Health Care; The Presidential Candidate’s Proposals

Over the next several posts, I’ll be reviewing and digesting the front runner’s positions and proposals on health care. All of the candidates have one but the only ones discussed here will be those that are easily available to everyone on a particular candidates website.

Most of them have broached the idea of health care reform and at times have used it as a topic of debate. No one has given details, at least in the debates or press conferences, how it will be paid for. As I mentioned in an earlier post, any hybrid program is doomed to failure because of corporate greed on one hand vs government inefficiency on the other.

The only way a hybrid program would conceivably work is if there were strict regulation, much like there is in the utilities industry. Many of you may recall when the oil and airline industries were regulated and what happened to prices AFTER deregulation. The reason for the regulation in those industries at the time was because of a small number of corporation having control of a high demand product or service, an oligopoly.

The insurance industry is much like that today. While there are many smaller firms offering health insurance, the bigger players still have the lion’s share of the market. The smaller outfits also can’t offer comparable benefits to as many providers because many providers don’t participate in smaller plans. It’s simply not worth their time.

So, if the candidates are truly committed to health care reform that provides good benefits at a reasonable cost, I’m ready to listen. But, I want details.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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Your Doctor as Social Worker? Or "beam me up Scotty, there’s no intelligent life here".

Most people assume that with the “MD” after your name it garners some form of respect, just because of the degree and expertise, the job you have to do. Maybe it did “in the day”, but certainly no longer. Physicians are looked on with contempt; looked at as an easy target for a frivolous lawsuit; spends as much time pushing paper and doing social work as caring for patients. The social work aspect of practice is increasing at an alarming rate and is directly proportional to the change in the demographics of our hospital patient population. In other words, the poorer the patient, the more services have to be arranged for them after discharge.

Don’t get me wrong. I don’t mind helping people who need help, but the people who utilize these other services the most are the ones who “abuse” the services always. Take for example a member of the working poor who simply doesn’t have health insurance. This type of patient worries about how long they will be in the hospital because of the hospital bill. They are anxious to get better so they can be discharged sooner. They are also the ones that ask “how much” their prescriptions cost and will ask if cheaper alternatives are available.

On the other hand we have the hard core professional patients. These are the ones with repeated admissions for the same problem. They hop from ED to ED and frequently get multiple prescriptions from several different doctors for, guess what, narcotics. They have developed their own specialized complaint that is difficult to disprove by exam or by laboratory study. If the ED doc believes the story or has never seen them before, they get admitted.

The admission isn’t the bad part. It’s the discharge. From the date they are admitted until discharge, and sometimes long afterward, they are consuming vast amounts of resources.

Here are some of my favorites;

A young woman admitted with stomach pain and maybe diarrhea, who likely has a mild case of stomach flu. Most of us would take care of it at home with fluids, acetaminophen and rest. She, of course needs large amounts of narcotics to control a pain we can’t locate with any exam or test. No diarrhea during her stay in the hospital, either. Appetite seemed OK and she was out of her room smoking whenever someone was looking for her. After several days, she was discharged but refused to leave saying she had no where to go. We were amazed. She had a place when she was admitted.

The answer, of course, was simple but new to me. She and her mother lived together. During her hospital stay, the patient’s boyfriend and mother decided to “hook up”. Since mom thought it would create a problem with all of them living together, she decided to kick her daughter out, leaving her homeless. Needless to say, our social worker had to put her thinking cap on. Eventually the patient was given a cab voucher, a voucher for prescriptions and, with the assistance of the social worker, located a family member willing to take her in.

My best stories are the alcoholics. They party 24/7 with reckless abandon. That is until they truly get sick or run out of money. One such person came to us after having a case of the stomach flu of the month. His routine was to drink 12-18 beers per day, a few Long Island Iced Teas, a bottle of wine and whatever else he could get his hands on. During sporting events, he would have 7-8 beers at the game PLUS his usual at home. Where the hell do these guys get the money?

