What Determines Success?

Prepare for the worse and hope for the best. 

We are health care providers. We are nurses and respiratory therapists. Our success is not determined by how many sick people we care for. Our success is determined by how many people don't need our services.

Look at asthmatics as a good example. Back in the 80s, it was common to have sick asthmatics. In fact, it got so bad that asthma organizations were formed. Heads of these organizations, along with many of the top asthma research physicians in the world, put their heads together. They created asthma guidelines.

Today, regional asthma doctors are educated on how best to treat their asthmatic patients. Asthmatics themselves, in turn, are well educated how to stay healthy and out of hospitals. And it was a huge success. Today, we don't see a fraction of asthmatics we used to.

See, that is a success. The fact that most asthmatics are able to stay out of hospitals is a success. If they were still being admitted at record levels, that would not be a success. Sure, we would make more money if asthmatics were filling hospital beds. But, that they are breathing easy and avoiding us is a good thing, not a bad thing.

COPD right now is at epidemic levels. There are COPD patients getting admitted every day. There are also many COPD patients that become regulars. They are discharged and readmitted on a regular basis. That, my friends, is not a sign of success. It is a sign that we are failing them.

Let's talk intubation.

You don't want to intubate people. Sure, it's very profitable when we have ventilators. Sure, it might stimulate your excitement level. But, it's not something that's good. It's a last-ditch effort to save a life. It's nice that we have that skill. It's nice that we know how to save lives this way. It's great that we manage ventilators.

But it's not something we should look forward to. Someone comes in the door of the ER, we should be praying that they don't need us. We should be hoping they get better. But, I'm afraid there are many of us who hope, maybe even pray, that we get to intubate.

That is a sign of failure, not a success. Success is not needing to intubate.

Obviously, some people LOVE intubating. That's understandable. You want to do it to keep up your skill level. And Managers WANT ventilators. In most instances, they are very profitable for respiratory therapy departments.

But hospitals, especially the not-for-profit variety, are not in the market to make a profit. That's the whole point. We are here in case we are needed. We are the cost of being in the healthcare business.

Why regulations increase healthcare costs copy

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, just 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.

They say 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 them 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, then 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's stay and see that, well, at least the patient was sick enough to need breathing treatments. So, he must have been sick enough to be admitted. So, in that case, we will reimburse the hospital.

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. And you know who eats this charge? Hint, it's not the insurance companies nor the government.  It's the hospital. This is because the hospital is reimbursed per diagnosis and not by procedure.

However, to assure reimbursement criteria is met, these procedures must be ordered. I know this sounds silly, but it's the way it is in our current healthcare system. This might explain why some patients receive breathing treatments even when they admit themselves that they are breathing fine and question the need. But, because the doctor ordered it, they don't refuse. Of course this would be different if they were paying the bill and not a third party.

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.  These people, what I like to call Obamacare workers, go over charts to make sure the correct diagnosis is written, and to make sure enough procedures are ordered (like breathing treatments for pneumonia, even though breathing treatments do nothing for pneumonia, but I won't rock that boat again).

And when they see a diagnosis the doctor did not write, one that would charge better, they (the Obamacare workers) call the doctor and tell them to write it.  When they see breathing treatments aren't ordered, the call to get the order. This is what they do.

This is how hospitals operate today. It's crooked. It's seems like fraud to my friends and me, but it's the way it is. It's even heralded as good. It explains why doctors who have historically fought cookbook medicine (treating all patients the same) now support them. And, to be honest, I don't think most doctors support order sets that order doctors what to order. I think they have just conformed out of need to get paid and keep their jobs. But I digress.

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. Yes, they have to raise prices. They have to charge higher prices for all those frivolous breathing treatments, or those not needed EKGs or X-Rays to make a profit. I mean, there's more to it that what I describe here, but that's the jist of it.

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

My theory why small, regional hospitals are disappearing

During the course of the past ten years many smaller hospitals have either closed their doors or merged with larger hospitals. There are various reasons for this, but I think one of the main reasons is corporate cronyism. It's always existed to a certain degree, but it has been put on steroids since during the Obama administration. This is not a criticism of Obama, it's just an observation.

