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.

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.  

Less government equals less healthcare costs

Here's a perfect example of why healthcare costs so much. I went into the patient's room and she said the following:

I have no insurance. I have all the stuff to take a breathing tx at home. I know as soon as you start the treatment it's going to cost me $100, and I'm going to have to pay it. If you can talk to the doctor and have him write me a prescription for Albuterol solution, I can get it for $4 and I can give my self treatments for free at home."

You see, she is paying for her own medicine, and so she questioned what the doctor ordered. Because she was paying on her own, she didn't want to pay for it.

Now if she had health insurance, and if she had medicaid or medicare, and she never saw the bill, then she wouldn't care what the cost of that treatment was. She wouldn't have questioned the order.

This is a perfect example of why we need to have a healthcare system where there is an incentive to question the order. The truth is, at present, most of us don't. And that's why healthcare costs so much. It costs so much because people keep getting, and they don't pay. Since someone else is paying, they don't question the order.

Think about it. If you give something away for free, everyone is going to come running to buy it. So while supply of hospitals, doctors and medical equipment stays the same, demand for it goes up because it's free. Per basic economics 101, the price has no choice but to go up.

The best way to get the price of medicine to go down is to force people to pay for it themselves. Back in the 1960s this is how it was, and medicine was affordable. Ever since the advent of Medicare and Medicaid and HMOs and third party payers, healthcare has skyrocketed.

It's not a coincidence. The way to get healthcare costs down is to get the government out of it. The way to get healthcare costs down is to get Jane and John Doe to question the therepy they are being provided.

That way, what isn't needed won't be given. What's needed they will pay for. And yet the healthcare reform bill passed 6 months ago does exactly the opposite of that. It places more patient's on the government dole, which means more free (but it's not free) medicine for more people.

Look, there are some people who really, truly cannot work and really, and truly could use a helping hand. I'm all for them getting help. Yet that system of helping out the needy, or our retired parents, has gotten out of hand or out of control.

It's time we had more patients like I had today. The patient who says, "Hey, before you open that and charge me $100 bucks..."

Crossfire appreciated, yet no flames aloud.

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.)

Thoughts about Advair and alternatives

As I blogged about yesterday, many people have been asking about alternatives to Advair and Symbicort due to the high cost of these meds. I have listed some options here on this blog as they've come to me.

Today I have another option that has popped into my always thinking head. I'm a very curious person, and therefore sometimes I find myself thinking of things other people may never have considered. I'm not saying they'll work, I'm just thinking here.

It's something that's far out there, but actually it isn't. Since Advair** is an expensive mixure of a corticosteroid (Flovent) and long acting bronchodilator (Serevent) meant to treat both the chronic inflammation and prevent acute bronchospasm, why can't a mixture of less expensive meds be used as a replacement for Advair.

Of course Advair is the asthma wonder drug of choice not just because of what it prevents, but because it's easy to carry around, easy to use, and only needs to be taken twice a day. It's highly convenient, and makes asthmatics much more compliant than in years past. If cost were no obstacle, Advair is the medicine of choice.

The only problem with Advair (aside for some minor side effects), is that it costs an arm and a leg. And, since it costs so much, people who do not work, are poor, or have no health insurance have no way of gaining access to it. And it's these people we see in hospital emergency rooms.

So, as a replacement for an Advair discuss that costs $120 a month, why can't Asthmatics (and COPDers too), take Vanceril at $38 a month and Ventolin, which costs $42. That's still a chunk, but it's $40 less than Advair.
I can see a doctor switching a patient from Advair to Vanceril or some other generic corticosteroid (like Azmacort, Beclovent, Aerobid, etc). But instructing every asthmatic to take Ventolin every four hours is frowned upon. Why?

The asthma guidelines themselves say that any asthmatic who needs Ventolin more than 2-3 times in a two week period does not have control of his asthma. If that is true, then why are people who need Serevent in their systems all the time considered under control? Aren't they the same type of medicine, except one lasts for 12 hours and the other 4-6?

And yet, while the asthma guidelines recommends Advair and frown upon overuse of Ventolin (overuse would consist of using it more than the asthma guidelines recommend), it seems every single patient admitted to the hospital with Asthma or COPD is given Ventolin*** every 4-6 hours regardless of whether their disease is exacerbated. Ventolin lasts in the system about that long.

So a wise man asks: Why is it okay to order Ventolin every four hours as a preventative medicine in the hospital, but not okay to order it the same way for outpatient therapy?