His family brought him in because he wasn’t acting right. After talking to the family, I knew right away the guy was going through withdrawal. To be perfectly honest, I wish they had brought him in sooner. It would have been easier and safer to give him a drink and send him home than to let him detox and go through DT’s. But that wasn’t to be. He did go through withdrawal and he did go through DT’s; for three weeks. He laid in our ICU, nearly unconscious, for three weeks. All because of alcohol. We are not a detox or treatment facility.

When he woke up, we sent him home because he refused outpatient treatment and didn’t even want any information for any treatment programs. He’ll be back.

Another of our alcoholic friends comes in often. Sometimes for falling down, sometimes for pain and sometimes just because he’ s drunk and has no where else to go. One such night he came in sooooo inebriated, that after several hours of “sleep” he was still too dunk to go home. So, the ED admitted him. When he finally woke up, I discharged him. But before he would leave, he wanted another meal, another shower, a new change of clothes and new shoes. The hospital gave it to him and then we gave him a a cab voucher to get home. Should’ve given him the cab voucher in the first place.

One of our most infamous frequent fliers is a diabetic aged 20 years. She’s had her diabetes long enough to know how to take care of the basics. That means that she should be able to keep herself out of the hospital. She splits her time between us and another hospital across town. She’ll spend a few days with us, stay out 1-2 days then spend a few days with them. The cycle repeats. She comes in with Diabetic Ketoacidosis, the most severe and critical illness a Type I diabetic can have next to acute hypoglycemia (low blood sugar). It is always serious and often life threatening. She knows full well that she isn’t taking her insulin like she’s supposed to. Soon she’s going to push it too far and die. She doesn’t seem to care.

She always does well while she’s with us meaning she’s not the “brittle” diabetic people hear of. We always go over her insulin regimen, what to do when her sugars are high and refill all of her medicines when she’s discharged. She also gets vouchers to get her meds refilled at the pharmacy. As often as she’s gotten vouchers from us, she’ll accumulate a year’s supply in about 3 months.

The best of all, and the predictor of things to come, was a young man who presented to the ED with belly pain. He had fever, white count (sign of infection), nausea and right lower quadrant pain. First thing we all think of is appendicitis.The ED physician ordered a CAT scan which the radiologist read as acute appendicitis. This is a surgical diagnosis and he needed an operation. The surgeon on call came in, examined the patient, looked at the CAT scan and then went to talk to the young man’s mother.

He introduced himself, explained what his exam, blood work and CAT scan showed, then proceeded to explain that her son needed surgery, an appendectomy. Her response was “You’re wrong and I’m going to sue you!”

That doctor finished the surgery then took himself off of the call schedule for the ED. Another pair of skilled hands has bitten the dust.

Their stories differ a little but the theme is the same. I did this to myself; yes I’m still going to smoke; no I’m not taking my meds like I’m supposed to; no I’m not going to see the doctor you found for me;I came by ambulance, can I have a ride home; can I get my meds for free; can I stay another day; no I want the stronger pain pills; well, Dr. X will give them to me, why won’t you; I’m going to sue.

And you all wonder why healthcare is in crisis; why more and more doctors are looking for a way out; why there are fewer applicants to Medical School; why costs are skyrocketing; why liability insurance premiums are outrageous?

Take a good look around. The finger of responsibility needs to be pointing back at the person looking in the mirror. The gravy train needs to be stopped before the whole thing derails.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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How do I fnd a good Family Doctor?

Working as a Hospitalist means that I have no outpatient practice. Many of my patients ask me near the end of their hospital stay if I can be their Family Doctor. Of course, I don’t have that type of practice and it would be a conflict of interest if I did. My patients have had the opportunity to “try before you buy”, although we’d all rather it not be under the circumstances of a needed hospitalization. Nonetheless, how do you find a good Family Physician? Or any physician for that matter?

I always encourage people to seek out a physician that friends or family are happy with or speak of highly. The best referral is one that comes from someone with personal experience. You are able to ask questions about the office staff, billing procedures, nurses, and better yet, can ask exactly what the person thinks and feels about their doctor. Don’t underestimate the power of public opinion.