Okay, so money has always played a significant role in politics. You will always have corporations that make a lot of money, everybody always wants more (I don't care who you are) and the lure of making more money is always seductive. 

Now, I don't have a problem with corporations making lots of money, and I never will.  I believe there is plenty of money to go around, enough so that every person, every corporation, in the world could be rich if they made the effort; if they sacrificed their time, and took the risks.  I mean, that's what American Exceptionalism is all about. 

So you have corporate cronyism, or socialist cronyism, or capitalist cronyism, or whatever you want to call it.  This is where large corporations, those with a lot of money like Walmart, send lobbyists or consultants to Washington to make sure laws are passed that benefit them; laws that might help them make more money. 

It is in this regard that Walmart supported a higher minimum wage.  Walmart executives know that they can afford the higher wages, while many of their smaller competitors may not be able to afford it.  In this way, Walmart is able to beat their competitors without having to beat them in the marketplace.

In other words, even if Walmart competitors have a better product, Walmart can beat them because it can afford to make deals with politicians, while their competitors cannot. (Ironically, Walmart's profits have stagnated, and they are now blaming the minimum wage hike.  Go figure!)

This is the same in healthcare.  You have large hospital groups that can afford to send lobbyists and consultants to Washington. They can afford to make deals with politicians. They give thousands of dollars to this politician, or that politician.  They even support laws that they otherwise would not support because they know they can afford it.  

For instance, Obamacare has required hospitals to hire 20 or 30 new people just to make sure they are in compliance with all the new regulations. They can afford to make all the changes that are required, while their competitors cannot.

Not helping here is that Obamacare made it easier for hospitals to merge, almost encourages it.

Because they cannot afford it, smaller hospitals have had to make decisions to either close shop or be bought our or to merge.  It is by this means that large hospitals have become larger, and smaller, regional hospitals have become a thing of the past.

I'm not saying here that I agree with Obamacare or not, this is just what is happening, or has happened. Money is important to get elected and re-elected. Money is important to get your agenda passed, and right now, like it or now, Obama is selling. 

Buying laws is important to benefiting your business.  So, so long as this is legal, it will continue to occur. And, like it or not, it has occurred under the Obama administration more so than in the past.

Further reading:

• Forbes: What '60 Minutes' Didn't Say: Hospitals Will Charge You More Under Obamacare 
• National Review:  An Arm and a Leg

Why healthcare costs have increased since 2010

So large hospital groups have succeeded in beating out the competition by supporting big government, which in turn creates laws that create regulations that smaller hospitals cannot afford. This, in turn, causes their competitors to either close their doors, or they have no choice but to merge with the larger groups. This, in turn, has resulted in higher healthcare costs.

This is contrary to the promise that healthcare costs would go down under Obamacare. Yet Obamacare has made it easier to merge, and easier to charge high prices. In fact, Obamacare almost encourages it through incentives. Check out here some quotes from Forbes.com.

This has had a great impact on the healthcare industry.  This is how larger hospitals have beat out their competition -- gobbled up the competition -- without even having a better product, or regardless of having a better product.

Here's a quote from Forbes:

The average day spent in a U.S. hospital costs five times as much as it does in other industrialized countries. That’s not because U.S. hospitals use higher technology or better care. It’s because they charge more for the same technology and the same care. Because they can get away with it.

Making matters worse, as I noted above, is that Obamacare encourages hospitals to merge, giving hospitals an even greater incentive to charge higher prices. This is due to less competition. According to Forbes:

The next thing Obamacare does is it encourages hospitals to merge, thereby giving hospitals even more market power to charge even higher prices. A study by Jamie Robinson of the University of California found that highly concentrated hospital markets–where one or two hospitals controlled most of the patient volume—hospitals charged an average of 41 percent more for common procedures than they did in more competitive markets.

