Dear Physician....A letter from you local PA/NP

Dear American Physician,

The changes in the landscape of the American healthcare system have called for some drastic changes in thought, process and execution over the past 10 or so years.  We have seen the invasion of computers into the medical landscape, the loss of autonomy as insurance companies require us to ask them for permission to provide care to our patients and a drastic change in who works for whom and how the American healthcare worker is paid.

In the middle of all of this, many Physicians are choosing to retire, leaving a significant shortage of physician providers to care for the masses in this country.  Emerging onto this landscape in the past 40 years is the "Mid-Level Provider".  The Physician Assistant and the Nurse Practitioner are poised for growth's in their fields unprecedented in the history of healthcare.  With this advent, the American Physician is concerned about how their jobs are going to change.  Will the Doctors act as team leaders, managing groups of Mid-Levels.  Will they act as consultants for the more difficult cases while the Mid-Levels focus their visits on "Healthcare Maintenance", or something else?  In short, the American Physician is wondering if they are going to be "replaced" by someone who has less education and makes less money, making them more attractive to business.

I hate to let the cat out of the bag, but the biggest elephant in the room no one is talking about is that you have already been replaced!  A physician preceptor once told me that some day, the actual practice of medicine would become the easiest part of my day.  I have found this to be true.  The place you have been replaced is not by lessor trained providers seeing your patients. 

YOU HAVE BEEN REPLACED FROM ABOVE, NOT BELOW!  You were in a unique position to guide healthcare organizations into this next century.  Instead, you have given up that job to less trained Healthcare Business Managers!  That's right.  The CEO of your local hospital, The CFO of the local insurance.  The business management staff of the medical group YOU own part of.  This has reduced the leaders of American Healthcare to "EMPLOYEES".  In a recent article in Medical Economics Magazine, the recommendation was made that Healthcare Organizations NOT hire physicians to the business management staff.  The reasoning was that they will think too much about patient care and not fiscal responsibility!

Yes it's true.  You have been replaced.  The CEO used to respect the Medical Chief of Staff.  Not anymore.  It's all about business and acceptable risks.  Is it worth risking a lawsuit so that you can save $100,000 by denying a life saving procedure?  What's the likelihood of a law suit?  Can we settle for less than the procedure would cost us?  These are the questions a Healthcare Business Administrator asks that a physician would never consider!

So the next time you feel like a "Mid-Level Provider" is stepping on your toes, remember, if we wanted to be Physicians, we would have gone to Medical School. (Every Nurse Practitioner or Physician Assistant I have ever met would have been more than capable of graduating from Medical School).  Remember, we are on your side!  We want the best for the patients in our clinics just like you do.  You need to fight to reclaim your role as the Director of the American Medical landscape.  We need you to set corporate policy, work with politicians to insure that the patients of this country are being cared for in the manner that is correct and proper.

We need to return management of healthcare to Physicians!  Remove the decision making from those that only care about the health of the corporate finances!  YOU need to return to your rightful positions as the leaders of this field!

And when you look around, we will be right there, supporting you in your efforts to provide high quality medical care the OUR patients!

Sincerely, your colleagues, your local PA/NP

Healthcare: Socialized Medicine VS Free Market? It doesn't matter!

Healthcare: Socialized Medicine VS Free Market?

(Spoiler alert!!!  IT WON'T MAKE ANY DIFFERENCE!!!)