If the doctor you would like to see isn’t accepting new patients, a personal referral from one of the doctor’s existing patients is an excellent way to try to get your foot in the door. The longer the referral has been a member of the practice, the more likely you are to get an appointment. That’s also a good indicator that the person referring the doctor to you is satisfied with with that particular doctor. If you do get an appointment, make sure you mention that you were able to get an appointment because “patient x spoke highly of you and referred me to you”. Everyone likes to hear feedback about how they are doing.

As far as surgeons go, some of the same rules apply. Referrals from previous or existing patients is key. Satisfaction with the pre-surgical consultation, surgery, if needed, and post operative care are all things you want to know.

One of the best, but sometimes confusing, key elements of selecting a surgeon are their reluctance to operate. I would rather that my surgeon explain all of my options, including no surgery at all.

And always NEVER be afraid to ask for a second opinion. The doctor should be confident enough in his/her examination and diagnosis that he/she would feel another physician would agree with his/her assessment. If your doctor gets upset that you ask for a second opinion, get a new doctor! I also like a doctor who isn’t afraid to say “I don’t know”, but finishes their statement with “but I’ll find out”. To me that means they can acknowledge their limitations AND are interested in you and learning more.

And finally, when you do find a doctor you are satisfied with, be sure to refer other patients to them. Return the favor someone else gave to you.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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You expect your Doctor to feel your pain. Do you feel theirs?

When most people go to see the Doctor, it’s because something is wrong. And when something is wrong, you expect the person you tell to have some compassion and empathy for your discomfort and vulnerability. You expect that from your Doctor and when you don’t get it, you feel put off, upset and have no problem telling everyone “what a jerk” your Doctor is. Some may resort to going to someone else.

People admitted to the hospital are much more vulnerable. At times they may be so ill that they are unable to communicate or speak for themselves. If no family is available, your Doctor acts as your advocate, making potential life or death decisions for you. In situations like these your Doctor may make those decisions by imagining “What would I do if this were a member of my own family?” Your Doctor is feeling your pain. Who feels your Doctor’s pain?

Contrary to popular belief, the traditional Hippocratic oath doesn’t say “First, do no harm”. The original oath can be read here; http://www.pbs.org/wgbh/nova/doctors/oath_classical.html. It also dosen’t say that a Doctor cares for others at the expense of himself or his family. But in fact, many of us have done just that.

When inclement weather keeps other people from traveling, or a “snow emergency” looms at dawn, illness occurs in the family or work force, some still carry out their duties. Among them are paramedics, policemen, nurses and Doctors. I, myself, have gone to work with a 104 fever from flu to take care of people MUCH less ill than I was. But, I didn’t give it a second thought. In over 20 years, I’ve only missed one day of work. We have become civil servants, expected to be at a certain place at a given time.

How many of you would have left your family during an emergency to go down the street to take care of your neighbor? And have that neighbor express no appreciation for the fact that you chose them over your own family? Patients don’t think that way.

My family has sacrificed more than I can ever repay them for. I’ve missed my kid’s birthdays, first steps, lost teeth, school dances and plays, family vacations, not been there to take care of them when they were sick. Left my wife by herself to deal with house and home, kids, family and urgent issues. There were times I was so detached, I didn’t appreciate the fact that things were still running smoothly when I did get home. I don’t have to deal with things that run “smooth” so that didn’t catch my attention. My oldest son wouldn’t give it a second thought if I said I had to go to take care of a patient while talking to him on the phone, even if he was talking to me about a concern with one of his children; my grandchildren. “I’ll have to call you back”. My wife isn’t my wife anymore either.

How many of you get phone calls in the middle of the night that aren’t a wrong number? How many times have you been out to a movie, tried to attend a dinner party, a picnic, a day at the pool, cutting your grass, planting flowers with your kids or spouse, etc., and had to stop (and possibly leave) because you were “on call”?

Can I or my colleagues regret the attention we have given to our patients? Do I regret the countless patient encounters, the lives I have literally saved myself? How much different would the world be today if we didn’t do what we do?

