How regulations raise health care costs

The following was written by Roger Canon, LRT

There have been accusations, including some by our president, that doctors sometimes order procedures just to make a profit.  For instance, that doctors are more likely to cut out tonsils, or cut off legs, or perform c-sections, because these make more money and are easier than trying to find out why the tonsils are swollen, why a leg is rotting off, or waiting for birth to be natural. The cure for this is supposed to be government run healthcare and not for profit healthcare, as these evils are the result of capitalism.

Yes, if you are a doctor and you are cutting out tonsils or cutting off legs just to make a profit than you are a despicable doctor.  Still, government run healthcare will not solve this problem, only make it worse.  I can give you some real life examples to make my point.

According to modern healthcare regulations, if you come to the emergency room with generic dyspnea, and the doctor even thinks you should be admitted, you will receive three breathing treatments.  This is because if you don't need at least three breathing treatments you aren't sick enough to be admitted and therefore do not meet criteria for admission nor for reimbursement.

The same is true once you are admitted.  One of the best ways to assure reimbursement criteria is met is to order breathing treatments on a frequency, such as Q6 or QID.  This way an auditor can looking back on the patient stay will see that, "well, the patient was sick enough to need breathing treatments, so he must have been sick enough to be admitted.  So we will reimburse the hospital for that patient."

Okay, so this is true whether breathing treatments are needed or not.  Breathing treatments cost over $100 each, and therefore rack up quite a hefty charge.  You add into this other procedures that are ordered just so the hospital meets criteria, and this adds up to a lot of money.

There's one other not anticipated aspect of Obamacare.  The authors did not expect that hospitals would actually hire people to make sure the above is done.  The go over charts, and when they see a diagnosis the doctor did not write would charge better, they call the doctor and tell them to write it.  When they see breathing treatments aren't ordered, the call to get the order.

These Obamacare workers make a lot of money.  And when you figure that over 30 of them work at every hospital, this adds to the cost of medicine.  So in order to pay for all these extra workers, hospitals have to make choices.  They have to cut back on the number of nurses they hire, or pay lower wages and salaries, or raise prices.

So, in this way, government healthcare raises healthcare costs, not lower them.

How to make health care costs affordable?

There are people, including our current president, who believe the way to lower healthcare costs is to take the profit out of it. They essentially believe people should not be allowed to profit off helping sick and vulnerable people. I would like to argue that this is not true, and that profit is an essential component of medicine, mainly because profit is the incentive to make it better.

According to the July 26, 2009, issue of the Wall Street Journal, Obama accused doctors of being more willing to decide to perform a tonsillectomy rather than search for other treatments because performing surgeries makes more profit for them.  While I don't doubt some doctors do that, it's a rather unfair to assume all surgeons would prefer to operate over treating their patients with less costly and less risky options.

Eduardo Porter of the New York Times even wrote an article about how for profit healthcare is bad, and how not for profit healthcare is good.

He wrote:

Thirty years ago, Bonnie Svarstad and Chester Bond of the School of Pharmacy at the University of Wisconsin-Madison discovered an interesting pattern in the use of sedatives at nursing homes in the south of the state.

Patients entering church-affiliated nonprofit homes were prescribed drugs roughly as often as those entering profit-making “proprietary” institutions. But patients in proprietary homes received, on average, more than four times the dose of patients at nonprofits.

Writing about his colleagues’ research in his 1988 book “The Nonprofit Economy,” the economist Burton Weisbrod provided a straightforward explanation: “differences in the pursuit of profit.” Sedatives are cheap, Mr. Weisbrod noted. “Less expensive than, say, giving special attention to more active patients who need to be kept busy.”

This behavior was hardly surprising. Hospitals run for profit are also less likely than nonprofit and government-run institutions to offer services like home health care and psychiatric emergency care, which are not as profitable as open-heart surgery.

He added:

"One study found that patients’ mortality rates spiked when nonprofit hospitals switched to become profit-making, and their staff levels declined. These profit-maximizing tactics point to a troubling conflict of interest that goes beyond the private delivery of health care. They raise a broader, more important question: How much should we rely on the private sector to satisfy broad social needs?

Essentially, he says that private sector profit seeking health care, higher death rate. Nonprofit medical care, lower death rate.  What he's saying here is that capitalism is bad and socialism is good. I would now like to explain why this entire premise is fallacious.

There's some who say the government should set price controls on medicine so that people can afford them.
Surely this would drop the cost of medicine, but it would also result in fewer medicine because profit is currently the incentive for pharmaceuticals to take the risks of finding that new medicine.

There's some who will say that the government should run healthcare, and the government should run the pharmaceutical market.  They want to do this because they don't think people should be making profits off the sick. In this case, doctors and nurses and pharmacists would all be paid the same. The problem with this is that it would take away the incentive and the desire to choose those careers.

Another problem with this is the government will eventually run out of other people's money to pay for it. When this happens, decisions will have to be made where to make cuts, and the risky and expensive pharmaceutical market could easily be one of them. Individuals will no longer have a choice between an expensive newer inhaler that works better than an older cheap version of a similar medicine.

Another scary thought here is that the government could also decide who gets what medicine.  Lord knows that Advair works better than Flovent, although Advair costs a ton more. The government official may decide that since Flovent is cheaper that's what asthmatics are going to get.

This is already starting in a way. I did an experiment with nearly every asthma combination inhaler on the market.  I tried Symbicort and Dulera, and both made me jittery.  I tried Advair and it works good.  I tried Breo and it makes me feel like I don't have asthma. Yet my health insurance won't pay for Advair and Breo, claiming that the other medicines are the same thing yet they are cheaper.  You see, we already have less choice at the expense of worse asthma control.

Another way the government could cut costs would be to decide in favor of a productive 40-year-old member of society getting a prescription for Advair at the expense of the 100-year-old lady with a will to live a quality life.

A similar situation was addressed at an ABC prime time special back in 2009 when a woman told Obama, about her one hundred years old mother who really had a will to live. She has a great spirit, a great will to live. She said, "My question to you is, outside the medical criteria for prolonging life for somebody who is elderly, is there any consideration that can be given for a certain spirit, a certain joy of living, quality of life? Or is it just a medical cutoff at a certain age?

Obama essentially said, "No. That's too nebulous. The will to live? How do you assess that? No, probably the compassionate thing to do is just give them a painkiller."

When it comes to respiratory diseases, that 100 year old lady will get the cheap pill that doesn't work as well as the $250 inhaler. Probably the logical choice would be to just give her a painkiller and wave good bye. When someone else is paying you don't get to choose. 

Essentially, drugs do not cost too much because of greed on the part of pharmaceutical companies: they are high because of the risk involved in trying to find new medicines to help people like you and me. And they have to make a profit because that's why they hunt for better medicine in the first place. So rather than complain that pharmaceuticals are greedy, we should be thanking them.

I believe that the way to improve healthcare, and to lower costs, is to try something that has never been tried before: Capitalism.

Further reading:

• whitehouse.gov: Remarks By The President In ABC "Prescription For America" Town Hall On Health Care, 6-24-09
• NY Times: Healthcare and Profits a Poor Mix
• Wall Street Journal: Dr. Obama’s Tonsillectomy
• Newsbusters: Surgeons Rebuke Obama's $50k Per Amputation Claim, Media Mum

Why is healthcare a such mess? How can it be fixed?