I'm not actually argueing one way or the other, privats vs socialized. However, keep in mind this destruction of the system is being CAUSED BY THE GOVERNMENT and their OCD desire to micro-manage everything in sight! The computerization of healthcare started in 1983! (Full steam in 2004) It has nothing to do with Obamacare!  In 2014, only 4% of Doctors offices have met the requirements.  (instead of saying "gee, maybe there is a problem with our requirerents, the gov't is plowing ahead with 2015 requirements!)Those that have,  face the rosey outlook I outlined in my last discussion. They (the gov't) have created a system so complicated it's not possible to navigate without errors. AND in the U.S. medicare system, HUMAN ERRORS=CRIMINAL FRAUD!!! They do not recognize that their systems are CAUSING THE ERRORS.  On the flip side, the private sector has taken to sucking as many Medicare dollars from Doctors offices as possible. They are micro-managing us to death! We are spending Trillions to save Millions. 18% of the U.S. GDP is tied up in healthcare! Somewhere around 90% of the people that make a living off the healthcare dollar (Pharm, DME, Insurance, IT, Education and lisencing, ect) NEVER SEE A PATIENT!!!  This is not sustainable! They (the gov't AND the insurers) are scared to death to allow Doctors to actually make medical decisions! We need to allow healthcare providers to do what they are trained to do.....TAKE CARE OF YOU WHEN YOU ARE SICK! Not spend >50% of their working day putting information into a computer that makes it hard for them to do their job! (Computers CAUSE medical errors!!!) Physicians, NP's, PA's, RN's and everyone else are trained to deliver care! Not Code for your diseases, perform data entry, do referrals and the myriod of other items included in this process. A proper medical note now takes 10-15 minutes to write-20 Times a day! All this is done in your Doctors and Nurses "spare time".

Until the whole system and billing process simplifies and the decisions of how to care for patients are returned to the people who actually see the patients, socialized or private does not matter! We have destroyed the moral of the American healthcare worker! That is the most dangerous part. They know, no matter how good they are at taking care of YOU, ultimately, your care is decided by a 12 year old with a medical cookbook and no formal medical education. They also realize they are paid on their ability to navigate a rediculously complicated system that even the government does not understand!

The answer is not as simple as socialized medicine (newsflash! We do have socialized medicine, it's callet Medicare) or letting the free market decide! Honest! DEATH CAUSED BY INSURANCE is a COMMON cause of death.

A Business Summary of Healthcare.

A business summary of healthcare:

By forcing your Doctor to computerize, they see 30% fewer patients, Work 50% longer to see the patients they do see and pay at least $100,000 per year just to have the computer in their office.

Everytime your insurance requires a prior-authorization for a test or proceedure, it costs your Doctor's staff approximately 2 hours of labor. (Add 2 more hours to that if you do not go to the appointment and the auth has to be extended) Keep in mind also that for every dollar in the staffs payroll, about a dollar is spent in other costs (taxes, insurance, various government programs) A $15 an hour employee costs almost $30 an hour by the time the IRS and everyone else gets their cut.

Consider on top of that, increasing mal-practice premiums, increased taxes, increased costs of keeping the building open AND the fact that reimbumsement has been declining for the past 10-20 years.  In my local area, utilitities have increased 500% in the past 15 years.

Consider also that lifetime costs to BECOME a doctor amounts to around $1,000,000 in a lifetime. Money loaned to idealistic young Doctors, NP's, PA's and nurses at interest rates that would make the neighborhood loan shark proud.

Your Doctors are also required to close their practice, travel and pay large amounts of cash for somewhere between 100-250 hours a year for "Continuing Medical Education". Not to mention the fees and dues to maintain "compliance" to various professional and lisencing bodies. (Paid in the Thousands of $ every year)

One last thing, the providers in the office are the Only source of income. EVERYTHING else in the office costs money! (if it doesn't save time and make life easier, it's a drain on the practice)

So the next time your Doctors seem in a hurry or pre-occupied, they may have recieved a huge electric bill, mal-practice premium or a suponea requiring them to close the practice for a day.

Maybe there are real concerns about even KEEPING THE DOORS OPEN!

So, does this sound like a sound business investment? NO? That would be why medical corporations are, today in America, unable to obtain business loans!   The financial institutions of this country consider partnering with the future of American medicine a POOR INVESTMENT!!!!

Pitfalls of patient satisfaction reimbursment

In the future, healthcare provider (physician/np/pa) pay is going to be very closely linked with patient satisfaction. The happier the patients, the fewer lawsuits. The happier the patients, the higher the insurance reimbursement.