A doctor recently gave me an answer when I questioned why she keeps ordering Ventolin Q4 on all her patients. She said, "Because they need it in their system to prevent shortness of breath."

Okay? So, if a patient needs it in his system while in the hospital to PREVENT shortness of breath, then why does this philosophy not apply outside the hospital? Either Ventolin is a preventative medicine or it is not?

It would seem to me if a patient does not respond well to Serevent, then Ventolin is a viable option. Of course you must consider what works for one patient does not work for all.

Personally, I don't think Ventolin prevents anything for most patients. The pre-use of Ventolin has never prevented me from having a bronchospasm. However, the pre-use of a corticosteroid has. However, I'm not saying Ventolin won't prevent for some patients.

I know Ventolin doesn't prevent for me because I had a pre and post PFT done to prove this. But doctors rarely order PFTs to determine if the Ventolin they are ordering on all their patients is working.

That would make too much sense. Better sense would be to use common sense and not order ventolin at all unless it is needed, or at least proven to be effected, which could be a subjective or objective measure.

But actually assessing to determine effectiveness would mean an actual assessment, which would be way to much work for some doctors to bother with. So they just order what feels right, not what is right (Kind of like Washington Politics, hey!).

I suppose you can create a third angle with this argument. If Ventolin should never be used unless a patient is having an exacerbation, then Serevent should never be used period. If the corticosteroid is doing its job, the patient should never get short of breath in the first place.

Yet that may not be a reasonable claim for many patients. Still, Serevent and Ventolin are the same medicine. And, while a patient is taking Serevent on a daily basis, it is still considered safe to use Ventolin with Serevent ( but never safe to use Serevent more than twice a days).

So, if you still need to use Ventolin every day regardless of being on Serevent, is the Serevent even doing it's job? Is it really preventing bronchospasm?

Or, is the reason Advair improves the lives of asthmatics so much more do do with the fact it's easy to use, convenient to carry around, and only needs to be taken twice a day, and not because it has both a corticosteroid and long acting bronchodilator. In other words, would a discus of Flovent alone work as well as Advair?

If the answer is yes, then any patient on Advair that costs $120 could easily be switched to a medicine like Vanceril which costs $38, and not lose any of the benefits. However, there would be one big if here: the patient would have to be as compliant with the Vanceril inhaler as he is with the Flovent discus.

Vanceril may be needed 4 times a day instead of the convenient two. Plus those patients who are now taking Vanceril will also have to lug around a bulky spacer. Obviously we're supposed to carry one around with our Ventolin too, but you and I both know most asthmatics (especially guys) don't carry spacers with them.

Ideally, Advair is better all the way around, except for cost. But, if you are strapped for money, perhaps an alternative generic corticosteroid may work just as well as the Advair, if proper technique is used. That means you have to use a spacer.

And perhaps, if you or your doctor thinks Serevent works so well for you, then why not take Ventolin every 4-6 hours round the clock too, regardless of what the guidelines say.

If I haven't lost you with my rambling here, tell me where you think I'm wrong (or right).

* costs listed are estimates.
**Advair and Symbicort are basically the same med, so when I refer to one, I'm also referring to the other.
***Xopenex may be ordered as well, and if it is the frequency is usually every 4-8 hours because that's how long the medicine lasts.

Just a thought about the inauguration

Here I am watching the presidential inauguration on the Today Show for some reason, and my wife made a good point. She said the broadcasters said some presidents are always late (Bill Clinton) and some always early (George W. Bush), but so far the Obama's are inconsistent. "That's quite unusual," said Tom Brokaw.

It's not unusual as far as I'm concerned. But I have kids, and therefore I understand that some days they can be easy to get dressed and cart off, and other days one can be a bull head and difficult to get off to school.

But no one said, "Well, he's probably discliplining his kids." That's what this RT dad did this morning anyway.

So then the cameras were on the hotel for at least 20 minutes, and the announcers kept telling us they were waiting for the Obama's to exit the building and get into the limousine. Then, finally they got on the limo, and it was a mere 20 second ride.

That was so exciting.

Obama says he's going to fix our health care system. I wish him the best of luck. However, I hope he keeps this advice in mind: "Sometimes doing nothing is better than doing something stupid."

Can you imagine how great Bush feels about now. Man, I bet he's having palpitations, just yearning for the moment this is all over. He's going to be so happy to be out of the limelight. He even admitted as much.

Obama, on the other hand, is walking into the most stressful, most criticized, job in the world. And he's doing it with little kids. It's hard enough raising kids with the stress of a normal job, one of which I don't have to think about my work when I'm not working.