Your Question:  The healthcare system is a mess.  How did it get this way? What is the solution?

My Answer:  Let me start by saying that in front of me right now is a bill from Paula Sterns Hospital in Ludington, Michigan, from March of 1943.  It is the bill for my grandma's entire three day stay when she had my dad.  The cost was $23.00.  The ambulance bill was $2.  If you adjust these bills for inflation, they come to $317.26 and $27.59.

The cost of just one breathing treatment today is $123.00, so you can easily see that something occurred in healthcare that inflated the cost of it by a stunningly high margin way over the rate of inflation.  What happened was that, during the 1960s, the progressives decided that the healthcare system was messed up and they could fix it. So they created regulations. So now hospitals have to hire people to make sure the regulations are met.  To pay these people the cost of healthcare increases.

In the 1970s they realized that the prices were too high for many people, so they had to come up with another solution. This time they created medicare and medicaid and DRGs and more regulations.  To make sure regulations are met, more people must be hired.  To cover the cost, prices go up.  But now people still can't pay, so third party system is created.  So now the hospital bill does not come directly from the hospital at all, but from insurance companies.  So not only do you have to pay the hospital bill, now you have to pay an insurance bill as well.

So this is the system until 2010.  Now you have healthcare prices that have skyrocketed beyond belief. You have 40 million people who have no insurance at all, some by choice and some not by choice.  You have the same people who messed up the system in the first place try to fix the problem, once again, with more government.  More regulations are created.  Hospitals now have to hire hundreds more personnel just to make sure regulations are met.  This is done at the expense of patient care, even though it is meant to improve patient care.  Instead of prices dropping, they skyrocket once again.

So who is going to solve the problem now.  Hopefully not the government.  The government got involved in healthcare during the 1960 and created the same problems they propose to fix.  And the more they try to fix it with their ideal solutions the more they make it worse.  They do not ever solve the problems they propose to fix, they only succeed at creating chaos.

The solution to all of this is simple: let capitalism work.  That's the only thing that has not been tried, at least since the 1960s.  When you go to the hospital to seek a service, you should get a bill from the hospital for that service.  The price would not include any middlemen, and therefore would be very inexpensive, like it was in 1943 when my grandma only paid $25 for an entire hospital stay.

Surely the price would be a little higher due to inflation and technology, but price of healthcare today is beyond reasonable.  Why? Because, back in the 1960s, government officials, sitting around a table in leather chairs drinking coffee, decided they could make it better.  Did they? Absolutely not.  These people need to get out of the healthcare industry, and let the people, the markets, the states, solve the healthcare crisis.

The real solution is capitalism. Here you would have individual hospitals compete for your services.  What one hospital did best to win you over, other hospitals would copy.  When one hospital creates a program that fails, other hospitals will not copy that program. That is what's needed. Competition is the best method of driving down prices.  If you charge too much, people can go somewhere else.  If you provide good service at a good price, then your hospital will be the one chosen.

I am not naive.  I understand there are outside forces involved in price increases.  There is better technology today, there is better education that costs more, etc.  But, still, the healthcare solutions since the 1960s have all come from Washington, and everyone of them has failed to solve the problem.  And so many people say, "Well, what else can we try?"  I propose to try capitalism, because it is the only solution that has yet to be tried -- at least not since 1943.

Are 'death panels' coming back?

Obama and I have our differences, but when it comes to end of life care we seem to see eye to eye. I think.

It is simply a fact that doctors need to (er, should) have that talk with their patients regarding end of life care. Doctors must (should) explain end of life care, and must have patients fill out advanced directives.

The difference Obama and I have regarding this matter is how such a directive should be enforced. I tend to agree with men like Thomas Jefferson, James Madison, James Monroe, and Grover Cleveland, that such matters should be dealt with by the states and not the federal government.

I bring this up because of an LA Times article titled "Obama Administration Revives Plan Once Criticized as Death Panels."  If the government gets to decide who lives and who dies, then I'm out.  If the government gets to decide that a 90 year old grandma cannot get the pacemaker she needs and wants, then I'm out.  If the government decides who lives or dies, I'm out.  This is unacceptable in my book. This is the end of the slippery slope I think conservatives are worried about, and how terms such as "death panels" came about.

If the government is just doing this to save money, then I'm definitely out.  When it comes to saving lives, money shouldn't matter. Human life is more precious than anything else on earth, even the earth itself.

However, if the goal is noble, then I'm all in.  If the goal is to get people to make smart decisions about end of life care, then I'm in.  I see too many people who want chest compressions and intubation who have no idea what that means.  Too many people get it all when they shouldn't.  I mean, I certainly don't want to be pounding on grandma's chest.  If that's what grandma wanted, I'm fine with that. But a responsible doctor would have at least had that talk with her at some more (hopefully by choice and not by mandate).

So, it should be grandma's decision and not Uncle Sams.  The government should have no say in who lives or who doesn't.  And I certainly don't think the government should even get involved in this.  They should not even offer negative incentives, such as they do with reimbursement criteria (if you don't do this we're paying you less.  Negative reimbursement is basically a nice way of saying you have to do it or else. There really isn't much of a choice there.

Still, I think it's a noble cause if it's done right.  It's a noble cause if there's an educational campaign that goes on, and not an Uncle-Sam-is-going-to-force-you-to-do-this-and-everyone-over-the-age-of 70-will-now-be-a-DNR-campaign.  I think doctors should be encouraged to talk to their patients about end of life care. It would be a noble public relations campaign to get into -- but it should not be a law, nor a regulation, nor a mandate.

Further reading:

• RT Cave: How Do People Die
• RT Cave: Most People Will Not Survive CPR, but many want it anyway
• RT Cave: Is It Okay To Keep Patient Alive Until Family Arrives?
• RT Cave: Believe It Or Not, You Will Eventually Die
• RT Cave: The Elderly Are The Seat Of Wisdom
• RT Cave: He Died Peacefully In His Sleep
• Wall Street Journal: How Doctors Die Differently

Changes due to Obamacare will collapse healthcare system????

The following is a guest post by our friend Will Lessons. I asked him to write his opinion about a recent article in RTMagazine.com called, "Reducing Readmissions in the COPD Population," by Robert Messenger (I wonder if that's a pen name).

Okay folks, I have no choice but to write about the future of healthcare.  Yes, I will delve into politics here, although it's something I must write about on this blog, because some of the changes that are coming to healthcare, compliments of the Patient Protection and Affordable Care Act, -- Obamacare, Affordable Care Act, Healthcare law, or whatever you want to call it.

This was a serious topic at our recent RT Meeting.  My boss says the newest measure that took effect October 1, 2013 is COPD reimbursement.  CMS already set reimbursement criteria for CHF, MI and Pneumonia, and now it is setting such criteria for COPD.  The goal is to diminish the cost the government has to pay.

The new COPD criteria for reimbursement says that if a COPD patient is readmitted to the hospital (ER and observation visits don't count) for any reason -- even if it's a stubbed toe -- the government will not reimburse for that patient.  Plus if the hospital has a poor showing overall -- a high rate of COPD re admissions -- CMS will punish that hospital by 1% this year, 2% in 2014, and 3% in 2015.