But, when pts are told to ask for this drug or that test by ads or Dr's on TV, they tend to be sicker longer, spend more time in clinics, money on meds, days in hospitals, AND DIE SOONER!

There's a reason Dr's go to school for 8 years, Nurse practioners/Physician Assistants-6 years. Add executives didn't go to med school. And Dr Oz is wrong 70% of the time. Plus, most of the tests he tells folks to get either aren't available or your insurance won't pay for.

We live in this consumer driven society.  While "The customer is always right" works in industry whose prime motive is to separate said customer from their cash, this is almost never the case in healthcare. The goal of healthcare is a means to an end. Healthy, happy patient while utilizing as little testing, medications and sick time as possible. All the while being pressured to do that "one more test just to make sure" if it will save the patient the pain and recovery of an invasive proceedure or spare the insurance company from a costly interveation. Being the one who will be held respondsible if the outcome is less than favorable is not a desirable position. Everyone is telling the provider what to do, yet the provider is the ONLY one who is accountable in the end.

So, be carefull what you are asking your Dr for. Pay attention to the look on their face. Make sure they aren't giving it to you to get you out of their office and avoid legal action.

It is said that doctors dont spend much time listening to their patients. In my 35 years of working with patients, it's never amazes me how many patiets never listen to their providers, never answer their questions directly and clearly and leave disatisified if they couldn't "have it your way".

National and State Healthcare Organizations, What Good Are They?

Open letter to all Physicians, Nurse Practitioners and Physician Assistants and all healthcare provider specialists. The healthcare industry is getting steamrolled by political concerns that couldn't care less about patient care. And MD's, DO's, NP's and PA's are in a giant pissing contest bad mouthing each other while the money interests are stealing control of medicine away from the only people in healthcare advocating for patients. Medicine is medicine people! We all diagnose a gallstone and clear a patient for surgery the same way, no matter what initials are after your name! We have to stand together for our own interests and the interests of our patients. So far, all we have been doing is whining, and complaining about each other and the system. Moaning about computers, legislation, and all the other laws that make our lives miserable and do nothing to improve patient care. We need have our national organizations say stop, enough is enough is enough. If the AMA, AOA, AANP and AAPA and the national organizations of other specialties all went to Washington and stood united, someone would have to take notice! Its time these organizations that collect hundreds of thousands in dues annually, if not millions, actually represent US! I'm going to explain a bit about my experience with these organizations. In my observations they tend to push for legislation to further their individual position and agenda. They go to state and national conferences slap each other on the back, bad mouth the other side and tell each other how cool they are. The physician groups are well established, but the Mid-Levels (PA's & NP's) are both new concepts. They both started in the late 60's and early 70's. With all the focus on midlevels for the future of healthcare, these two groups can ill afford to bicker amongst themselves. As someone with a foot in both camps, this arguement is foolish to me. We both provide healthcare, and both lisences are trained to provide high quality healthcare, reguardless of what initials are after your name. At this point in time, more so than at any in our past, it is important that Physician Assistants and Nurse Practitioners put aside their differences and come together for the good of the patient, the survival of the individual providers and the future of Mid-level Practice. Now is the time to craft our future. In 06 or 07, while at a California Academy of Physician Assistant and then winthin one year at the American Academy of Physicían Assitant conferences, I ask Board of Directors members if they were going to have lectures on the impact of computerization on healthcare. The answer I recieved caused my jaw to hit the floor. It also drove home the uselessness and cluelessness of our state and national "Leadership". "We don't feel that the computerization of healthcare is going to have enough of an impact on heacthcare to warrant lectures." After that, I never bothered to renew any of my annual memberships. James D. Gutzman, Rn, NP, PA.

The IDI-Odyssey of Medical Records.