Furthermore, as noted by Forbes, since Obamacare there has been a spike in hospital mergers. Forbes noted:

The spike in hospital mergers is being driven by two things. The first is that Obamacare expands government-sponsored insurance, like Medicaid. Government insurance pays less than private insurance pays, so hospitals seek to merge so they can gain more leverage on private insurers to charge whatever they want. In 1993, for example, Harvard’s two main hospitals—Massachusetts General and Brigham and Women’s—merged, and immediately began jacking up prices to the privately insured and uninsured populations.

The second is that Obamacare creates a government program, called Accountable Care Organizations, whose explicit goal is to encourage hospitals to consolidate the provider industry, thereby giving them more leverage to charge higher prices. In 2011, a Federal Trade Commissioner called attention to this problem, noting that “the net result” of ACOs “may therefore be higher costs and lower quality health care.”

Some say that the best way to bring down prices is for Obamacare to add price controls. Although all that would do is cause hospitals to stop offering services that are under priced offer procedures that are over priced.

The real resolution to this problem is to try increasing competition, something that has never been tried in healthcare. This would entail breaking up the large hospital groups with antitrust proceedings, loosening up restrictions on hospitals, repealing Obamacare, and allowing the sale of health insurance and hospital services across state lines. This would get hospitals and insurance groups to compete with one another, and the ones that offered the best quality service at the lowest price would prevail.

Further reading:

• Forbes: What '60 Minutes' Didn't Say: Hospitals Will Charge You More Under Obamacare 
• National Review:  An Arm and a Leg 
• National Review: Hospitals are to blame for obscene healthcare costs

Fake Diagnosis: Is any diagnosis accurate?

Fresh out of respiratory therapy school 20 years ago the medical profession seemed so right.  Doctors always properly diagnosed patients and everything they ordered was always necessary. Then, after studying charts and assessing patients before and after every procedure I did, unexpected revelations occurred.

1. Most of what we do is a waste of time or delays time
2. No diagnosis can be trusted

Look, what I am about to say does not reflect, in any way, my respect for physicians and the institutions they work for.  In fact, I in no way expect any person to be perfect, and therefore it's not possible for every thing they order to be necessary, nor every diagnosis to be accurate.  

What is my evidence?  Why is this true? Yes, I will get to the answers. 

I've written enough about useless breathing treatments on this blog to choke a cow, so I don't want to get into that too much here.  But any respiratory therapist is taught to assess a patient before and after every treatment. When three treatments are ordered 20 minutes apart, and the patient is breathing normal after the first and still breathing normal before the second is due, that the second one is not needed. 

But the Quality Assurance people will cry on your shoulder if you did not do the second two treatments, because the patient required three failed breathing treatments to qualify for admission.  

So, while doctors sometimes order breathing treatments because they "think" they will help, or because they will make the patient "feel like we are doing something" or because "it can't hurt."  Many more now appear to be ordered just so the hospital gets paid.  

Now I don't know if it started with ICD-10 or DRGs, but most diagnosis' now appear to be incorrect as well.  Long ago a coworker of mine showed me a diagnosis of pneumonia.  He went over the patient's chart with me and said there is no evidence here that the patient has pneumonia at all.  

"Look," he said, "the x-ray is normal, there is no elevated white blood cell count, and the patient is not having trouble breathing. The only reason this patient was diagnosed with pneumonia is because the patient was too sick to go home and needed a reimbursable diagnosis."

From then on I paid attention every time a diagnosis of pneumonia was written, and, on many occasions, there was no evidence of pneumonia.  

Recently a doctor came to me and asked me a logical question.  He said, "How do you, as a respiratory therapist, define hypoxemic respiratory failure? Or, worded another way, what do they teach about it in respiratory therapy school?" 

I said, "Well, the easiest way to diagnose it is a CO2 greater than 50 and a PO2 less than 60. Why?

He said, "I just find that hypoxemic respiratory failure is often written as the diagnosis and there is no evidence of it.  Most of these patients do not even have a blood gas." 

I said, "Keep in mind that a patient can be in acute respiratory failure and have an SpO2 of less than 90 and still be diagnosed with it.  During some such episodes there is not time for a blood gas."  

