my patients – well with the exception of really aggravating drunks that piss on the floor, people who choose to vomit on the floor even though the trash bin in 3 feet away and parents who let their kids kick me in the groin when I’m trying to evaluate them. So, ok maybe I don’t apply it as faithfully as I should, but you get the idea. One group that really challenges our reservoir of compassion and empathy though are drug seekers. For those readers who are unfamiliar with what a drug seeker is, an explanation is in order.

Everyone gets pain from time to time. Some unlucky people though have to suffer with pain on a daily basis. These two groups of people are legit, and it provides me great immediate gratification in my work to help relieve their pain when they come to me. Yet there is another group of people out there which totally obscures the pain picture and makes this task very challenging. This pathetic group of losers has lovingly been dubbed “drug seekers” by virtually all ER’s around this great nation.

Drug Seekers are people who typically fake pain in order to get pain medications that provide a euphoric feeling (in other words, they get high with them). Such drugs are usually narcotics that act like heroin, benzodiazepines that mimic alcohol in many ways and then some other really crazy FUBAR stuff that I won’t get into now.  Here is a typical drug seeker encounter:

Doctor walks into patient room to see drug seeker (DS) sitting calmly on the stretcher.  More often then not, they are munching on some chips and drinking a soda (in other words, they look totally healthy without the slightest indication of any sort of suffering). He introduces himself and asks the patient what brings them into the ER today.

DS (the drama begins): “Oh Doctor, I have been having a horrible _____ (fill in the blank – headache, stomach ache, back pain, etc. – for extra points can use more than one area of pain to complicate the picture) for the past 2 days!”

Doc: “I’m sorry to hear that DS. Have you ever had pain like this before?”

DS (ratcheting up the drama): “Yes doctor, it happens a few times a year. My doctor has put me through all the tests before – a CT, an MRI, blood tests and even a specialist saw me, but they can’t seem to pinpoint the problem.”

Commentary – As Whitecoat has mentioned on his blog, there appears to be a Drug Seeker handbook or Standard Operating Procedure (The DSSOP) out there. They often give the line about getting tested or evaluated, but strangely it is usually in another city/state and in almost 100% of cases they report “normal” findings. Of course they never have any written documentation of these evaluations and asking them what doctor they treated is useless as they never remember of give some generic name like Dr. Smith. Truly fascinating.

Doc: “I can imagine that it must be very frustrating to not get any answers, even from a specialist.”

DS (thinking she’s got this doc in the bag): “Oh yes doctor, soooo frustrating. It just seems that no one understands what I’m going through, but I can see that you do. I can’t even begin to tell you how comforting that is.”

Doc: “So how have you been able to control the pain in the past?”

DS (nearly salivating now): “Well, in the beginning I used to get by on Tylenol. I even tried aspirin and ibuprofen, but I had some reactions and my doctor explained to me that I am allergic to NSAID’s. So the only thing that worked after that were medicines like Vicodin or Percocet … except when it flares up and I need to come in like now.”

Doc: “Yes, it seems that you really have had a tough time. When you do get these ‘flares’, what seems to help then?”

DS (faking an inability to accurately remember): “Oh, its a medicine that starts with a D … deme … dama …. Oh, I can’t remember exactly. Do you know which one I’m referring to?”

Commentary – From an underground version of the DSSOP: “It is imperative to demonstrate that you have tried over-the-counter medicines and that they have not helped, and even better, to say that you are allergic to them. That way they won’t try to prescribe you any crap like Naprosyn or that Toradol BS they try to inject you with in the ER. Then you need to feign unfamiliarity with what you really want so that a naive sucker (the doc) will imagine that you get this medicine so rarely that you can’t even remember the name.”  Those of you in the ER will agree that it is amazing how textbook this act is pulled off. Worthy of an Emmy, or a “Narky” as I like to call this award.

Check back tomorrow for the exciting conclusion and to read about my personal approach to dealing with these fine, veteran actors.

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You Did What with a Hot-dog???

April 11, 2009
Need I say more?

Need I say more?

After a week of more serious posts, we’re overdue for a laugh, especially as we hit the weekend. And what better to discuss than the age-old tongue-in-cheek subject of vaginal foreign bodies …

That was all that it said on the ER board when I signed up for this patient not too long ago. She was a respectable 57 years old, so my expectations were not too exotic. How naive of me.