In today's leg of our Idiots Odyssey through healthcare, I would like to take a look at medical records and how our current attitudes and legal positions are not only non-productive, but can be potentially harmful to the patient. Let's step back a few years. I'm sure many of you remember High School or College Biology class. Remember those notebooks you kept recording the data of all those life changing experiments and original research? Well, that element of recording basic scientific process is the basis of the medical record. In the days before Medicine became "Evidence Based" (that deserves a posting all by itself), physicians would record their interactions with patients, reactions to certain therapies and just general observations. These notes were considered the personal property of the physician and the contents were as tightly guarded as trade secrets. For one physician to get ahold of another's medical records was akin to Apple or Microsoft planting spies in the others company, in other words, industrial espionage. Fast forward a few years, the medical records evolved into a tool for providers to communicate during the transfer of knowledge say when a patient was referred from their primary Doctor to a specialist. The notes were very much written in "Medical-ese" and anyone outside the business would have a somewhat difficult time understanding them. Not so much trade secrets anymore, but a useful tool for the transmission of knowledge. Then, as society changed and the legal system began delving deeper and deeper into the function of medicine, the legal medical note began to be viewed with more scrutiny. I feel I should point out here that this was the period of time when translating the language of medicine from a means of communication among individuals who spent their lives dedicated to their science to a language understood by the masses truly began to complicate issues. When one is taught the art of the physical exam, how to take an extensive history and develop a feel for the health issues of an individual, there is a standard of care. Medical notes (and Nursing notes for that matter) used to be "charting by exception". There was a medical standard and you only had to write down what was outside the norm. So, lawyers being lawyers who appear to be incapable of functioning without every detail being covered minutely, began to demand that EVERYTHING needed to be written down. The end result was a LOT of very useless information being put in a Medical record, forcing the reader to search for useful information in a see of flotsam and jetsam. It should also be noted that the escalation of medical costs beyond the finances of the average individual coincided with the entry of lawyers into medicine FOR THE SAFETY OF THE PUBLIC. So, this brings us to our current times, not only does the legal system force Providers to waste HUGE amounts of time documenting to C.Y.A, it now means that needless testing and delays are being done to practice DEFENSIVE MEDICINE. Thus ordering tests which can be both costly and sometimes dangerous because they don't want to risk a law suit if their medical knowledge is incorrect. (Generally, it is not!) Additionally, with the advent of the electronic medical records, ease of access and oversight of the whole medical process is greatly enabled. Initially this might sound like a good idea, but it really isn't. First off, when medical records are requested from another provider, the receiving clinician often receives what is know as a "DATA DUMP". A 2-3 day stay in the hospital can easily translate into well over 100 pages of information, 95 of which are completely useless to transferring care of the patient. The rest results in a dangerous pile of useless information which may include ONE important line, easily overlooked, that may be a key to the patient's future health and treatment. So now let's say that all of the clinical record is scanned into a computer. Generally, these are stored as PDF files. Nothing but pictures that cannot be filed, sorted or searched. With the ease of transfer of data, a patient can have literally hundreds of pages of records, all of which the provider is legally responsible for and none of which is useful. "Now where is that Cat Scan done 6 months ago?" Computers are great at storing information, they are horrible at presenting it to the user at appropriate times. Enter the insurance company. They want access to these records also, Frequently, it appears, for no other reason than to delay or deny care. I have seen insurance companies deny an entire Emergency Visit, ambulance ride and testing because what originally appeared to be a heart attack ended up being indigestion. (Talk about MONDAY MORNING QUARTERBACKING) This is dangerous because patients no longer have faith the service they are paying for will support them when a real emergency does present itself. Also please keep in mind that the individuals who make these decisions to approve or deny payment are now second guessing the training and education of highly committed and educated health care professionals, while they themselves frequently only have a high school education. Now let's take a look at the complications of the Electronic Medical Record and the Patient. Current health standards require that a patient be given access to their medical records, generally through a computer "portal". I am going to contend (while some