So he's walking out into the crowd of a billion people. He has a serious expression on his face. I bet he's thinking, "Man, I have to pee real bad."

Just a thought.

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.

New strategy for change in the RT Cave

In my past few posts I emphasized the problem that has caused low morale in this RT Cave, in this post I will state the proposed solution to improving morale.

Actually, the best way of improving morale is to have happy employees. If you have happy employees, everything else simply falls into place.

Yesterday I told my supervisor I was going to quit. I was serious. In fact, as soon as I got home I downloaded an application to another hospital, filled it out, and then went to bed. However, by the time I woke up I had a more level head on. I was ready to tackle the problem head on. The time had come. I had nothing to lose.

At first I thought my bluff wasn't taken seriously. But, when morning came about, and the hour of 4:00 rolled by and I didn't hear from my supervisor, I knew something was amiss.

And, as I was just about to wrap things up for the day, the head RT boss approached me and wanted to see me in his office. Apparently, the supervisor had told him I wanted to quit, and he asked me what the problem was.

"The problem is simple", I told him, "that I have gone home miserable the past few days, and while I had planned on working another 22 years at this place, I refuse to be miserable for 22 years."

"Well," he said, "How can I make it better for you." Wow. Is that all I need to do to get some attention -- threaten to quit. I suppose the squeaky wheel gets the grease. I'm taking advantage of this.

"The answer to that is simple," I said, "Communication. I think that we all seek the same goal of improving the department, but you guys decided you were going to do something and didn't' tell us about it, and then all of a sudden you expect us to be perfect in our charting. That's simply poor business. Thus, I propose, simply that you better communicate."

I could have sat in his office complaining about how poor of a communicator he is, or how stupid the administration at this hospital is, which is what the RT Complainers may do anyway, but I didn't want to stoop to that level. I wanted this meeting to be productive.

"What do you mean by communicate?" he said.

"Exactly like you are doing right now. You are listening to me, and allowing me to speak. And, I am sure, you will explain to me why you are all of a sudden cracking down and expecting us to chart perfectly."

"That makes sense." And he proceeded to explain to me why the crackdown. He explained economic hard times. While the hospital might be really busy today, it has had many slow days. So, when random procedures don't get charted, that amounts to money that is not made for the hospital.

He said, "Okay, any other ideas."

By golly I did. I rattled off a list off the top of my head:

1. I would like a 12 hour leeway in which we can do our charting, or fix any errors in our charting.


2. At the end of the day, I want to be able to print off a sheet that lets us know what we charted, so if we didn't chart something, double charted, or didn't chart something at all we'd be able to see it right then so we could fix it. He thought we had this list already, and I explained we didn't. There, one communication problem fixed.


3. Another co-worker I talked with proposed that instead of leaving notes every day that we made a mistake, that we create a monitoring system where this data is recorded, and at our monthly meeting we can monitor progress or lack there of. If a certain person has more charting errors than the average RT, then he should be set aside and a plan should be worked out to determine how this might be improved. If the department as a whole is making the same errors, then perhaps a new strategy for charting should be implemented.

After I left his office, I coincidentally picked up a book I had in my basement and read it, considering it was only 174 pages long and pertained exactly to the situation at hand in our RT cave. The name of the book was The Effective Executive by Peter Drucker.

In this book he talks about a model for effective executive leadership. It shows a way to turn a failing model around into a successful model. And, considering the new policy in our department that attempted to make us RTs perfect on a dime, and that resulted in excessive complaining, animosity and low morale, this situation was on my mind as I read the book.

According to Newt Gingrich in his new book Real Change, Drucker's strategy goes something like this:

1. What do you VALUE?


2. What VISION of success do you have for achieving what you value?


3. What METRICS would tell you whether you are making progress toward your vision?


4. What STRATEGIES would enable you to achieve your vision?


5. What PROJECTS would enable you to implement your strategies successfully?


6. What TASKS have to be done well to complete each project?

Before I left his office I cracked a joke to lighten up the atmosphere, and then I told him I felt better now that we communicated, and I thought it would be a good idea to communicate like this with the rest of the staff as well. I was impressed when one of my co-workers called me to inform me she was to have a meeting with the boss later in the day, as has every other RT in the Cave.

"What the heck did you tell him," she said.

"Everything," I said, "What did I have to lose."

We value more communication and good morale in our department. We want back what was stolen from us when this new policy was enacted. Our vision of success is involving the entire department in the decision making.