He said, "True.  But in most cases, that is not the case, and yet patients are still getting diagnosed improperly. I'm getting tired of it." 

I said, "I see your frustration.  I think most doctors have no clue what a bronchodilator is and when they are needed.  I think that most doctors order albuterol because they think it will do something for pneumonia, and there is no reason why it would. And this has gotten so out of hand that CMS requires albuterol for the patient to meet admission and reimbursement criteria."

He said, "I agree. If I don't order albuterol I have QA people knocking on the back of my head saying, "Hello.  Hello. We need albuterol ordered on this patient. We need a diagnosis of pneumonia.  We need a diagnosis of asthma.  We need a diagnosis of COPD.  Those are much more reimbursable than what you wrote.  We need a diagnosis of hypoxemic respiratory failure."

I said, "It's sad."  

He continued to show me examples.  He opened the chart of a cancer patient.  Her charting showed the following:

• Respiratory Assessment: Dyspnea noted
• Breath sounds; rhonchi
• SpO2: 98% on 2lpm
• Temperature: 98.5
• White Blood Cell Count: normal
• ABG: pH 7.4, PO2 95% on 2l, CO2 35
• Diagnosis: hypoxemic respiratory failure; also pneumonia, lung cancer

He said, "An accurate diagnosis is exacerbation of COPD secondary to pneumonia or lung cancer.  You see how this is not a good diagnosis.  It throws off statistics, and it also causes the doctor to seek medical solutions that are not best for the patient. It causes the doctor to treat what doesn't need to be treated, wasting money and resources."

I said, "I agree."

He gave me another example.

• Respiratory Assessment; no respiratory distress, coughing spasm
• Breath sounds; rhonchi
• SpO2: 98% on room air
• Temperature: 100.5
• White blood cell count: normal
• ABG: none ordered
• Other: patient has peg tube
• Diagnosis: hypoxemic respiratory failure, aspiration pneumonia, sepsis

He said, "First, there was no ABG done. Second, the physician charted that the patient was in no respiratory distress. So how could he diagnose hypoxemic respiratory failure?"  It's simply wrong. 

I said, "Agreed."

He said, "So I charted that I disagreed with the above diagnosis, and entered that the patient had probable aspiration pneumonia. The next day the QA officials was all over me.  She said, 'That's a difference of $20,000 in reimbursement.' I said, "It's also fraud, and why healthcare costs are so high.'  So she was mad at me. The other doctor was mad at me, and I proceeded to explain to her why I was right and she was wrong. It was a learning experience for her.  But the next day I worked I saw that she had written, 'I respectfully disagree with the other doctor's diagnosis.'  Fine.  And you wonder why the healthcare profession is so screwed up.  QA officials are so concerned with making money for the hospital that they are trained, encouraged to falsify, or exaggerate, diagnosis. It has caused doctors to become lazy. Rather than think, they just chose a diagnosis from a list of ten most reimbursable."

I said, "The same happened with asthma.  Since DRG law was passed in 1978 or 1979 or 1980, asthma rates have skyrocketed.  Did asthma rates really skyrocket, or was it because asthma is a reimbursable diagnosis?"

He said, "Agreed.  It sucks."

It does suck.  

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.

Asthma/COPD Inhalers: Why They Cost So Much

Some of my asthmatic friends constantly criticize pharmaceuticals as run by a bunch of evil rich people who are greedy and make money at the expense of the sick.  Their evidence is the fact that newer, non-patented, asthma medicine costs so much.  I would like to argue that pharmaceutical companies (or most of them) are run by people who simply want to make enough profit to stay in business.

It is true that asthma medicine costs too much. Consider that if your doctor prescribes Advair to control your asthma, it will cost you about $250 a month if you pay out of pocket.  If you have a copay the cost will be about $70 per month.  This copay is high, considering a typical copay for generic medicine is between $20 and $40 a month.

 Consider the following facts as reported by medicine.net, "Drugs: Why they cost so much?"

