We Don't Want Elitists To Fix Healthcare

Elites are fine. Elites are people with a lot of money and who attend the best colleges and universities. They end up with lots of knowledge and a lot of money. They are generally the people who end up with important jobs, such as lawyers and politicians. 

So, I don't have a problem with Elites. What I have a problem with is elitists. These are Elites who think they they know what's best for you, and they ought to have the power to control your life. In other words, they are smarter than you and their ideas should replace whatever systems are in place. And this is exactly what some of them intend to do for healthcare. 

And it's by this means that things like Obamacare got passed. Obamacare has some great ideas in it. But many of the things in it had never been tried before. So, they were untested. The only way they made the bill was because elitists decided they knew better than the systems already in place. And that's how we got this system where hospitals do not get reimbursed for COPD patients who are readmitted within 30 days, a system that has caused many smaller hospitals to merge with larger ones. 

So, let's discuss systems already in place. What are they? Why are they in place? Well, most of the systems we use were developed over thousands of years. They evolved over time and have been tested over and over. That doesn't mean they are the best systems. But they are the best systems that mankind has ever thought of. They are there for a reason. 

Then we have chimeras. These are ideas that elitists get into their head. And they think their ideas are better than the systems already in place for thousands of years. And their ideas have never been tried or tested. And that, despite this, they will be better than the systems already in place. They need to come up with evidence proving their ideas are better. But this rarely happens. And it didn't happen when Obamacare passed. And this is why you heard people like Nance Pelosi saying things like, "We need to pass it before we know what's in it." 

Elitists are the ones who tried to remake our healthcare system. They got this bright idea and now we have to live with it. 

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

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.

H.R. 3862: Obamacare Amendment

H.R.3862 - Respiratory Care Amendment to Obamacare 115th Congress (2015-2016)

Sponsor: Rep. Ding, Bill  [R-NY-11] (Introduced 03/06/2015)
Committees: House - Ways and Means
Latest Action: 04/23/2015 Referred to the Subcommittee on How to Screw Up Healthcare Even More

Shown Here:
Introduced in House (03/06/2015)

Amendment to Obamacare  - Amends the Patient Protection and Affordable Care Act of 2010 to:

• Creates many senseless policies to ensure a high procedure count for respiratory therapists; to assure that they can keep their jobs; to keep the U3 unemployment number as high as we can get it so we can assure the president looks good.
• Authorize the newly created state police to better prepare patients for emergency services in the hospital setting.  
• Mandate that all patients with lung diseases be clean shaven so it's easier to fit a BiPAP mask over their faces.  
• Based on studies that show the COPD patients who wear BiPAP at home are less likely to make repeated and costly visits to the emergency room, it is requires that all COPD patients be fitted with, at a minimum, the cheapest BiPAP equipment and be required to wear it between the hours of 10 p.m. and 6 a.m.  Settings will be made up by physician rather than wasting government monies on sleep studies or relying on a respiratory therapist who knows how to actually manage the BiPAP.
• Requires all physicians to talk to their patients about end of life planning so physicians no longer have to waste their time asking, and respiratory therapists and nurses no longer have to waste valuable time that could be spent watching reruns of Columbo wondering.  
• Requires that all respiratory therapists prioritize emergency room patients over all other patients, even if the patient in ER was using it as a medical clinic.  
• Further enforces that all patients who are to be admitted to the hospital must be sick enough to have received three bronchodilator breathing treatments in the emergency room.  
• Once admitted to the hospital, all respiratory patients or patients who produce or might eventually produce annoying lung sounds (i.e. asthma, pneumonia, heart failure, pulmonary fibrosis, kidney failure, faux pneumonia, phthisis, lung cancer, ETOH, dehydration, Sepsis, DIC, altered mental, over the age of 85, on a ventilator, will be on a ventilator, might need a ventilator, requires BiPAP, smells nasty, is annoying to nurses and doctors, sun downers, etc.) must require at least a minimum of four breathing treatments a day to meet criteria for admission and criteria for 
• On the other hand, if a patient really does require 3-4 breathing treatments in the emergency room, this certainly does qualify them for admission.  It is, however, essential that these patients be ordered to receive Q4ever breathing treatments. 
• Initial orders for breathing treatments for children under the age of 10 must include Q2 times 4, Q3, times 4, then Q4-6.  It is also highly recommended that mucomyst and pulmicort be thrown in.
• No two respiratory medicines can be mixed in the same nebulizer.
• All nebulizers must be cleaned with normal saline after each use by a respiratory therapist.  Surely there is no evidence this will do any good, but it makes us feel like we are doing something useful
• Requires that all patients show evidence that they are trying to obtain their ideal body weight, with a three year time frame to obtain it.  Punishment for violators is: 1st offense -- 3 days forced BiPAP with a rate set 6 higher than spontaneous rate; 2nd offense -- one practice intubation and extubation (to be performed after office hours as to not interfere with profitable hours); 3rd offense -- a practice intubation by a first year respiratory therapy student followed by one day on a mechanical ventilator without any sedation and run by a physician who barely passed med school and was trained at the same school that teaches physicians not to oxygenate ALL COPD patients.  
• The 15 year phase-in of a respiratory therapy bachelor's requirement for all respiratory therapists, because just having an associate's degree does not qualify someone to know more than a physician. Of course a bachelor's degree won't either, but, hey, we like to create laws that don't make sense. Violators will be subject to an increasing workload of stupid doctor orders until retirement (which may be forced, because dogmatic, seasoned therapists know too much and must be stopped from educating the young ones that we are tying to indoctrinate.  
• Nurses and respiratory therapist must scan a patient's band and the medicine prior to administering a medicine, regardless of how urgent it is needed.  Patient suffering and risk of not administering a medicine is no reason to skip steps and cut corners.  Punishment for violators is spend a week doing nothing but making wrist bands for patients. 
• Punishment for taking the time to check and see what someone else charted and just copying it is branding with the word "Dipshit!" or "Dingdong!" on forehead.  
• Respiratory therapists are no longer allowed to write "no change" or "no difference" in the post treatment assessment phase.  The reason for this is because we know (we, as in people who sit in suit coats in Washington) that no doctor would order a breathing treatment unless it had some potential benefit.  "No Effect" is likewise unacceptable in the post treatment charting area.  Punishment for violation will be to read the entire 3,000 pages of the Patient Protection and Affordable Care Act