The goal here is that we need to work harder to prevent these patients from getting readmitted.  We need to be proactive.  We need to spend more money so the government doesn't have to.  This is not market driven, and it is not common sense.  It's impossible.  This is according to my boss, and, he says, according to his boss too.

He said government basically sat down one day and decided to look at diseases that cost the government a lot of money, and decided to set goals that were impossible for hospitals to meat.  In this way, the government won't have to pay, my boss said.  The problem, he said, was that the government costs will go down, but hospital costs will skyrocket.

The new criteria are impossible to meat, and within the next few years our hospital will be forced to close its doors.  The only hospitals that will be able to stay open will be large hospitals, and therefore there will be universal healthcare.  "I think this is the goal of Obamacare," he said, "to collapse the healthcare system and so people cry to the government for help."

Think of it this way: COPD patients usually have co-morbidities.  A patient could be admitted today for COPD, next week for CHF, the week later for kidney failure, next month for diabetes, and later on for GI bleed, and then  for a blockage in the intestines.  You see, you simply cannot prevent these patients from being readmitted.  These are our bread and butter.

Yes, the government knows COPD is the fastest growing disease, and #4 on the list of most common ailments.  So they simply are creating criteria that cannot be met so they don't have to pay.  Our hospital has already hired 30 people -- lawyers, statisticians, QA analyzers, accountants, etc. -- just to make sure we will comply with Obamacare.  This is all wrong, because the focus is no longer on patient care, it's on: how can we make money?

Some COPD patients are noncomliant, and there's no way you can get them to take their medicine.  Some patients won't wear oxygen, some won't wear BiPAP, and some won't take some unproven cancer medicine.  and I can't say I don't empathize with these concerns.  I wouldn't want to wear BiPAP, for example.

My boss said, "And you can disagree with me, but people get readmitted not due to poor quality of care (most of the time), they get readmitted because they are very sick people.  The government is too stupid or too blind to see this. Either that, or they are bound and determined to create a system that is guaranteed to fail.  Do they have an agenda here?  You decide."

I personally think it's good to create programs to decrease admissions, although I also believe a better incentive should be in place other than cutting government costs.  People talk about not fair, it's not fair that the government gets to pay less if hospitals fail, and there is no benefit to the hospital if the government fails hospitals.  That, to me, is not fair.

I personally cannot say I disagree with my boss.  I think the intent of Obamacare was to collapse the healthcare system.  I think all those people who said the following were either lying to sell the law, or are ignorant altogether:

• Obamacare is not a tax (the Supreme Court said it is)
• People won't lose their own insurance (many people are)
• Healthcare costs won't go up for you (they are, and by a lot, up to 146% in California alone)
• Healthcare costs will not go up they will go down (hmmmm?)
• Obamacare will only cost????? Every government program eventually costs most than they say!

Note: this post was not written with the intent to political bash a certain party.  Both parties are equally responsible for the current position of healthcare.  This is our problem, although it's one created by our government.  Our government, the one we have elected, has failed us big time. That's why Congress has a popularity rating less than 5% (and this rating has been consistent regardless of who controls it).  

And all of this stuff I predicted on this blog, and many of you guys said I was nuts.  I even got hate mail from some of my readers.  Trust me, I don't want to write about this stuff.  I am forced to.  It definitely effects what we do on the job, and it shouldn't.  Doctors should be deciding how to treat patient, not politicians.  It makes me sick just thinking about it. 

Thanks for allowing me to write my opinion.  Will

Now it's your turn.  Be nice!!!! However, before commenting, please educate yourself by studying the law, and reading posts like this over at RTMagazine.com. I believe the best way to improve healthcare is through education and passion.

The opinions expressed in this post may or may not be the shared by the authors of this blog.  

52 reasons we need a health system do over

Here are a whole bunch of reasons we need to start over with our healthcare system, and I'm referring to the entire healthcare system, not just the one in the U.S., or Canada, or Britain:

1. Common sense is better than dogmatism
2. Medicine is an art based on common sense, pharmacology is a science
3. The hypoxic drive theory was never proven, and neither were many other theories used 
4. Such as the one that states all shortness of breath must be treated with a beta adrenergic
5. Lab, x-ray and respiratory therapists should be respected as professionals
6. Doctors should be treated as equals
7. Medicines, tests and procedures should be ordered when needed, not just because
8. Order sets should be a list of recommendations, not mandates
9. Protocols should encourage competence
10. Smoking cessations should be recommended for patients who smoke, non makdated for all
11. We should not be encouraged to chart that of which we did not do just to meet criteria for reimbursement, i.e. smoking cessation, vaccinations, etc.  
12. Computer charting updates should be improvements and make charting easier
13. Medicine shouldn't be prescribed by men in suits sitting in leather chairs in capitols
14. Medicine should be prescribed at the point of patient care, i.e. by those at the bedside
15. Guidelines should help guide decision making, not mandate it
16. Doctors should not be saluted
17. Doctors should have to work a year or two as a nurse or respiratory therapist or EMT to get hands on experience and to learn how to work with people, like nurse practitioners and physicians assistance 
18. HMOs have been an utter failure.  They have increased needless procedures, and increased the cost of medicine, instead of the opposite.  
19. At present insurance companies get a discount on medicine, while private payers pay the full price
20. The government and HMOs pay a flat fee for hospital visits and services
21. HMOs have made it so asthma rates skyrocketed 180% between 1980 and 1995 (i.e. for medicare to pay for PFTs, an asthma diagnosis is indicated)
22. Private payers should pay the same for medicine as all others
23. Third payer systems eliminate patient questions like: "Do I really need this?"
24. Free medicine increases the cost to those who pay
25. Free medicine inundates emergency rooms, thus turning them into glorified doctor's offices
26. If it's free people will come, with their penile warts, simple cough, acne, overgrown toenails, and their common sniffles and sneezes, and aches and pains
27. There's no incentive to stay home and tough it out like grandma and grandpa did
28. Medicine should be a pay as you go service, and a start over would significantly lower the price so even the poorest among us could pay for it
29. Physicians shouldn't have to order procedures just to make sure the patient meets qualification for admittance (i.e. automatic IVs, hourly neuro checks, breathing treatments, etc.)
30. Pneumonia is the most reimbursable diagnosis, and therefore the most commonly diagnosed disease.  Ah, you see so many fake pneumonia diagnosis's that you can only imagine how skewered the statistics are.
31. With smoking cessation charted for every patient, statistics are skewered.  
32. Most pharmacology studies are funded by pharmacologists
33. Albuterol is a bronchodilator
34. Xopenex is a bronchodilator
35. Albuterol is safe enough to be an over the counter medicine
36. Xopenex is Albuterol
37. Advair will not kill you if you take an extra puff
38. Symbicort will not kill you if you take an extra puff, it's actually used as a rescue inhaler in Britain
39. Eurpoeans have access to more medicines
40. Americans should have access to new unapproved medicines to use at their own risk
41. People should be encouraged to not smoke, eat right, bathe, brush their teeth and exercise, not forced to
42. Studies should be interpreted correctly (i.e., 100 post op patients were given Albuterol and they were all eventually discharged, so now all post op patients are given Aluterol?  Huh? Or, new studies show those who used excess salt live longer.  Hugh?)
43. A 1960s doctor speculated Albuterol prevents post operative pneumonia, so now albuterol is automatically ordered via order sets on all pneumonia patients.  
44. In the 5th century B.C. Hippocrates speculated all dyspnea is asthma and should be treated as asthma.  What has changed?
45. Cardiac asthma is not asthma and is treated completely different
46. All that wheezes is treated as asthma
47. All wheezes are not bronchospasm
48. Upper airway wheezes are not bronchospasm
49. Audible wheezes are not bronchospasm
50. Dyspnea on exertion is heart failure, not asthma
51. Hospitalized patients should not need an order for 
52. One size fits all medicine does not fit all

What do you think of the Obamacare ruling?