• The high price of Advair is not the result of greed, but of regulation. In fact, pharmaceuticals are constantly looking to find new medicines to help people.  They continue to do this even though they know that only one out of every 10,000 discovered compounds actually becomes approved by the FDA
• The early stages of development are not only expensive, but much of the expense incurred will not become approved drugs.
• It takes about 7 to 10 years and an average cost of 500 million dollars to develop each new drug. Keep in mind this money is spent before the FDA approves the drug. This means that if the drug is not approved, the company loses the money. 
• These expenses must be covered by the revenue from compounds that successfully become approved drugs (like Advair). 
• Moreover, only 3 out of every 20 approved drugs bring in sufficient revenue to cover their developmental costs, and only 1 out of every 3 approved drugs generates enough money to cover the development costs of previous failures. This means that for a drug company to survive, it needs to discover a blockbuster (billion-dollar drug -- like Advair) every few years. 
• After a drug is approved, millions of dollars are spent on marketing in educating healthcare providers and conducting post-marketing studies. Drug companies spend a lot of money on marketing because of the stiff competition they face from other drug companies for their drugs, and in order to develop each drug's highest revenue-generating potential. 
• Given the poor odds of discovering another successful drug, it is more efficient to maximize the returns on a drug that is already on the market through advertising. In this sense, drug companies are no different than any other type of company. They exist to make a profit by helping people.
• In addition to maximizing returns on their investment through advertising, drug companies also spend money to find new uses for drugs or better ways of using them. These efforts increase the use of the approved drugs and also benefit patients. 
• Additionally, drug companies donate millions of dollars to charities and provide free drugs to individuals or countries that cannot afford medications. In fact, it was through a program that I was able to get free Breo for a year (otherwise, I cannot afford it and I have insurance). 

Surely any person working for any company wants to become rich, but in order for this to happen the company they work for must develop, market, advertise, and sell a successful product. Due to the high risk of failure and the low risk of actually gaining FDA approval, the medicines that are approved will have a hefty cost.

Further reading:

• medicine.net, "Drugs: Why they cost so much?

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.

Hospitals charging different prices for same treatment

Getting back to prices of healthcare, it seems that some hospitals are ripping patients off, charging more for services even than hospitals in the same city.  This is according to an AP article titled "High hospital bills go public."

The article ponders some interesting questions:

Why does a joint replacement cost 40 times as much at one hospital as at another across the country? It's a mystery, federal health officials say... The average charges for joint replacement range from about $5,300 at an Ada, Okla., hospital to $223,000 in Monterey Park, Calif., the Department of Health  and Human Services said.  That doesn't include doctor's fees... Hospitals within the same city also vary greatly.  At Beth Israel Medical Center in New York, the average charge to treat a blood clot in a lung is $51,580.  Down the street at NYU Hospitals Center, the charge for the same care would be $29,869. 

Interesting.  I wonder what the different costs for breathing treatments are?

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.  

Hospitals, Doctors Blackmailed by the Government

We have to face the facts, fellow RTs, that one of the main reason we are doing so many non--indicated procedures, and our morale diminished, is because the government is blackmailing hospitals and doctors.

You heard that right. Hospitals are being told by CMS they have a choice whether they want to do something, yet if they don't do it they will not make as much money. Hospitals and doctors, in essence, are being blackmailed.

A perfect example of this is the smoking cessation program. Chances are your hospital board has discussed the smoking cessation program. The choice is this: You do a smoking cessation on a patient you get reimbursed more for that patient, and if you don't do it you get reimbursed less

In my opinion this is not a choice. It's more of a nudge. If you don't do the smoking cessation on a patient, the hospital will get paid less. So the hospital is basically forced to do it. This is blackmail.

CMS actually says it's a choice to make it look good to us, because most of us Americans love to have choices. Yet a true choice would be one of many options, including the option to do nothing. You also have an option to be smart and an option to be stupid. You should not be punished if you decide to be stupid.

So instead of choosing to use common sense, many hospitals are doing smoking cessations on every patient just to cover their bases. This means that even if you don't smoke you will be educated.