Mrs. S had a slight problem. Turns out that she and her husband were looking to “spice up” their love life a little, and so they thought “wouldn’t it be kinky if he sexually stimulated her with a hot-dog?”. Problem is that they believe a piece broke off the tip of the ill-fated hot-dog in question, and their attempts to find it were not successful. Hence the embarrassing ER visit. (The husband didn’t have the gall to come in with her and hid out in the parking lot)

Stifling all attempts at bursting out in laughter or asking her WTF, I hurried out of the room after telling her that I needed the nurse so we could go fishing – I mean searching – for the missing hot-dog tip. I momentarily considered asking what kind of hot-dog, but figured that might be in bad taste, no pun intended.

So after trying to remember something really serious and depressing to suppress my laughter, I returned with my nurse (after telling her she had better not make any funny gestures). When I looked inside, the first thing that surprised me was the excoriated appearance of her cervix. Thinking with my medical brain first, I asked her if she had recently had a pap smear since cancer can sometimes appear in a similar fashion. She said that she indeed had, and that it had been normal for decades now.

Having confirmed that, I then switched to my ER brain and asked her to tell me more about this hot-dog and the force that was used. She turned beet-red and said that it was “pretty vigorous”. The nurse wanted to know if it was a Kielbasa which at the moment seemed to be a reasonable question. I then asked her if she had actually seen a broken part of it, or if it just seemed shorter? She said it just looked shorter, and that they hadn’t examined it further and just assumed a piece was inside her due to the extreme discomfort in her vaginal area.

So I did another thorough check of her entire vaginal area and still came up empty. As embarrassing as it was going to be, I had to tell her that it looks like the poor hot-dog tip was literally pounded and thus seemed shorter.  All the redness over the cervix though and the subsequent swelling was creating a foreign-body sensation as opposed to left-over hot-dog.

We all then had a good laugh when she said she wouldn’t be doing that again, and this gave both me and my nurse a good opening to let out all that pent up laughter in an appropriate way. We patted her on the back and told her that  people had done stranger things (ok, that was a total lie, but with good intentions) and she felt a little better. She walked, bowlegged, out of the ER to the waiting car that promptly sped away. I only wish I could have heard the conversation that followed 🙂


Why is My Hospital Bill So High? Final Part: 5 Ways to Pay Your Bill

April 10, 2009
There is hope. You don't have to move to Mexico.

There is hope. You don't have to move to Mexico.

In this last installment of the series, we finally get to the question that many people need answered – “How do I pay my ridiculously high hospital bill?”

Seriously speaking, huge medical bills are one of the three most common reasons that drive people to bankruptcy and about 75% of those who did go on to bankruptcy had insurance at the time (2001)! With our current financial melt-down driving more people to be uninsured these figures are sure to be even more tragic.

To get a basic idea of what a typical hospital admission cost for an uninsured person, the Healthcare Cost and Utilization Project published their study in Feb 2009 that showed:  “Hospital charges for uninsured stays grew by 76%, from an average of $11,000 to $19,400 per stay (after adjusting for inflation), compared to 69% growth in hospital charges overall.” And this doesn’t typically include ambulance fees or things like ICU or emergency surgery.

So for the average person barely staying afloat in troubled financial waters, getting that $20,000 medical bill has led some to even consider suicide. But it doesn’t have to be that bad thankfully.

Just a few weeks ago, I met Margaret when contacted me after having to take her son to the ER. It was a traumatic and overwhelming event for her when she watched her 5 year old vomit and then his eyes rolled up into the back of his head and he became unconscious.  She immediately called 911 and EMS took the boy to the closest ER where he was intubated (was put on a breathing tube) and then flown out by helicopter to the Children’s Hospital downtown. There, he spent 3 days in the Pediatric ICU where he had a CT and MRI of his brain, a spinal tap as well as numerous blood tests. Thankfully, he was released in good condition 4 days later without any exact diagnosis for his episode.

The most important thing was that her son was ok, but since Margaret had no medical insurance, she knew even before getting the bill that it was going to be a bear – a really big, hungry and mean Grizzly bear. She didn’t exactly qualify for medicaid due to her income either. Worried and overwhelmed, she tried to get answers before the bills came which was the right thing to do. Her story thus had another good ending that she found some clever ways to lower her son’s bill (which incidentally was about $67,000) to something more manageable. Here are a few tips:

1. Remember that hospitals and doctor’s offices are HAPPY to work with someone who actually wants to pay. they spend enough time tracking down people who have ignored bills that they will gladly work with you. Even if you cannot reduce your bill, you can always pay monthly installments without interest. I personally know people who have arranged to pay as little as $50/month and less after a childbirth for example.