Since the Supreme Court Ruled today on Obamacare, your humble blogger here finds himself in a state of......?  Well, I guess it doesn't matter how he feels.  Today I want to know how YOU feel.  I'm going to let YOU write the post.  Please email me with YOUR thoughts on the Obamacare ruling.  You can email me by clicking on the "Contact me" tab to the right.  Please do not leave a comment, for my comments section is broken.  We'll share thoughts tomorrow and have a nice discussion in this arena of ideas.  Thanks  Rick.


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42 undeniable truths about healthcare

Surely some of these may be controversial, as the truth often is.  Yet the following are the 42 undeniable truths of the healthcare industry:

1. All medical professionals have an inert yearning to be self reliant and use the education and experience they've obtained
2. The way to improve the healthcare system is to get the government out of it.
3. The RT (doctor, RN) at the bedside knows what's best for the patient more so than an order set
4. Order sets are are socialistic and are an excuse for doctors and nurses to be lazy
5. Protocols are capitalistic and encourage thought
6. I am not arrogant
7. Supervisors quickly forget what it was like to work on the patient floors
8. The way to reduce healthcare costs is to make everyone pay for each service
9. DRGs increase medical waste and lying about a diagnosis just to assure reimbursement
10. Keystone Committees are an attempt to enforced socialized medicine
11. Evidence Based Medicine is a nice way of saying everyone must do it the same
12. Intensity of Service is an excuse for doctors and nurses to lie
13. Quality Assurance Analyzers are only needed because the government is involved in healthcare
14. Tylenol is not a default cure for all that ails a patient
15. Throwing everything at a patient in the hopes something works is not common sense
16. Regulating hospitals does not make for better healthcare, it makes for fewer hospitals
17. We need more humor in healthcare
18. Bronchodilators treat shortness of breath due to bronchospasm and nothing more
19. They hypoxic drive theory was a hoax created to make respiratory therapists relevant in the 1960s
20. Xopenex is the same as Albuterol with the same effect and same side effects. 
21. IPPB does not work better than patient coaching with an incentive spirometer to treat and prevent atelectasis, and studies prove this.
22. Too many patients are put on a ventilator out of panic rather than logic
23. Much of what respiratory therapists do is either a waste of time or delays time
24. Dyspnea with exertion is not asthma and should not be treated with a bronchodilator
25. If it's audible it's not bronchospasm
26. If it's coarse it's rhonchi.
27. The best way to hear lung sounds is to use a stethoscope on the patient's chest
28. The best way to assess a patient is by touching the patient (not by talking over the phone)
29. It's immoral to NT suction an awake, alert and orientated patient
30. Respiratory therapists are not ancillary staff (they are professionals knowledgeable in an area beyond the scope of most physicians)
31. Doctors and nurses who are stupid about respiratory therapy don't know they are stupid about respiratory therapy and most will never admit it
32. If you refuse to do a breathing treatment that isn't indicated you are not being lazy
33. BIPAP does not help fulmonating edema by forcing fluid out of the lungs, it reduces fulmonating edema by reducing venous return and therefore reducing cardiac output so the heart can catch up
34. Supplemental oxygen will not treat anemia, and is not indicated just because someone has chest pain because if all the seats on a bus are full, the extra passengers won't get a seat
35. The truth hurts before it makes you better
36. Scientific evidence disproves that albuterol will treat pneumonia, CHF, rickets, cystic fibrosis, lung cancer, pulmonary embolism, pneumothorax, pleural effusion, detox, dehydration, and even emphysema and chronic bronchitis.  It only benefits these patients if asthma (hyperactive airways) is a component of said ailment.
37. All that wheezes is not asthma
38. All dyspnea is not asthma
39. If a patient is obnoxious, annoying, belligerent, rancid, or has maggots, respiratory services are not automatically indicated
40. Order sets and physician convenience are not indications for using the word stat.  
41. The clinical picture doesn't always match the science (i.e., hypoxic drive hoax, hoaxenex, and studies showing inhalers work the same as nebulizers)
42. Some studies are conveniently ignored by the medical community (such as beta adrenergic receptors don't exist in lung parynchema and renal tibules.)

My solution to fixing the healthcare industry

Running a medical care facility is as complicated as caring for an end stage COPD patient.  While a doctor will need to find the right balance of medicines to deal with all the facets of lung disease -- bronchospasm, heart failure, anxiety -- hospital administrators need to find the best potion to keep the hospital afloat.

Finding the best potion is accomplished by balancing the following core goals:

1. Improving patient care
2. Reducing costs
3. Creating a good image of the institution
4. Maintaining a good morale among employees

What is the current trend?

The current trend is to focus on 1-3 above, and to incorporate employee morale into a public relations campaign which involves things like midnight meals provided by administrators, summer parties, Christmas parties, giveaways, and having administrators participate in meetings.  While this is a step in the right direction, it has done nothing to improve morale.  However, studies show the current trend has improved patient care.  

All of the above goals can be accomplished through the creation, implementation and monitoring for the following methods:

1. Order sets
2. Protocols

Quite often these two terms are used as synonyms, and more frequently an order set is called a protocol.  I think this is done more as window dressing, because most people in the medical profession believe every patient and every situation must be treated individually.  It didn't used to be this way, yet this is the current trend.

In reality, the difference between order set and protocol is similar to the difference between capitalism and socialism.  One allows for individualism, and the other creates equality.  While one might "sound" like it solves problems better, the other actually does.

So what are hospitals presently doing right, and what can they do better?  To answer these questions we must first have some definitions:

Order set:  Synonym:  Social Justice, socialism.  Every patient with a given diagnosis (DRG) is treated the same.  Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient.  The purpose of these is to make sure best practice medicine is followed for every patient.  Basically, a committee -- usually in Washington -- determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking.  Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met.  This assures that the patient will meet reimbursement criteria.  In the past physicians were presented with a sheet that listed all the options.  Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not.  The reason for this is to make sure reimbursement criteria is met (see below).

Cook book medicine:  Treating all patients the same.  This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.

Protocol:  Synonym:  Capitalism, individualism.  Every patient and every patient situation is treated individually and uniquely given the patient status and the wisdom of the caregivers.  The institution has set guidelines, and the caregivers use their education and wisdom to solve the problem at the bedside. Given proper training and well written protocols, best practice medicine should occur by default because protocols encourage critical thinking.

Ideally, according to Egan, a protocol would work like this:

1. Therapy can be adjusted more frequently in response to changes in patient status.
2. Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.
3. Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.
4. RCPs (Respiratory Care Practitioners) become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated and qualified practitioners.