may disagree) that patients do not need to know everything in their record. Knowing without understanding can actually be dangerous. First, consider the internet. Anyone can go to any search engine and look up every disease known to man and a few more that only exist on the internet. ANYONE can read a medical textbook and get a lot of information from it. If that was all there was to practicing medicine, I could give you a list of books, give online tests to see if you understand the material and send you a medical diploma. We do not go to school to learn Medicine, Nursing or any of the other healthcare professional licenses that people hold FROM A BOOK!. I heard the following statement the first day of Nursing School and the first day of my Physician Assistant/Nurse Practitioner programs: YOU WILL TEACH YOURSELVES THE MEDICINE, WE {the teaching faculty) WILL TEACH YOU HOW TO APPLY IT!!!!!! Too many people grab ahold of some medical fact about their health, research it on the internet, fail to consult a professional, try to treat themselves or demand certain therapies from their providers. THIS CAN BE VERY DANGEROUS and ruin any hope of a productive relationship with your Provider! Now for what I feel is the biggest danger of all. Under current guidelines, we are working towards a system where the note needs to be completed and handed to the patient at the time of the appointment (Currently, the time limit is 3 days.) This is a problem in several areas: 1) the provider is now required to make a snap judgement on diagnosis and treatment. Frequently, there is a need to do research, review the records, obtain other information or just plain think about it for a while. 2) Since the patient will be reading EVERY word in the medical record, certain thoughts WILL NOT BE RECORDED. Trust me, the patient does not WANT to know every time I consider a potentially fatal diagnosis while performing a workup. We have DIFFERENTIAL DIAGNOSIS for a reason, what is most likely, what is most fatal and the priority of working up several differentials at once. Also,certain concerns will never make it into the record. Let us say I have an elderly person with a family member in the exam room. The family member satisfies Federal Privacy requirements to have access to the patients chart. Now let us say I suspect some form of abuse, physical, financial or other, but may need more time to get to know the family dynamics. I'm not going to document that for a couple of reasons. First, when the family member reads of my suspicions, they may just not present for care anymore, certainly not helping the person at risk. Secondly, there is now huge room for conflict in the office, potentially leading to legal actions for slander or violence. We already have patients calling up and yelling at us because they don't like the diagnosis we gave them (for many reasons). To a large extent, the public, the law and insurance companies are demanding access to information that they really do not understand how to process, how to apply it or see what kind of impact any single piece of information has. It is the job of the providers to educate and inform, help the patient understand what is important and what is not. Medicine is not a bunch of statistics that can be applied to all circumstance. People are INDIVIDUALS! It is an art of understanding and caring. It is the responsibility of the patient to find a provider they can work with. Sometimes a difficult task when insurance companies search for the lowest cost provider to provide care at the lowest standards to the most people possible (CATTLE CALL). So the next time you go to a Dr's appointment, and the provider spends the entire visit with their back to you, typing into a computer, please realize that the system that was supposed to provide YOU with quality medical care has devolved to a check box mentality with DATA ENTRY being to most important part of your visit. I guarantee, some day, no amount of data entered into a computer will be adequate. Maybe the next step is a camera and microphone in the room, recording all of your visit and an insurance adjuster giving immediate input as to the future of your healthcare. Have a nice day, more as the IDI-Odyssey of 21st Century Healthcare continues.

Purpose statement

The purpose of the Blog is to point out and highlight the truly dumb ideas our friends in the federal government are pushing on the medical system of the U.S.A. The Affordable Care Act (I will not say Obama-Care, it evokes too much emotion and prevents a rational discussion of the issues) As an outline, there are several issues going on in healthcare at once. Affordable Care Act (ACA) the computerization of healthcare. the new payment structures going into place ICD-10 implementation in October, 2014. There are a number of other issues, all of which goes to prove that the regulatory agencies and the insurance companies have very little idea of what it take to actually deliver care to a patient. Today, we went through a webinar that just finished which was a weekly update for Meaningful Use 2 and the Health Information exchange. 3 providers wasted their lunch hour watching this presentation, the info provided was not helpful, filled with Buzz Words and spent too much time telling us we needed to try to meet the requirements and very little time on how to meet the requirements. what a huge waste of time...... more as it comes along.