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lauramontini

What’s the Real Emergency Room?

Aug 24, 2012• 2

By David Allen

My summer job before I left for college in 1965 was the night admitting clerk in the emergency room in the Huntsville, Alabama county hospital – a facility built to support a few thousand in a small rural community but now taxed with serving hundreds of thousands, brought to town by the new Apollo missile program. Saturday nights in the small emergency room were often pure chaos, with auto wreck victims lined up on gurneys in the hallway. Those shifts passed the quickest for me, and I slept the best, afterwards.

Crisis promotes a kind of serenity. Why do people commonly tend get into their “zone” then? It’s because of what the situation demands: appropriate engagement. Think about the last time you were in such a circumstance. What were the fundamental components of your experience and behavior? Immediate integration of potentially meaningful inputs; clear definition of desired outcomes; trust in your intuitive judgment; decisions about specific next actions and physical movement on the most critical; consistent recalibration of all factors as required; acceptance of what can’t and needn’t be done at that moment. Those are all core elements of triage, and, actually, appropriate engagement with anything. Put together they’ll get you into your “zone.”

What Am I Worth?

Aug 24, 2012• 12

By Dr. Wes

Recently I was asked to serve as a consultant on a medical matter. Interestingly, they requested my hourly price for my services. I thought about this and wondered, “What am I worth in per hour in the open market?”

It is an interesting question to ponder.

I have decided to ask the blog-o-sphere. Call it a bit of “free market economics.” For the record, 100% of my hourly wage for my services will be sent to our cardiovascular research fund at our hospital to avoid any conflict of interest. I will not see ANY of the money the blog-o-sphere decides personally, but I really want to know what people think.

So where to begin?

Should I compare my hourly wage to MGMA standards for the annual physician salary of a physician of my subspecialty? If so, do I pick the 50% percentile, 25th percentile, 75th percentile, or 95th percentile? On what basis do I have to assure this is a fair price? Who sets this price? Are these data accurate or based on earlier years’ hospital data and physician surveys? Can I verify that their hourly price is justified? If so, how? Or are their data proprietary?

Medical Apps: The Next Generation

Aug 23, 2012• 3

By Kenny Lin, MD

Doctors of my generation have experienced dramatic changes in the way we access the information we need to care for patients.

As a medical student 15 years ago, my “peripheral brain” consisted of fat textbooks sitting on office bookshelves or smaller, spiral-bound references stuffed into the bulging pockets of my lab coat. As a doctor-in-training, I replaced those bulky references with programs loaded onto PDAs. Today, smartphone apps allow health professionals at all levels to access the most up-to-date medical resources such as drug references, disease-risk calculators, and clinical guidelines—anytime, anywhere.

Apps have several advantages over traditional medical texts. First, the information is always current, whereas many textbooks are already dated by the time they hit shelves. If I have a question, I can look up the answer on my smartphone without leaving my patient’s side. And unlike textbook chapters, many medical apps have interactive features that help doctors choose appropriate screening tests for patients, recognize when immunizations are due, or calculate a patient’s risk of developing heart problems.

Lastly, apps can enable remote monitoring of high-risk patients and reduce the need for office visits. In a small study published in PLoS ONE, for example, researchers found that patients hospitalized for heart vessel blockages were able to complete “supervised” rehabilitation exercise sessions in their homes with a portable heart monitor and GPS receiver that transmitted real-time data to doctors via smartphone.

Why Medicare Matters

Aug 22, 2012• 3

By Henry J. Aaron

Now that Mitt Romney has picked Paul Ryan to be his running mate, a major national debate on Representative Ryan’s so-called ‘premium support’ plan has become certain. Ryan’s plan would replace the current Medicare program for workers under the age of 55. When eligible, they would receive a flat dollar amount—or voucher—that would cover part of the cost of a health insurance plan. The value of the voucher would be adjusted annually according to a pre-specified index. If health care costs increased faster than that index, enrollees would have to pay the added cost themselves or accept narrowed insurance coverage.

Because that plan would not apply to anyone age 55 or older, supporters claim that older Americans don’t ‘have a dog in that fight.’ For reasons I explain below, that isn’t true, even if one looks only at Representative Ryan’s Medicare proposal. Other elements of the Romney/Ryan health care program have even larger implications for older Americans, but let’s start with the Ryan Medicare plan.

Costs for Seniors Could Rise

The claim that the Ryan plan leaves American’s over age 55 unaffected is untrue because it is likely to raise the amount they have to pay out-of-pocket for insurance. The reason is technical, but easy to understand. The premium for those who stay in traditional Medicare under the Ryan plan would be calculated as under current law, but the average cost of serving those who remain in traditional Medicare would go up as private insurance companies market selectively to those with relatively low anticipated costs.

All Hell Hath Broken Loose

Aug 21, 2012• 46

By Robert Laszewski

I’ve never seen a week in health care policy like last week. The media reports have to be in the thousands, all trying to make sense of the furious debate between Obama and Romney over Medicare.

As someone who has studied this issue for more than 20 years, it has also been more than exasperating for me to watch each side trade claims and for the press to try to make sense of it.

This blog post is quite long because the subject matter is complicated. If you want to cut to the chase, see my conclusion and summary at the end of this post.