Advantage of protocols:

1.  Benefits the patient:  The medical professionals working with the patient (RT and RN) decide what the patient needs at the moment the care is needed.

2.  Less calls to physician:  Doctors will receive fewer irritating phone calls

3.  Improved morale and apathy:  RTs and RNs will be able to use the wisdom they obtained by education and through experience, and this will improve their dignity, mercy and self worth.   

4.  Less burnout:  With only those patients who need therapy receiving it, there is a good chance the RT or RN won't feel so run down and overwhelmed, and the patients who truly need their services will benefit as a result.


Reasons your hospital might choose not to use protocols:

1.  Procedure counts:  RT bosses need procedure counts to justify staffing load.  They fear, and often needlessly so, that protocols will result in less work for the department

2.  Reimbursement criteria:  Quality Assurance (see below) wants to make sure government quotas are met for each given patient.  If the RT decides a patient doesn't need certain procedures (such as bronchodilators), then the hospital may not be reimbursed.  This is one of the main reasons many smaller hospitals avoid protocols (note:  see reimbursement criteria below).

Order set/ Protocol combination:  This is where a hospital committee creates order sets for a given DRG yet allows the medical staff freedom based on well designed protocols to use critical thinking in determining what is best for the patient.  Once order sets are initiated, the caregivers at the bedside (RN and RN) decide which ones are to be followed and how.  For example, a post operative order set may include an incentive spirometer order.  By using the protocol, the RT will decide whether the IS is appropriate, or if cough and deep breathing might be better for that particular patient.  An Albuterol breathing treatment is another example.  A pneumonia order set may automatically order Q6 breathing treatments.  The RT will give an initial breathing treatment and monitor it's effectiveness.  If there is no benefit to the patient and the patient the order would be changed to as needed or discontinued.  This would save the hospital money (treatments are $80 to 100 each) and allow the RCP an opportunity to help patients with greater needs.

Order sets are the current trent.  Personally, I think these have some advantages.  It assures that best practice medicine is followed.  So, what is best practice medicine?

Best practice medicine:  Based on scientific evidence, this is what is proven to work for a given DRG.  For example, breathing treatments improve work of breathing for asthmatic patients and should be ordered.  Likewise, oxygen should be an option.  This also focuses on preventative medicine.  Incentive Spirometers use is proven to reduce post operative pneumonia and atelectasis, and therefore an IS order is automatic with post operative order sets. 

Intensity of Service:  Basically, does the patient meet reimbursement criteria?  Is the patient sick enough to be admitted?  Doctors would prefer to use their own judgement to decide which patients go home and which patients are admitted for observation.  Yet the Centers for Medicare and Medicaid Services (CMS) will refuse to reimburse the hospital for a patient admission unless the patient is sick enough to need certain pre-determined procedures.  For example, if a patient admitted with asthma didn't receive any breathing treatments, then why did he need to be admitted?  If no treatments are given, CMS has a right to refuse reimbursement.  Order sets make sure what is required is given regardless of need.

Keystone Committee:  This is a committee formed to make sure intensity of service is met, reimbursement criteria is met, and best practice medicine is met for each DRG.  The goal is to reduce costs for the hospital,  make as much money for each DRG, and to provide best practice medicine for each DRG that results in improved care for the patient. 

Core Measures:  These are measures set by the Keystone Committee that work as goals for the hospital to improve patient care and reduce costs.  They are based on best practice medicine and reimbursement criteria.

Quality Assururance (QA):  This is the fastest growing area of the medical field, especially since the passing of Obamacare.  This is the department responsible for checking charts and making sure core measures are met.  The goal here is to make sure the hospital is making as much money for a given patient as possible.  They also work on committees with other department heads in the hospital to create methods of assuring best practice medicine and reimbursement criteria is met. T'his is a noble department set to make sure the patient is getting the best care possible and the hospital is making a profit.  However, because of government regulations on the medical field and new regulations imposed by Obamacare, one of the main emphasis's of late is on meeting these regulations. 

This department hides under the guise of best practice medicine, although their real intent is always to make sure the patient is profitable.  They're often referred to as the nitpickers of the hospital, or the people who make sure we dot all our i's and cross all our t-s per se.

Quality Assurance Analyzer:  This is one member of the QA team who is a former nurse who has the responsibility of reviewing charts to make sure intensity of service is met for each patient.  They carry a book around with them created by an independent company that lists all the orders for a given DRG that must be ordered for that patient to meet reimbursement criteria.  It is illegal for the QA analyzer to tell a doctor the patient doesn't meet criteria because a certain order was not made.  For example, it is illegal for the QA analyzer to observe treatments were not ordered for an asthma patient and to tell the doctor he must order them so the hospital gets reimbursed.  However, doing this is part of their job.

Reimbursement criteria:  This is criteria set by CMS that must be met for each DRG.  If not, CMS has a right to reject reimbursement for that patient.  If CMS deems a patient was not sick enough to be admitted, they will not reimburse the hospital.  It does not matter that the doctor was worried about the patient and wanted him admitted for observation.  This is one of the main reasons many procedures are added to order sets that are not needed:  Ted stockings for every patient, neuro checks every two hours, IVs, EKGs every morning times 2 days for chest pain patients, bronchodilators for RSV patients and pneumonia, etc. We must also note that the purpose of reimbursement criteria is to reduce cost to the government, not to reduce cost to the hospital.  Since these actually increase the number of procedures ordered to meet criteria, this actually results in increased cost to hospitals.

The only way to reduce costs when you have order sets is to also add protocols.

Public relations:  Creating a good image of the hospital in the community and among staff working for the facility.

Diagnosis Related Group (DRG):  This is a diagnosis related group and each patient is assigned one.  Based on the DRG chosen, the hospital will receive a set payment.  Because hospitals know in advance how much they will make for that patient, this may help determine the type of care this patient receives.  Because there is a flat profit, hospitals therefore have an incentive to do only those procedures that are essential.  Thus, the fewer procedures the hospital does the more money the hospital will have once the bills are paid.  This is an incentive to do more with less.  One of the best ways to do more with less is to have order sets and protocols.

What are the current trends? 

The current trend is for hospitals via keystone committees (or something similar) to create order sets for every DRG.  In the past this included a list to remind a physician of his options.  However, more recently it's evolved into simply checking options so that nothing is missed.  The goal is to meet core measures.

However, we must keep in mind that while the intent is to improve quality and decrease costs, it is my assessment that due to government intervention, not enough common sense is involved in the process.  The emphasis is moving away from protocols and toward order sets that make certain orders are mandatory regardless of need.

The result of this is the following:

1. Increased workload on all staff
2. Increased ordering of procedures that are not needed
3. Increased burnout
4. Decreased critical thinking
5. Decreased morale
6. Increased apathy
7. Decreased dignity, mercy and feeling of self worth
8. Worsening of patient care (due to burnout and apathy)

What is the best approach to take in the future?

I believe the best approach to accomplishing the four core goals for hospitals is to take a combination approach to public relations, order sets and protocols.  I believe order sets will assure core values are met, and protocols will assure costs are reduced and morale is improved.