Now this isn't so bad, as even people who say they quit smoking are still hanging around people who do smoke. These new ex-smokers are not aware second hand smoke is bad for them. Believe it or not, there still are uneducated people like that. So education on our part is good.

Yet we RTs don't necessarily have time to do smoking cessation on every patient. We barely have time to do the ones that are needed, yet we certainly don't have time to do them on every patient. We are overwhelmed already as it is due to all the order sets and lack of RT Driven protocols at most hospitals.

So you can see how the blackmailing of hospitals to do smoking cessation programs has unintended consequences. It results in burnout and apathy of workers. Yet Administrators don't care so much because in any business, the bottom line is that we get reimbursed, or that we make money.

Another good example is the so called "death panels" as passed by the Obamacare legislation. The death panels really aren't death panels, but they do create a script doctors must follow with each of their patients about discussing end of life care.

Now, a part of me likes this. I think all doctors should discuss with patients what they would want at the end of their life if they are unable to make decisions. If a person has terminal cancer, do you want CPR done on you, and do you want to be kept alive on a ventilator.

I think this is good. And I also it should be up to the doctor to discuss this with a patient. So this is what Obamacare does: it gives doctors a choice. The choice is this: You do end of life care and you get reimbursed for that patient visit. If you don't do end of life care, you still get reimbursed, but you make less money.

So what doctor in his right mind will not do end of life care, and use the government script. In this way, CMS is nudging the doctor to do what an expert sitting in an office in Washington believes is idea. It's blackmail.

Is this choice? Yes! Is it a good choice? No really. It's a nudge. It's forcing us to do it your way. It's blackmail.

A government script is an attempt to convince people that death is imminent and we shouldn't be spending money on you, then the death panel discussion is valid. Now end of life counseling is good, and it should be done on all patients, yet it should not be a mandate by the government.

Likewise, it allows doctors to decide if a 90 year old lady should get a hip replacement, or 100 year old lady a hearing aide. The patient and the family should be deciding if the cost is worth it, not Uncle Sam.

It will, in essence, become nothing more than a screening program to cut out the most expensive years of your grandma's life. It will save the government millions of dollars per year, if not billions. To the government, it's all about saving money. To hospitals, whether they agree with this blackmail or not, it's all about making as much money as they can. So they have no choice but to "COOPERATE!"

One concerned mother asked a famous person in Washington about whether Obamacar would pay for her 100 year old mother to get a hearing aide she wants so bad. The politician answered, "No, no, we gotta start talking quality of life, too, we can't calculate spirit and how much she wants to live. Give her a pill. People like that we should just give 'em a pill."

He later said, "I don't think we can make judgements based on people's spirits." If you are terminally ill, or if you have a bad heart, or if you have the beginnings of a disease like Altzeimers or Parkinsons, your doctor will, by law, have to encourage you to not seek any procedures that will prolong your life.

That means no expensive CPR or breathing machines. That means no expensive life saving medicine. That also means no hip replacements. No nursing homes. No hearing aides. No pacemaker.

Some people, even at 105, have a certain spirit, a certain joy of life, a certain love of live, a high quality of life and they want to do whatever they can to live another day. These people should be able to get the hip replacement, the hearing aide, the pacemaker or whatever.

Will a government in Washington be able to see this spirit, this joy, this quality of life. Or will that government official, that government expert, only see her as a 105 year old burden on society who will die anyway soon so let's not waste our time or money on her.

That government expert will see it as a government shut off at some age, perhaps 75, or 65, or if the cost of healthcare becomes too much of a burden, perhaps even 55 or how about 45? Where does it stop?

Will my mother have to go to the government to get a procedure done? What if it's a lifesaving procedure? By the time the government has an answer it may be too late anyway. This kind of thinking sends chills down my spine. This is America not Cuba.

Since the government's flipping the bill, This sounds Orson Wellish, 1984 type stuff. I never in a million years could have imagined we'd be having this discussion in America.