I think most of us would just like to hear “thank you” a little more often. And maybe, not have to take care of sooooooo many people who are abusing the system and making us all way too cynical.

So the next time you visit your Doctor’s office, they answer a call after hours or weekends, or you’re looking up at them as you recover from an illness in the hospital, remember who and what they left behind to take care of you.

Thank YOU for listening.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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Universal Health Care? We Already Have It!

The hot topic in the last several presidential elections has always centered around the same or similar issues; the economy, international affairs/terrorism and healthcare. The Clintons made health care such a large issue that Hilliary had to take that bull by the horns herself. Unfortunately, the bull drug her into the dirt. That’s a beast that needs Paul Bunyan to bring it down.

Now more than ever before, the issue of health care, specifically “universal health care“, is one of the most discussed topics. The news is rife with stories about the increasing number of uninsured who have no access to health care. More and more corporations that used to provide health insurance benefits to their employees, are more often opting for insurance plans that offer fewer benefits with larger deductibles and copays. The employees are paying more for their coverage than ever before. Medicare recipients have also seen their deductibles and copays increase. The bottom line is that the patient is becoming responsible for their own health care.

The government has already enacted legislation that insures that everyone has access. It may not be cheap, efficient or cost-effective, but it is access just the same. From Medicare to Medicaid and “anti-dumping” laws, the government has assured you of access.

Take for example a person who works at a fast food restaurant, has no employer sponsored health insurance and can barely afford to live from paycheck to paycheck. What do these people do when they need care? They visit their local Emergency Room (ER). Because of government legislation initially designed to address patient “dumping” (sending a patient away that may not have had the ability to pay, to a public hospital), we now have created the largest, most inefficient and expensive clinic system in the US. No one who presents themselves to the Emergency Room can be turned away. The ER is required by law, to “evaluate and stabilize” that patient, regardless of the trivial nature of their complaint.

In my own personal experience, a typical day in the ER consists of truly ill people needing emergency care. But intermixed in this group are a large number of patients with these bullsh*t conditions; overdose on illegal street drugs; an alcoholic, currently intoxicated, who ran out of money and is afraid of going into withdrawal; a woman and ALL of her family who have a cold, called 911 and came by ambulance; a return visit for another STD; drug seekers who go from hospital to hospital looking for narcotics; a felon trying to get admitted to the hospital to keep from going to jail; “I ran out of my meds and I need a refill”; “I didn’t get my prescription filled that you gave me two days ago and now I’m worse”; alcoholics who develop pancreatitis because they drink too much; illegal aliens; etc.

Guess what? NONE of those people have insurance and NONE of them will pay their bill. This is what happens every day in every ER in the country. The numbers of these patients increases every year. They have free access and so does everyone else. So why is everyone complaining? The government isn’t paying for them. The insurance companies aren’t paying for them. The politicians aren’t paying for them. Do you know who IS paying for them? You are. The hospitals are. The doctors are.

The government doesn’t pay. The budget reconciliation act demands that Medicare payments be frozen. All they do now is change the slices of the pie, the pie stays the same size. The insurance companies simply increase premiums and decrease your benefits while they decrease payments to doctors and hospitals. When was the last time a health insurance company went bankrupt, didn’t show a profit or didn’t pay a bonus to their executives (I buy stock in insurance companies as a way to get some of my money back)? The politicians in Washington certainly aren’t paying for it. We pay their salaries, staff and benefits with our taxes. They have one of the richest benefit plans (including health insurance) that you could imagine.

You pay for it by paying higher premiums, deductibles and copays. Hospitals have no choice but to pass those expenses on to the paying patients. Doctors pay because they are providing free care. They also have to have health insurance just like everyone else. And believe it or not, the lovely patients I described above are also more likely to file a frivolous lawsuit. Can anyone say “lottery”?

Everyone has access to health care, if they need it. Unfortunately, the people who routinely take advantage of that privilege are the ones who have learned to manipulate the system with petty, self-abusive, self-inflicted diseases and not the working stiff who deserves a break.

What a shame.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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