Allow me to list a few of the questions people are asking and give you my take on it.

Will current seniors suffer under the Romney-Ryan Medicare plan?

No. Let me start by saying something that will likely surprise you. If I could be king for a day, I would prohibit anyone over the age of 60 from voting in this election. This election is really about the future and the big decisions on the table are about the long-term government spending and entitlement issues that should be made by younger voters who will have to pay for them and will benefit or suffer from them.

Those in their 60s and older are almost surely going to cruise to the end with the benefits they now have.

Whether its Obama’s Medicare plan, based heavily on the Medicare cost control board imbedded in his health reform bill (which doesn’t begin to impact hospital costs until 2020), or the Romney/Ryan Medicare premium support plan (that has no effect on anyone now over the age of 55), today’s seniors’ benefits are insulated from this issue.

The Age Rating Game: Will Older Americans Pay More Under Health Reform?

Aug 20, 2012• 107

By Maggie Mahar

The Affordable Care Act leaves it to the states to decide whether they want to let insurers charge older Americans more for coverage. If a state takes no action, a 64-year-old buying his own insurance in the individual market will pay up to three times more than an 18-year-old. In the small-group market – if a small business employs an unusually large number of older workers – the same 3:1 ratio applies.

Today, in most states, there are no caps on how much insurers can charge a 60-something forced to purchase his own insurance. In the individual market, only New York State bans age rating altogether, and just three other states limit how much premiums can vary, based on age, to less than 3:1. When insurers sell policies to small businesses, Vermont also prohibits age rating, but only five other states cap increases.

To check whether your state shields older boomers in either of these markets, take a look at these charts. (A checkmark in the right-hand column means that age rating is now unregulated in that state.)

Help from the younger generation?

10 Ways to Make the EMR Meaningful and Useful

Aug 20, 2012• 27

By Rob Lamberts, MD

I am an EMR geek who isn’t so thrilled with the direction of EMR. So what, I have been asked, would make EMR something that is really meaningful? What would be the things that would truly help, and not just make more hoops for me to jump through? A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here’s my list:

Require all visits to have a simple summary.
One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that is not useful for anything but assuring compliance with billing codes. I waste a huge amount of time trying to figure out what specialists, colleagues, and even my own assessment and plan was for any given visit. Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).
Allow coding gibberish to be hidden.
Related to #1 would be the ability to hide as much “fluff” in notes as possible. I only care about the review of systems and a repetition of past histories 1 out of 100 times. Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter. The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed. It is only input into the note for billing purposes.

Continue reading…

Profits, Quality, and U.S. Hospitals

Aug 20, 2012• 8

By Ashish Jha, MD

The recent articles in the New York Times about the Hospital Corporation of America (HCA) have once again raised important questions about the role of for-profit hospitals in the U.S. healthcare system. For-profits make up about 20% of all hospitals and many of them are part of large chains (such as HCA). Critics of for-profit hospitals have argued that these institutions sacrifice good patient care in their search for better financial returns. Supporters argue that there is little evidence that their behavior differs substantially from non-profit institutions or that their care is meaningfully worse.

To me, this is essentially an empirical question. Yet, I read the through the articles, I was struck by the dearth of data provided on the quality of care at these hospitals. Based on the comments that followed the stories, it was clear that many readers came away thinking that these hospitals had sacrificed quality in order to maximize profits. Here, I thought an ounce of evidence might be helpful.

Measuring quality:

There is no perfect way to measure the quality of a hospital. However, the science of quality measurement has made huge progress over the past decade. There is increasing consensus around a set of metrics, many of which are now publicly reported by the government and even are part of pay-for-performance schemes. While one can criticize every one of these metrics as imperfect, taken together, they paint a relatively good, broad picture of the quality of care in an institution. We focused on five metrics with widespread acceptance:

Who Owns Patient Data?

Aug 20, 2012• 34

By Fred Trotter

Who owns a patient’s health information?

·The patient to whom it refers?
·The health provider that created it?
·The IT specialist who has the greatest control over it?

The notion of ownership is inadequate for health information. For instance, no one has an absolute right to destroy health information. But we all understand what it means to own an automobile: You can drive the car you own into a tree or into the ocean if you want to. No one has the legal right to do things like that to a “master copy” of health information.

All of the groups above have a complex series of rights and responsibilities relating to health information that should never be trivialized into ownership.

Raising the question of ownership at all is a hash argument. What is a hash argument? Here’s how Julian Sanchez describes it:

All American Physicians Should Be Members of the AMA

Aug 18, 2012

By George Lundberg, MD

All American physicians should be members of the American Medical Association (AMA). And, while they are at it, they should also be members of their county, state, and principal specialty societies.

Why? Because they are the only games in town, and both security and safety are top Maslow imperatives.

The only real political power any physician has is the individual power of persuasion and participation (or not) and the power of a group.

American physicians, if united, would have huge clout, speaking with one voice. American physicians, divided as now, speak with hundreds of thousands of individual voices, a cacophony of futility.

As The Bard saith in Macbeth “… tales told by idiots, full of sound and fury, signifying nothing.”

If you are an American physician and you don’t like what the AMA has done and is doing, if you are not a member, shut your mouth, you have no right to complain.