focus

For the Daily Prompt: cringe.

I took this on the ridge on top of Mount Zion yesterday. Absolutely gorgeous hike, with the rhododendrons floating among the tall trees and tons of wild flowers. Here are little wild strawberries…. we will have to come back in September.

Cringe: I cringe when I hear the discussion on the news being about health INSURANCE  and not health CARE. We need to change the focus.

We HAVE a mandate that anyone in the US can have health CARE. That is, the emergency room cannot legally turn anyone away. But the bills can bankrupt you and take your house away. Not only that, but the emergency room is the most expensive and worst way to take care of people in the world. The emergency room cannot treat cancer, cannot treat hypertension, cannot help a person with depression, cannot do the long term chronic care that I do. Per person in the US we pay twice as much as the next most expensive country and they have universal care. What is the matter with the citizens of the US? We care more for corporations protecting their profits than we do for our citizens health. And I think this will bring our country down….. we will collapse.

I am a physician but I also run my own clinic. I am a small business owner. And I really expect that health INSURANCE will force my clinic to close.

Call Congress. Say we want health CARE not health INSURANCE.

 

My clinic and the state of medicine

January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.

Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….

Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.

So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.

A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.

I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.

Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.

If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.

If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.

Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65

We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.

And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.

https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/

This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..

I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….

Coming soon: The Unaffordable Health Care Act!

Coming soon in the United States!

Aren’t you sick of the Affordable Care Act? aka Obamacare? Time for a new administration and time to get rid of Affordable Care. We don’t want that! Competition, Corporations and Profit First!

Call Mr. Future President Trump, call you congress persons, call your senator, call your representative, call your state ones. Stand up and be heard, US Citizens! Tell them you are all for the Unaffordable Health Care Act! We can kill more small businesses faster! We can make doctors and nurses quit by age 50! We can have more people turn to addictive drugs for numbing and comfort!

Come on, US Citizens! You voted! Now call! The Unaffordable Health Care Act! brought to you by an all conservative all corporate all discriminatory group of unbelievably rich congresspeople and your stinking rich and suing everyone future president.

Or you could say you want Medicare For All! Hey, one system, one set of rules, all US citizens have care, we could start small businesses, business might return to the US since they don’t have to pay more and MORE and MORE for health insurance, wages would go up instead of yearly decreases in health care coverage….nah, US Citizens, you wouldn’t want that, would you?

Your health care dollar

I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.

Think about it. What do you want to spend that dollar on?

Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?

How much of your health care dollar do you want to go to corporate competition?

I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?

No, no, no, and no.

Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:

US Preventative Task Force

The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.

You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.

Join Health Care Now and Physicians for a National Health Program.

I want my health care dollar to go to HEALTH CARE.

For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.

Doctors don’t charge for phone calls

Doctors don’t charge for phone calls.

Attorneys do: they charge in fifteen minute increments.

Doctors don’t charge for phone calls: oh, but actually that is a myth. And it’s raising the cost of health care in the US because the insurance companies are using this myth to their advantage. Not only is this costing every one of us more money, but it is driving doctors out of practice. And it’s making patients bitter and angry at the doctor, when it is the insurance that should bear the blame…

Why do I say this?

A patient calls their health insurance. “I need x.”

The health insurance says, “Have your doctor’s office call for a prior authorization.” Now, we are definitely paying the health insurance to have someone say that to the patient.

The patient calls the doctor’s office and requests the prior authorization. There, a second person is being paid to get that phone call.

The doctor’s staff runs it by the doctor. The doctor says, yes, the patient needs that or no, I would like a visit to discuss this. More time that we pay for.

If the doctor says yes, the doctor’s office contacts the insurance by phone or on line to do a prior authorization. This means a different website for every one of 1300 insurance companies in the US. We are paying the doctor’s office staff to be on the phone and on the computer to fill out prior authorization forms to get permission from the insurance if your doctor agreed that you need x or that x would be helpful. We also are paying for all of those websites that the insurance companies have to slow down giving the patient care.

I don’t have an office staff to do this. I have a bare bones clinic so that I can spend more time with patients. I call the insurance myself with the patient in the room.

More than half the time the insurance company says that x is not covered under the patient’s plan.

But wait. The patient already called the insurance to ask if they could get x. And the insurance said have your doctor get prior authorization. So in the usual office, the patient is called and told that x is not covered. The patient is angry, because they think that the doctor’s office has messed up the prior authorization. The insurance does not want to tell the patient it is not covered. So our costs spiral up and up and up, because the insurance has realized that they would rather have the patient angry at the doctor’s office, not the insurance.

And we all are paying for it with our health care dollars…..

Cloudy with a chance of hope

This is for the Daily Prompts: hopeful and year.

I took this from the beach with my zoom lens: fog, clouds, lowering, indistinct. My daughter left for college in September and is home now…. well, sort of, except she is off with friends all over the place, including right now.

It’s been a cloudy and hopeful period, since September. It is the first time in 24 years that I have not had children or teens at home, and the first time in 28 years that I have lived nearly alone…just the cat. The cat is not happy with then young adults leaving. She blames me.

I am worried about the US Medical system, the corporate takeover where more and more physicians are employed and then have no connection to how their patients are billed. They also take no responsibility for people going bankrupt over medical bills. We physicians are as responsible for the mess of US Health Care as the patients are, as Congress is, for letting 1300 insurance companies use 500 billion dollars on administrative costs….And people say I don’t trust government healthcare….but don’t take away my mother’s medicare, the VA benefits, medicaid for the disabled and very poor or the healthcare for our active duty. And yet I see for profit companies like triwest: the government contracts my local VA care to them and I fought Triwest for a year to get them to pay me for my Veterans Choice patients. And they won’t pay me for the time we spent fighting to get paid, nor the interest for waiting on a payment for an entire year. Guess who got that money? The For Profit Contractor Corporation: Triwest. And Noridian, the local medicare contractor, held my payments for 6 months. They said my paperwork was wrong….turned out it had been wrong for six years but they frankly didn’t care until they were getting audited. So who paid the price? I did and you did. In rising costs and confusion and physicians quitting. Again, I did not see a penny for the time on the phone, for the time spent trying to ask Noridian why, after 6 years of payments, they were refusing my renewal…..and meanwhile I saw my patients and went further into debt. And do you think the bank corporation wrote off their profits? No, you laugh at that…..

But, you say, where is the hope? The hope is that I think we are at the point where enough physicians are quitting outright, enough Veterans Choice patients are calling their Congress People, the patients refuse to be patient any longer….and I am seeing more people fight for a single payer system, for a system where the money does not go to profit and administration while people die waiting for prior authorization and insurance corporations change the rules every week and refuse and refuse and refuse care…..I think people: patients and physicians: will wake up and change the system.

And that, Mr. Trump, is what I would do to make the US great again….

 

 

 

 

 

Far from the maddening crowd

For the Daily Prompt: maddening.

The early morning is my time to write and think and be quiet. And the other time is outside walking with my camera.

The medical money machine in the US grinds people up, grinds doctors up, doesn’t care, and makes money. Sometimes it is so maddening….