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.

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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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