With a fine balance of public relations, order sets and protocols, the following will be the result:

1. Improved patient care results in improved patient satisfaction and outcomes
2. Improve individual choice results in improved worker morale and feeling of self worth
3. Reduce unnecessary procedures lessens burnout and reduces apathy
4. Improved option results in a reduction of redundant  and unnecessary phone calls to physicians
5. Increase critical thinking at the bedside likewise improves patient care, reduced calls to physicians, and improved worker satisfaction
6. Improved morale would result in better word of mouth advertising by staff and physicians

However, due to government regulations and reimbursement criteria, hospital committee members are forced to make reimbursement criteria a top priority, and, unfortunately, this comes at the expense of patient outcomes and worker morale.  Due to order sets that pre-mark and automatically have certain procedures ordered, this results in the staff becoming overwhelmed.

A good example of this is if a patient is admitted with sepsis, COPD, pneumonia, asthma, heart failure and anxiety.  The order sets for all those DRGs must be followed.  The unit secretary can be bogged down for hours just on one patient, and implementing those orders will bog down a single nurse, and often require a second nurse and a nursing assistant.

With limited focus on creating protocols, there are no methods of getting rid of redundant and unnecessary procedures.  This results in staff being overwhelmed, it causes burnout, and it results in apathy.  Due to the recession, most hospitals are unable to hire new nurses to help out.  Burnout, decreased morale and increased apathy is the result.

This effects public relations too, because a staff that is burned out is going to have a poor view of the institution and the administration, and will be less likely to spread a positive word about the hospital.  This makes the job of public relations more complicated.

With any future approach to medical care, you'll obviously want to continue positive trends and get rid of what doesn't work, and add what has worked at other hospitals.  The problem is due to government intervention, most hospitals are a) forced to set core measures based on reimbursement criteria, and b) forced to do things the same way.

This takes away individualism.  Since all hospitals are doing things the same way, this decreases  the implementation of new out of the box ideas that might revolutionize the medical industry in the future.  If forces hospitals to focus in one area (reimbursement) and slack in others (worker morale).

I think Keystone Collaborative Core Measures have improved patient care.  One recent study shows that critical care core measures have reduced ventilator acquired pneumonia and reduced readmission rates for pneumonia and COPD.  Yet gains in this area have not improved worker morale  and have not improved hospital image within the institution and the community.

Likewise, when worker morale is low, so too is patient morale.  On top of this the patient is needlessly having to be awakened every time a staff has to come into his room to do a certain procedure. Apathetic and overwhelmed RTs and RNs aren't going to care about working together to make sure the patient isn't awakened every hour.  Apathetic and overwhelmed staffers are simply going to do what they have to do to get their assigned work done.

They, in essence, become overwhelmed button pushers and automatons.  They become robots.  This is bad because these RNs and RTs are right at the bedside and provide an image to the patient of the hospital.

I believe the best way to accomplish all of the above four hospital goals this is via the following:

1. Reduce government regulations on healthcare industry that discourage innovation and create an emphasis on reimbursement criteria over patient outcomes and worker satisfaction
2. Continue the Keystone Collaborative to set core measures that focus mainly on best practice medicine and less so on government regulations and reimbursement criteria.
3. Creating a combination of order sets that remind doctors of the core values 
4. Creating protocols to allow point of care fine tuning of order sets to meet patient needs and improve worker satisfaction which will in turn result in improved patient satisfaction with the hospital
5. Reduction of costs because only procedures that are needed will be given

It's a tough balancing act to find at potion that works to improving patient care, reducing costs while creating a positive work environment that lends itself to good worker morale, and lends itself to good word of mouth advertising to compliment a positive public relations campaign.  

Yet I truly believe less government intervention will result in more creativity by individual medical institution in accomplishing the four goals:  improving patient care and outcomes, reducing costs, creating worker satisfaction, and improving the hospitals image.

A combination of core measures that result in a positive balance of order sets and protocols that assure best practice medicine is met at the same time as worker and patient satisfaction is accomplished.  

It is possible to accomplish all the above goals at the same time, yet it will take a collaborative effort on the part of hospital administrators, nurses, respiratory therapists, patients, and Congressmen and Senators on both the state and federal level.  

The goal should involve increasing individual thought, and decreasing cook book medicine.

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Breathing treatments make no money for hospital

When it comes to your RT department boss being happy by the breathing treatment count, he is not happy because a breathing treatment means higher profits for the RT department and the hospital. That's not the case at all.

The truth is, he's happy because of the procedure count. Procedure count is important because the more procedures a department does, the more money is allocated to your department. Likewise, the procedure count has to be high enough to justify the allocation of a staff position.

That's right. In order for you to keep your job you have to do so much work. So the next time you or your co-worker complain about needless work, just think of it from this perspective. I like protocols, yet if we discontinue all needless procedures, we RTs will be our of work.

And trust me, I too am one to complain about needless work. For one thing it makes me feel like an assembly line worker: it diminishes self esteem, dignity and mercy. However, a job is a job. It pays the bills.

As far as reimbursement is concerned for a specific patient, it is a fact that it doesn't matter if you give 1 treatment or 100 to a patient on Medicare or Medicaid, because the Centers for Medicaid and Medicare Services (CMS) reimburses a flat fee for each diagnosis related group (DRG).

This is what happens when we allow the government to make the rules. This is what happens when the government is flipping the bill. So while your department charge for a breathing treatment might be $100, the only person paying that $100 is the person who has no health insurance.

Actually, the best health care reform would be to make it so that people without health insurance paid the same as those who do. This might help lower the cost of medicine as far as the customer is concerned, and it might just allow people visiting hospitals a better opportunity to pay the bill. It might prevent some health related bankruptcies.

On a related issue, Anthony L. DeWitt (AARC Times, December 2010), Whisteblowing 101, wrote that a hospital can bill for the 10 treatments that were ordered while the patient was admitted, and this will not be considered as fraud even if the treatments were not given.

The same principle applies: CMS reimburses a flat fee for a specific DRG (diagnosis). DeWitt writes that:

"In essence, the hospital is banking on being able to treat the patient efficiently and get them out of the hospital quickly. So whether the patient gets one treatment or 10 treatments, the cost to Medicare is the same because it's calculated on the basis of the diagnosis. Internally, the hospital can bill for 40 treatments never done, and it won't have any effect on the final bill to Medicare."

Poppycock? Why sure it is. Yet such is how it is when the government is in charge of flipping the bill. However, as goofy as this sounds, useless and un-indicated breathing treatments that burn you and me out might be what's keeping us on the job.


Something to think about anyway.


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Healthcare bill looks goulish and scaaaary

(Editor's note: The following was written by Dracula while I was in that long dreamy trance. I'm still whoozy and my neck aches. )

Dear my friends (ahahahahahaaaaa):

I just got done sucking the blood of the RT Cave publisher (MMM!!! It was soooooo tasty!)

Now that he's out of the way I will take this time to voice my opinion about something that would make my blood boil -- well, if I had any it would boil.

I have obtained a copy of the healthcare reform bill released by the leadership of the U.S. House that merges all the versions of the bill passed thus far. This piece of work is expected to be "considered" by the full house next week.