Jane Sage is the one who thought of a strategy for metrics, and this is her idea was to create a monitoring system that showed us what we were doing wrong and whether it was the entire department or if some of us were more more prone to making mistakes than others, and what exactly were the mistakes.

Metrics is more than just the statistics that are pounded on us at each department meeting, statistics that show ups and downs in the monthly financial status, or how well the hospital is perceived within the community, or the RT department for that matter (as a side note, we are viewed as excellent on a regular basis).

While the statistics can show some trends, statistics cannot show morale. Likewise, statistics can become stale. Thus, having good metrics is a far better means of solving a problem.

By my meeting with the head RT boss I listed some of my ideas for improving the problem. And, as he plans on talking with other RTs, they will list some of their strategies, projects and tasks, and then we will get together in our next departmental meeting an analyze all the information accumulated and try to implement a plan.

Newt Gingrich, in his book Real Change writes that "Albert Einstein had a firm rule for thinking about new solutions. He asserted the following: thinking that doing more of the same will lead to a different outcome is a sign of insanity (Emphasis added).

Thus, even before any of us had read any book on the subject, we were on the right track to obtaining better communication and, perhaps, better morale.

Thus it only makes sense for the RT bosses to implement a new strategy to achieve their goal. This meeting I had with the boss was only the first step, I'll keep you guys updated on how things progress from here.

You can control your own health care costs

You are responsible for your own healthcare costs. That is why I hereby link you to an excellent post on The Respiratory Report, "Cut your Health Care Costs. This humble blog post will provide you with a few personal weapons you have at your disposal at battling the high cost of medicine, and the importance of battling those who wish to resort to governmental or "universal" health care.

It's your responsibility to make sure you have control of your own health. Please check out the link above. A great post.

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.)

The conundrum of busy emergency rooms

"God, how long are we gonna have to wait. We should have just stayed home."

I hear that often as I walk by the crowded waiting room on busy nights at shoreline, and I think, "If you're even thinking of leaving, maybe you shouldn't be here in the first place.

Trust me on this: RT Cave Rule #7: if you are having a true emergency, you will not have to wait to be seen by the ER physician. If you are suffering from anything critical, you will find yourself in an ER bed faster than you can say ER.

"It's ridiculous I have to wait this long," I hear.

And I think to tell them, "So, do you want us to treat you before the man in room F who's having a heart attack, or should we treat you right away so you can get back to your beer and cigarette."

Being the good boy I am I usually keep on walking.

I had a discussion with an elder doctor who told me that 20 years ago he didn't even stay in the ER at night, he simply went home. If he was needed he was paged. And, he said, that when he came in he knew it was for an emergency, which is what the EMERGENCY room used to be for.

Not anymore.

So why are todays ERs so busy?

Anonymous over at Respiratory Therapy 101 wrote an excellent post on this today. I encourage you to read it, because he is right on. I can honestly say I agree with him 100%.

He writes that ERs are busy because the government does not reimburse independent doctors enough money, so these doctors have no incentive to accept Medicaid patients. This leaves Medicaid patients with no option but to flock to the ER for their non-emergent medical problems.

That, coupled with the threat of a lawsuit, has resulted in doctors ordering a bunch of tests that aren't' even indicated just to "cover my ass." This makes for a long ER visit.

There's another factor involved here, and that's the idea of FREE. It is a natural human tendency that when people hear that something is free, they flock to it.

And, since it's illegal for ERs to turn people down, they have no choice to accept Medicaid patients, and even uninsured patients they know will never pay up.

Like Anonymous RT, I'm not proposing that we throw these patients out of the ER. I do, however, believe we have a serious conundrum here that needs to be addressed.

Here is my 2 cents worth of ideas that should get the ball rolling:

1. Do not go to a Federalized Health Care system. Giving away more free stuff will only make the matter worse.


2. Force doctors to do the procedures they order. Frivolous orders would soon be a thing of the past. The ER will clear out faster.


3. End frivolous lawsuits by forcing people who file them to pay all court fees if they lose. Doctors will no longer have to order procedures, "just to protect myself."


4. Encourage RNs and RTs to chart when they think a therapy is not indicated and hope that insurance and government agents read that charting. When agencies stop paying for these not indicated therapies, hospital administrators will be forced to crack down.


5. Encourage politicians to spend a day shadowing in the ER. I bet it wouldn't take long for them to catch on.


6. Have mandatory health education classes for anyone using government health care programs. Here they will learn what constitutes an emergency.