Now you might say, "well, it's not a mandate." But it is. When the government tells you you won't get paid if you don't do it, then doctors who accept Medicare will have no choice but to do it. Thus, it's mandatory. Either that, or it's blackmail.

Granted, this is not an opinion, it's fact.

What do you think?

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ER assessments no good in court of law

The ER Doctor on tonight had a good point. He told me that gone are the days you can go to the emergency room with a headache, get a pill for your aches, and be sent home. Gone are the days when you can simply examine a patient, know what's wrong, and treat the patient.

He said, "Emergency Room patient assessments are basically useless now in a court of law. If you assess the patient, you have to have the test to back it up."

It's true. When my daughter is having trouble with her asthma I take her to the doctor's office, where she is given a breathing treatment, a few prescriptions, and sent home with me. Quite frankly, this is the ideal approach to medicine -- the common sense approach.

If I were to take her to the ER, even though the ER doctor is as smart as the pediatrician in the office and knows what's wrong with my daughter, he would also have to order a blood draw and x-ray at a minimum. My daughter might also end up with an I.V. or heplock for no reason.

So if you want to know why healthcare is so expensive, now you know. The cure for this is tort reform.

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.)

8 ideas for those who can't afford Advair

Yesterday I wrote about some ideas I had to help people cope with the high cost of Advair. This may perhaps be the greatest medicine ever invented for asthma patients, and yet it costs so darn much. Those with no health insurance may have to choose between Advair and nothing at all.

But that's not necessarily true. There are options. Here are some of the ideas people have emialed to me.

1. Talk to your doctor about free samples
2. Advair comes in two strengths--for example, if the doctor prescribes the 250, to be used twice a day, and the patient needs only the smaller 100, and uses the 250 once a day, maybe that is better than not using it at all.
3. Perhaps the doctor could prescribe one puff once a day to make the discuss last 2 months instead of one.
4. Talk to your doctor about taking alternative Corticosteroids, like Beclavent, Azmacort, Advair, Vanceril.
5. For those who need the added corticosteroid, they could take Advair in the morning and a substitute corticosteroid in the evening.
6. You could do a combination of the above to make the med last longer
7. Check this website out to find the cheapest asthma meds: http://www.needymeds.org/.
8. Pharmaceutical companies have programs for folks who can't afford drugs- call them!

These are just some ideas from me and some of my readers to help those of you who cannot afford these meds. You can discuss these with your doctor and see if they might work for you. You may have to experiment a little, and get creative.

But, please don't stop taking you preventative asthma meds just because you can't afford them. And please don't stop taking them just because you feel good after not taking them for a week. Asthma can pretend to not be there at times and then can show its ugly head on a dime.

More money wasted in the ER

Well, you get what you deserve. After I jinxed myself yesterday morning when I gloated about not getting paged once on my shift Thursday night, I ended up spending last night in ER until about 1:00.

No, I didn't save any lives. In fact, I really didn't do much good at all. But, the doctor wanted those Q1 hour treatments on all her SOB patients. Who did the infamous Dr. Krane order Q1 hour treatments on last night?

1. A lady with a history of pneumonia.


2. A lady who was diagnosed with a pneumo


3. An elderly gentleman with lung cancer (Left lower lobe removed) and Lymphoma. He never smoked a day in his life, so I would rule out COPD here.


4. An elderly man who was scheduled to have a pleural effusion drained. He was diagnosed with sepsis and probable pneumonia.


5. PE.

Sure, these all presented with symptoms similar to asthma, and the initial treatment did help on a few of these, but treatment # 3, #4 and #5 certainly weren't indicated.

Let's see. According to my new research, that is $88 * 5 = $440 worth of treatments when one and a good assessment would have been suffice.

ER treatments at our hospital are $88 a piece. Pharmacy probably charges even more for the medications used.

If Obama and McCain want to address something that would benefit the health care crisis, this is it. What a waste of resources.

Check out my 'olins at the bottom of the blog. I've finally updated them.

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.
(CHECK OUT MY POLL)
(Here is a doctor's perspective on the high cost of medicine, and an RT from Canada.)