The following are the major provisions of the bill and how it might effect you and other future sources of lunch (in blood red):

• Expansion of health insurance to an estimated 96 percent of legal US residents under 65.
• Individual mandate with penalties. (unconstitutional)
• Employer mandate for those with payrolls over $500,000 with penalty (unconstitutional).
• Subsidies for low- and middle-income families. (spreading wealth)
• Medicaid expansion for families at or near poverty level Insurance reform (paid for by taxing people who have succeeded. This bill calls for a tax on insurance companies which will fall to the taxpayers by higher premiums, thus a tax hike.)
• Ban on pre-existing condition exclusions. (a better way of doing this would be to give private insurance companies a tax break for taking the risk.)
• Ban on rate adjusting based on pre-existing conditions or gender (this I like. Insurance companies could also get a tax break for taking on the increased risk, which is rewarding the risk takers).
• Limits on rate adjustment, limited to age and family size.
• Public Option with negotiated provider payment rates (check out this post. You ll learn the public option isn't so great after all).

Here's how the bill will be paid for:

• $480 billion tax increase for singles $500,000/families $1 million. (Punish the achievers to the benefit of the have nots. This will be another disincentive for companies to take the risks needed to move up to the next income level)
• $20 billion tax on medical devices. (which will be passed down to consumers, which are mostly the middle class who were promised no tax hike).
• $400 million in spending cuts (mostly Medicare) (In a bill signed in the early 1980s, Congress promised to cut spending and never did. Can we trust Congress now. A recent poll shows 90% of Americans want all new Congressmen, a testament they don't trust the people who are responsible for this bill).

The bill also includes:

• Medicare coverage of end-of-life counseling (described as "advance care planning" in the bill). (hHmmm??? What might this lead to)?
• SSI eligibility exemption for clinical trials participation compensation - Improving Access to ..Clinical Trials. Expansion of Comparative Effectiveness Research.
• Provisions to address healthcare workforce shortages. Physician payment "sunshine" requirements - but with an exemption for industry- sponsored CME ..activities.
• Expansion of Medicare quality programs. Expands Medicare and Medicaid beneficiary access to preventive services by eliminating. cost- ..sharing. (Cost reduction is great, but can more easily be done by reducing regulations for private health insurance to improve competition)
• Strengthening of the public health infrastructure through creation of a Public Health Investment ..Fund with authorized funding of $33 billion over 5 years.
• Creation of a Prevention and Wellness Trust Fund for community-based prevention and chronic ..disease management with authorized funding of $34 billion over 10 years.

The basic premise of this bill is Congress doesn't trust private companies or people like the (tasty) publisher of this blog and you to do what is right, which is extremely scaaaary. They believe it's the role of the government to tell us what to do for your own benefit. Some people call this the nanny state.

I don't know about you, but this is enough to give even my lifeless bones the eebie jeebies. Just reading it sends a cold shiver up my dead spine. I don't trust your government with a ten foot pole. Sure your gov should have some power, but not this much. If this bill passes it will change the fabric of your lives. It'll be, excuse the pun, a pain in the neck to get rid of if it fails, if not impossible.

It should send a shiver down your spine too, especially considering the slippery slope that is bound to ensue in your neck of the woods. This post and this one describe this bloody, slippery slope.

Healthcare reform is needed, but not a government takeover. Better options would come from reforming the current system and letting people like you guys solve the healthcare problems that exist. Better options are on the table, as you can see by clicking here.

That's my take on it. Feel free to disagree.

Sincerely: Dracula

HAPPY HALLOWEEN!!!!!

What will happen to us RTs???

My coworkers and I were having a discussion a few days ago, and the topic was: What will happen to respiratory therapists if Obama's Healthcare plan is eventually signed into law by the president. The general consensus was that many of us may need to look for new jobs.

First of all, the first thing Obama would order to diminish healthcare costs is for a complete and thorough investigation into procedures ordered and whether or not they are really needed. Hence, once this investigation gets to the RT Cave of any hospitals, a stunning revalation will be made: 80% of bronchodilator breathing treatments ordered are not indicated.

Right now the RT Bosses of the RT Cave count the "un-needed" bronchodilator orders as procedures, and the more predicted procedures the more staff positions are justified. If this procedure load is lapsing, then there is no way to justify, say, having two RTs on during the day.

After such an investigation, doctors would be instructed to attend "bronchodilator instruction classes," where they will be informed on the correct times where it is appropriate to order bronchodilators.

The end result here is doctors won't want to think that hard, so they will piss and moan enough for Obama to mandate (make an executive order) that all hospitals within the U.S. incorporate RT Driven Protocols that make sure that the RT decides who gets breathing treatments.

The good news is obvious: we'd have the protocols we've yearned for for years.

The bad news is obvious too: fewer RTs will be needed. We RTs on the low end of the totum poll will be out of luck, as will many to be RTs just finishing RT School.

Of course, when it comes to the government making decisions such as this, you never know what to expect. The alternate course will be that government bureaucrats will think along the lines of the RT Bosses, who would rather pay for un-needed therapies as opposed to forcing thousands of RTs out of a job.

Those who run the government, as you know from recent stimulus bills filled with pork projects, sometimes prefer to spend money where it isn't needed to stimulate demand and create jobs. If this is the route bureaucrats decide to take with RTs, then we are safe -- although we ardent supporters of bronchodilator reform will continue to cry foul.

It's possible our position may be absorbed by nursing to the detriment of the patients, and all us RTs will be out of a job. No disrespect to nursing here, but we are the one's with all the RT Wisdom. The major decider here: money!

And, what happens to us RTs will not be made by thousands of independent hospital administrators where we work, but by one bureaucrat sitting in a chair in Washington. He will decide, because he knows what's best for everyone.

So, if you're not a gambler, perhaps you best call your local U.S. Representative and U.S. Senator and make clear your opposition. On the other hand, if you're a gambler, stay put and hope for the best.

Note: This is an editorial and does not necessarily represent the views of the publication.

Two well respected doctors discuss health care

After the code in the critical care unit I was standing behind the nurses station listening to the anesthesiologist and the Internist discuss how much they hate President Obama. I did not participate other than to say:

"You better not say that in front of Susan." Susan, of course, is the CCU RN who was in charge of the patient we just coded.

The Anesthesiologist said, "I think he is wrecking the country."

The Internist said, "I voted for him, and I think he is doing a terrible job. He's not doing what he said he would do when elected. He is trying to solve all the world's problems."

"I'd have to agree."

"And now he wants to screw up the health care system. You would agree that we do have the best health care system in the world do you not."

"I do."

"The only problem is not the health care system, but the cost. The government has made some stupid laws in the past that make it too easy to sue doctors. Because of this, we doctors have to order procedures that often are not indicated."

I was shocked they were saying this in front of me. I stood as still as a deer hiding in the woods during rifle season hoping they wouldn't figure I was standing right behind them.

"I mean," the Internist said, "He's trying to solve all the world's problems, to rush all these bills through Congress, when it's not even possible that he nor any one else has even read the bills. This is what you call anarchy. I say this and I voted for him."

The anesthesiologist said, "I don't see why you are surprised, because he's doing exactly what he said. But I completely agree with you he is rushing too much too fast."

Susan arrived at the station, and the discussion stopped on a dime.

Here's a great con to Nationalized Healthcare

Here is one very good reason I am against a nationalized health care system. I discussed with my boss yesterday about the budget. He said his bosses want him to come up with "everything and anything" ideas for further cutting the budget.

He asked me, "Any ideas."

