Enjoy our most current issue of the most popular medical e-newsletter on the internet.
Blogs and Thoughts for February 8th to February 14th, 2018
Here is what we had this past week:
- A Valentine to the Nurses by Pat Conrad MD
- The AAFP Blows Another Chance to Promote DPC
- Peer-to-Peer Physician Reviewer Bullsh%t
- Whine of Fire by Pat Conrad MD
- Are You Advanced?
- Friday Funny: Exam Table
- Quote of the Week: Louisa May Alcott
1. A Valentine to the Nurses by Pat Conrad MD
February 14, 2018
On my long since defunct website, “Doctors For Freedom,” I always devoted my February column to nursing, my Valentine to the profession. And of course, I always included some sophomoric photoshopped rendition of Nurse Ratched. Yes, I realize that the above picture is clichéd, and imprecise given the ever-increasing presence of men in the nursing ranks. But I think it’s funny, so try to power through.
What is not as funny is the continuing nursing shortage, which has been worsening for over the past decade when I first started writing about it. This bit from The Atlantic in 2016 calls it:
“According to the Bureau of Labor Statistics, 1.2 million vacancies will emerge for registered nurses between 2014 and 2022. By 2025, the shortfall is expected to be more than twice as large as any nurse shortage experienced since the introduction of Medicare and Medicaid in the mid-1960s.”
Funny how that ties nursing shortage with the installation of de facto government health care. And the year before, do-gooder-in-chief Lyndon Johnson signed the Nurse Training Act of 1964 to alleviate projected shortages. A half-century later, the problem is only worse. We have a heavily graying population, which means more acuity, which means more costs, which means more budgetary pressure against those who actually do the work. Scumbag Big Insurance follows the prime rate of Medicare, keeping things expensive while keeping payouts low and always adding to the regulatory costs. Hospitals – themselves not paragons of fair play – are caught between flat revenue levels and high, mostly wasteful, administrative overhead. How many extra nurses could be provided annually for the cost of extortion JCAHO pre-inspections? How many nurses could get real raises for just by doing away with a fraction of the money blown on IT flatulence every year?
Nurses have the hardest, more often than not, most thankless jobs in the hospital. They get to absorb every bitch and whine from every patient and family member, in between mountains of pointless paperwork and retina-fusing computer screen staring for hours, all to fill in the gaps with a little bedside time, and ruining their health lifting an increasingly obese society. Physicians rely on good nurses, and they keep us out of trouble on a lot of sleepy, even error-prone nights. Good nurses are getting spread too thin, burned out, aging, succumbing to the dilutions of administration jobs and the NP ranks, or are just plain tired. And for my money, the good ones are worth a hell of a lot more than they are paid. The fix? Chalk up another lance, and go find a windmill, for all the success you’ll have porting dollars to the ones who actually provide the care.
But while we have you, ladies and gentlemen of nursing, thank you for somehow still showing up and keeping it all running. You are great, and sincere thanks.
2. The AAFP Blows Another Chance to Promote DPC
February 13, 2018
The big wigs at the AAFP recently came out with another letter (their “go to” technique) and it said:
“The AAFP maintains that the current regulatory framework with which primary care physicians must comply is daunting and often demoralizing,” the letter stated. “Standardization is not required among public or private payers, and many family physicians participate with 10 or more payers. Physicians spend needless hours reviewing documents and literally checking boxes to meet the requirements of each health insurance plan.”
You can see more information here where they “spell out specific administrative burdens that draw physicians away from patient care, including EHR documentation, prior authorization and the proliferation of quality measures.”
Let’s pretend for a moment that they didn’t agree to allow EVERY ONE OF THESE BURDENS to happen, which they did allow. Why couldn’t they say something in their letter like:
The AAFP maintains that the current regulatory framework with which primary care physicians must comply is daunting and often demoralizing. We appreciate the willingness to negotiate and fix this issue, however, if we are unable to work together and change this then we have no choice but to put all our efforts into having our family physicians move into the Direct Primary Care field where they are no longer burdened by ANY of this.
Now doesn’t that sound better? Wait, wouldn’t a move by family docs into DPC eliminate all the courses and money making schemes used by the AAFP to teach docs about EHR documentation, prior authorizations and quality measures? Hmmmm…..
3. Peer-to-Peer Physician Reviewer Bullsh%t
February 12, 2018
I am almost embarrassed to write this blog entry because it is so obvious. Here is what just recently happened:
California’s insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients’ records when deciding whether to approve or deny care.
During the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.