2. If you can pay a substantial downpayment – say for example 10-25% of the bill – this can make even the greediest hospital ready to negotiate a lower total bill. And again, the rest can be paid monthly. You will have more success with this step as with the first, if you contact them before the creditors come knocking on your door.

3. Always, always ask for an itemized bill and challenge what you see. Mistakes in this area are exceedingly common and you can always find something wrong. A medicine you were charged for that you never got, a box of tissue that you never used, a pregnancy test for your husband or a new set of spark plugs for your doctor’s Corvette. Ok, that last one you probably won’t find, but just wanted to be sure you were paying attention.

Authors at Bankrate.com report, “Estimates on hospital overcharges run up to $10 billion a year, with an average of $1,300 per hospital stay. Other experts say overcharges make up approximately 5% of hospital bills.” So don’t get fleeced on this easy step.

4. Consult with a medical billing advocate. Billing advocates basically work with hospitals and doctor’s offices on your behalf to get your bills reduced. A colleague recently spoke with Holly Wallack of Administrative Solutions Plus and was impressed by her services and dedication to helping patients control outrageous medical expenses.

Holly, who has been featured by Katie Couric, states on her website, “We review provider bills, hospital bills, and insurance documents for errors and overcharges. We negotiate with the party that has made the error, often reducing the charges to you and reducing your out of pocket cost. We can even help you recover money you’ve overpaid in the past. We believe that the majority of medical bills contain errors. Don’t pay more than you really owe.”

5. Check with your hospital to see if they offer any type of financial aid for overwhelmed patients.  Hospitals usually don’t publicize these programs or provide much guidance on how to apply unless asked and pursued with diligence.

Things to avoid:

a. Bankruptcy – yes it is an option, but most would recommend against it and it stains your record for 10 years. If you can arrange a monthly payment then why would you go for bankruptcy? And no, “So I can keep watching cable” isn’t a good excuse.

b. Getting a loan – also an option advocated by some, but not a good one. You are only trading one mess for another in most cases.

c. Running to Mexico – sure they have nice sandy beaches and great weather, but better to leave that as a vacation option rather than your only option. Plus those drug traffickers and their pesky little wars can really throw a wrench into things.

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Why is My Hospital Bill So High? Part Three: 5 Ways to Keep Costs Under Control

April 9, 2009

Yesterday we discussed the importance of both patients and medical staff (nurses and doctors) being cost conscientious. I forgot to mention another common myth in this area, that expensive tests = good medicine.  This has never been shown to hold, and in fact more commonly, it has been shown to be bad medicine. The best medical care is when patients and medical staff communicate effectively and test with a direction in mind as opposed to randomly.

So as promised, here are 5 simple things that can do to help keep costs down the next time you have to go to the hospital:

1. Ask your doctor if the test that is being ordered needs to be done today. A test done in the ER can be significantly more expensive than the exact same test being done in your doctor’s office or as an outpatient. Sometimes we need to know now, but in other cases these tests can be delayed without risk.

This also applies to, “Do you mind checking my ____ level today.”  Many times people get other blood tests checked while at the ER since they’re “already there”. I personally have no problem doing it for them, but I always remind them that it may be more expensive.

2. As stated above, make sure that you give your doctor the most detailed understanding of your problem. The more they know, the more specific they can be when ordering your tests if necessary at all.

3. It is also important to understand that tests are not always needed. Some people feel “cheated” if they don’t get a blood test or x-ray and forget that the doctor’s exam is itself a test. People still got better before the days of CT scans and immediate blood tests through careful attention to detail in the examination and a good back-up plan. If we want to curb our national appetite for outrageous medical expenses we need to get back to basics again.

4. In the case that your condition may involve a hospital admission, discuss with your doctor if the admission is absolutely necessary or if instead you can see your doctor first thing in the morning. If nothing essential is being monitored overnight and you’re not receiving essential medications during the night by IV, then an admission can be avoided in many cases.

5. In the case that you do get admitted to the hospital for further tests or treatment, get a hold of your hospital’s billing department as soon as possible to find out what that room charge will cover. You can sometimes save big $$$ by having a family member run home to get you a box of Kleenex, bottle of Tylenol or aspirin, etc. – all things that can be charged at an outrageous premium in many hospitals.

This also applies in the ER. When appropriate, going home to use your own medicines (prescription and over-the-counter medicines) as opposed to getting them in the ER out of convenience can save considerable amounts of money. Your doctor will be happy to tell you if it would be safe to do so or if you really need to get that medicine in the ER.

Feel free to share any of your own suggestions or experiences in this regards!