I said, "Create a treatment protocol so we can get rid of all the breathing treatments that are not needed. That would save us a ton of money." (To learn how much money this would actually save our hospital, click here.)

He said, "Rick, you should be happy just to have a job. We need all the procedures right now we can get."

Here's something to consider. The hospital does not get paid by the government per procedure completed, it gets one flat rate for the patent's stay. So, the fewer procedures done while the patient is admitted the more money the hospital would make.

Thus, if Shoreline Medical Center could come up with a protocol to prevent doctors from giving an asthma/COPD medicine just because a patient is short of breath or sounds bad or looks funny (or to prevent bronchodilator abuse), that would save the hospital hundreds of thousands of dollars a year.

What I understand here is that when it comes to cutting the hospital's budget my boss only thinks in terms of his own wallet, while ignoring the wallet of everyone else. What he fails to understand (what many people seem to misunderstand these days) is the government's wallet is OUR money too.

My boss is afraid if we get a protocol, the number of procedures in our department will go down, and someone will lose his or her job. It seems to me many hospital bosses would prefer the procedure than to prevent government waste.

Yes government reform is needed, but not in the direction the current House, Senate and Executive Branch visions. The change we need is to provide an incentive for hospital admins to spend the government's money as wisely as it spends it's own.

As the old saying goes: people are more likely to spend their own money wisely, yet when it comes to spending someone else's money, they appear to be less wise (or is that a saying I just made up). Anyway, it's true.

Feel free to discuss because, as always, I could be mistaken.

(Other than the links above, for more of my opinion on Nationalized Healthcare, click here.)

The skyrocketing healthcare cost debacle

Over at Respiratory Therapy Driven is posted an interesting post noting the high prices for various respiratory therapies, followed by an interesting discussion.

I no longer get to see the prices of therapies at our hospital because charges are automatically dropped when we chart, however I know that prices compare from hospital to hospital, and they all seem to charge way too much.

It seems ridiculous that each day in a hospital room would cost over $800, or almost $2,000 for an ICU bed per night. Or that one day on a vent would cost as much as $1,500, or that a BiPap charge per day $800.

However, after I think about it further, perhaps some of this cost can be justified because they do include services. And all you RTs and RNs know full well that one patient might require much more attention than just the usual Q2 or Q4 vent check. Some patients can be easy, but others can be down right challenging.

And then there is the liability involved. If the hospital gets sued there could be millions of dollars on the line, and the hospital would have to be able to cover this cost. Thus, the prices get jacked up a bit more.

And then there is the increase in supply of patients coming to the hospital since the inception of Medicaid in 1965. The general rule taught in economics 101 is that when people perceive something as free they tend to seek it.

Another basic economics 101 rule is that when demand for a product increases and supply stays the same the price goes up. This simple law of economics would explain why the cost of medicine has skyrocketed since 1965. Top that off with frivolous lawsuits and you can see why healthcare costs continue to rise.

I can buy a nebulizer for less than $100, a box of Ventolin for around $20, and give myself breathing treatment to myself for free. I can buy a ventolin inhaler for $20 and each puff is free.  When I can do this myself for this low of a cost, why then does it cost as much as $350 for QID Albuterol and Atrovent nebulizers?

Likewise, why would doctors continue to order Nebulizers when they aren't indicated?  Studies show that nebulizers work the same as MDIs, so why not order MDIs on stable patients? Most patients can do MDIs on their own for free, minus the initial education and cost of the inhaler.

And, if the cost of Nebulizers treatments is so high, why then do not more hospitals have more treatment protocols to cut down on useless breathing treatments? Would not this drive down the price?

Some of the cost of a hospital stay can be justified, as I mentioned the risk involved, but also for the simple reason of being able to pay competitive wages to doctors, nurses, ancillary staff, and all the other people needed for a hospital to function.

Likewise, hospitals have to be able to cover the cost of keeping up to date on all the expensive new technologies in order to stay ahead of the game and provide the best care possible for its patients. In this regard, the high cost might be understandable.

I read somewhere that the cost of medicine used to be trivial before the government got involved, mostly because once people realized they could get medical attention for free in emergency rooms, they flocked to emergency rooms.

At the same time, regardless of the indication for an emergency room visit, hospitals are not allowed by Federal law to turn any person down for treatment.

Even illegal aliens get free health care in the U.S., and they have no billing address of which to send a bill to either. All of this, as per economics 101, drives up the cost of medicine for all of us who pay, and makes it challenging for those without health insurance to pay for hospital services.
Some people contend that the U.S. needs to create a federalized health care program in the mould of Canada and Europe. I for one am not convinced that this would solve the problem, and you can check out posts I've written on my other blog regarding Federalized Health care and decide for yourself (and feel completely free to disagree with me, but be nice if you decide to leave a comment.)

A good discussion on this topic in the arena of ideas is something that is much needed, and with the coming presidential elections, all options should be on the table. The only way to solve a problem this big is via debate, regardless of how hard this might be.

Still, $40 for a sat check is quite ridiculous. At our hospital doctors get paid $40 for just reading an EKG. I calculated once that if one doctor read all the EKG in a year, he would make $40,000 a year. And that was ten years ago.

Yet, 40 years ago people could simply walk into a hospital and pay cash for services rendered.
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(Here is a doctor's perspective on the high cost of medicine, and an RT from Canada.)

A Canadian's opinion on Federalized Medicine

It is estimated that 40 million people in the U.S. do not have healthcare insurance. Therefore some politicians have proposed we go to a nationalized healthcare system, where the government makes healthcare available for free to everyone.

I've done a ton of research on this, and have decided this type of system sounds great on the surface, until you consider somebody has to pay for it. Well, we all know that will be you and me via more taxes. So, in essence, it will not be free (more on this tomorrow).

“But the fact that taxes will go up is the least of your worries,” wrote a friend of mine who lives in Canada.

She explained it this way to me: Lets say such a program passes through the legislature and is signed into law by the president. Within a week, since healthcare is now free, people start to rush into hospitals to get that knee replacement they couldn’t afford a week ago. Or, maybe it’s to finally see a doctor about that ailing back, bum shoulder or mole on your ear that you’ve been living with fine the past 10 years.

These surgeons will become inundated with new patients, and will be reaping in the profits. Right out of high school young kids will be filing in droves to attend medical school so they can participate in this profitable business. New surgical doctor’s offices will spring up all over the United States, and they will all be filled with new patients -- it’s all free, the government pays.

Dishonest and honest surgeons are having a field day while they are all making tons more money than they ever would have dreamed of making under the old system, but the government starts to get all stressed out. “How are we going to pay for this? We are running out of money.”

New government offices spring up filled with bureaucrats and red tape, and they start to require permits as to who is going to be allowed to perform surgery in an attempt to cut down on the number of surgeons, and as to what types of equipment surgeons will be allowed to buy.

Then there will be new laws limiting the types of surgeries surgeons will be allowed to perform, and potential patients will have to file for permits to get operated on. Officials will be asking, “Is this mole really bothering you? You’ve been getting along fine with that heart your whole life, why do we need to replace it now?”

There is so much red tape now that long lines develop. People that just want to be routinely checked will have to wait in line with the person with a clogged artery in his heart. Of course, this heart patient won’t be able to escape his country to go see an American doctor, because that’s the medical system that is now broken.