All of us doctors knew this already. It is obvious these reviewers are scam artists when you talk to them. They are lowlife sellouts who just deny your requests. They ALSO have been taught to pretend to be victims if you get mad at them. That is their new strategy. They start reading set responses like:
- “Dr ___, your tone is abusive and this call is being recorded.”
- “Dr ___, your anger is inappropriate and will be reported.”
All these are scare tactics. I don’t know the answer. Maybe this case will blow up but I recommend you try this when talking to a physician reviewer (this info was told to me and it works):
“Hi, before we start can I get your name and exact spelling, please? Thank you. I am putting it in the chart so if this procedure/test/referral is denied then your name will also be there for the attornies to question.”
So here are my questions:
- What are your most ridiculous rejections?
- What line do you use to get things approved?
4. Whine of Fire by Pat Conrad MD
February 11, 2018
Writer Bob Brody tells us “Why I Almost Fired My Doctor,” and reinforces those reasons that payers, academicians, government, and medical organizations will ignore. Brody liked his doctor, “But I often questioned his judgment in medical matters.”
As a patient, the writer doesn’t like the doctor giving obtuse answers and ineffective patient handouts, after not performing a complete exam. I can see his point. He wonders at the doctor advising instead, to see a specialist. I can see the doctor’s point. He wondered why the doc would prescribe what he admitted was an unnecessary medication. I can see why both the doc and patient would have a point.
Much is made in the article of the relationship between patient and physician, and how a poor one predicts the patient leaving the practice. Makes sense to me. But how did this writer and his doctor get to this poor place? Between the lines, I read physician burnout, and mistrust. A tired or apathetic doc might well not examine a wrung neck and toss it off to the orthopedist. Like this doc, I have written statin scripts aplenty not to treat the patient, but only out of lawsuit fear. As this unhinging progresses, the writer has finally had enough when the doctor spends the entire visit with his back to him, pecking away on his computer.
The author raises an important concern, asking, “Was I going to risk my longevity to avoid hurting my doctor’s feelings?” I applaud taking charge of one’s health, and responsibility for seeking out the right physician. I also suspect that this is a nagging “former health care journalist” that made a pain of himself by debating minor clinical points in the middle of a busy day, but that’s just my gut.
Of course, referencing a former AAFP president is emblematic of poor public insight. And Brody quoting a director of the Center for Primary Care at Harvard Medical School on the deleterious effects of mandatory EHR’s is akin to asking the fox to wipe the chicken feathers off his chin. “How do you go about firing your longtime doctor? Does the American Medical Association recommend a protocol?” Not satisfied with this deep digging, Brody seeks out an academician, who had written a book on physician-patient collaboration. The advice he gets: “You should reach out to talk to your doctor. That’s the key. Make clear how you feel. Say what you need.” And you should do it in the little 10-minute blocks you get while his back is turned sweating over the keyboard, fulfilling the dreams of tenured med school professors and Big Insurance-cms.gov parasites.
In the end, the old doc retires, saving Brody the trouble of hurting his feelings. “As it turns out, he’s done me a big favor. Ending his career just might have saved my life.” Yes, writer Brody covers a lot of reasons why doctors are increasingly ineffective, even if he left out “jerk patients.”
5. Are You Advanced?
February 10, 2017
CMS released a table of Alternative Payment Models for 2018 that highlights which alternative payment models (APMs) qualify as Advanced APMs this year. Wow, I am so excited. It’s almost like the feeling you would get if the Publisher’s Clearing House people came to your house. Before anyone gets too ecstatic, though, you first need to know the rules:
The document lists three criteria an APM must meet to be designated an Advanced APM. First, it must require participants to use certified electronic health record technology (CEHRT). Second, it must rely on quality measures comparable to those used under the Merit-based Incentive Payment System (MIPS) as the basis for providing payments. Third, it must either “be a Medical Home Model expanded under CMS Innovation Center authority” or require participating entities to assume a greater degree of financial risk.
Got it? Good. Now here is the list 38 APMs, 10 of which qualify as Advanced APMs, including the Bundled Payments for Care Improvement Advanced Model:
Okay, so are you a winner? Are you “Advanced”? I know I am. Hooray!!!!
6. Friday Funny: Exam Table
February 9, 2017
This guy from Bizarro.com is brilliant. Check his other stuff out.
7. Quote of the Week: Louisa May Alcott
February 8, 2017
“I’m not afraid of storms, for I’m learning how to sail my ship.”
Louisa May Alcott
UNTIL NEXT TIME, KEEP SMILING, KEEP LAUGHING AND KEEP OUT OF THE SAMPLE CLOSET!
Douglas Farrago MDTweet