Are 'death panels' coming back?

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

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

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

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

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

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

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

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

Further reading:

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

Disadvantages to COPD reimbursement program

On Monday I published the post "Obamacare May Benefit COPD Patients." This was my response to an initiative in Obamacare that allows CMS to punish hospitals that have too many COPD readmissions.  It explains the benefits of this initiative on the patients.

I want my readers to know that this post was in no way an endorsement of Obamacare.  It was mainly an objective post to to show that this "initiative" is noble, and will benefit COPD patients.  The post was addressed to COPD patients on a COPD website, and therefore I felt it was not appropriate to address the advantages and disadvantages of this initiative on hospitals.

The truth is, that while the initiative was added into Obamacare because statistics showed that COPD readmissions are both unnecessary and costly, there was no market drive for hospitals to address this issue.  Now that hospitals are being forced to address it or risk a reduction in reimbursement, hospital administrations are scampering to solve this problem.

The problem here is that, while statistics show programs like this that already exist have been effective in reducing COPD readmissions, it might be impossible to meet this criteria.  I will provide here a variety of reasons:

1.  Most COPD patients that fit this category are at or near the end stages of their disease, are frail, and have co-morbidities, any one of which may result in a readmission. It is therefore impossible to prevent all, or even most, of them from being readmitted for one reason or another. In fact, as Stephen F. Jencks said in the April issue of AARC Times, "Two thirds of Medicare fee-for-service medical discharges are readmitted or dead within a year."  In other words, they are very sick, and it may be impossible to keep them out of a hospital regardless of the efforts and good intentions of healthcare providers.

2.  Staffing at hospitals will always be an issue, and this is because, while hospitals do view trends, it is impossible to accurately know when the census will be high or low.  For this reason, there will be times when a hospital simply doesn't have the staff to meet all the demands of the patient population.

3.  Along the same lines, respiratory therapists will be asked to take on more responsibilities when many are already dealing with high workloads and high levels of burnout and apathy.

4.  There is no reimbursement for the added procedures that will be necessary to fully commit to this initiative, and therefore hospitals will hit hard with the cost of applying, and the possible cost of a reimbursement penalty.

5.  Educating COPD patients is always a challenge.  Jencks explains that these patients have anxiety, are on medications that may impair their judgement, are often disorientated, and are simply sick.  They also may be confused or depressed, and this only exacerbates the problem.  Sometimes these patients say they understand what you are explaining, but they don't.

Bottom line:  Consider once more the following quote: "Two thirds of Medicare fee-for-service medical discharges are readmitted or dead within a year." The reason this statistic is true is not because they don't receive good care, it's because they are really sick people.

It only makes sense that efforts made on behalf of the healthcare profession will reduce COPD readmissions.  The questions that remains is: will these efforts be good enough to meet criteria set by the government?  It is my humble opinion that this system is set up to fail.

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New mandate may benefit COPD patients

This post was originally published at healthcentral.com/copd on 5/5/14

Obamacare may benefit COPD patients

The Patient Protection and Affordable Care Act, nicknamed Obamacare by some, might perhaps be the most controversial law of our generation. Despite this, it might prove to be a boon for patients with chronic obstructive pulmonary disease (COPD).

According to the Centers for Medicare and Medicaid Services (CMS):

“Section 3025 of the Affordable Care Act added section 1886 to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012."

Readmission is defined as any patient who is readmitted to the hospital within 30 days of discharge from the same or another hospital. While the initial conditions applicable to this measure were heart attack, stroke, heart failure and pneumonia, COPD has since been added.

While hospitals may already be punished for excessive readmissions for these other diseases, hospitals may start being punished for excessive COPD readmissions beginning in October 2014.

So an effort is now ongoing by hospitals and hospital groups to create programs meant to benefit COPD patients.

Perhaps the driving force behind this movement are the following statistics, provided by the American Lung Association, the COPD Foundation and the Agency for Healthcare Research and Quality:

• COPD is now the third leading cause of death in America
• About 1 in 5 hospitalized individuals over 40 has a diagnosis of COPD
• 24 million adults have it
• About 715,000 patients were discharged from hospitals with a COPD diagnosis in 2010
• The disease cost the nation an estimated $49.9 billion in 2010
• Over 800,000 hospitalizations per year from COPD
• About 20% of hospitalized patients are readmitted within 30 days
• Up to 76% of readmissions occurring within 30 days are potentially avoidable
• Avoidable hospitalizations and re-hospitalizations are potentially painful, harmful, and always prolong recovery
• The average cost of an initial hospital admission with COPD is $7,100
• An average cost for a 30-day readmission with COPD is $8,400, which is 18% higher than for the initial admission

It’s understandable that COPD patients will have flare ups and will need to be admitted to a hospital from time to time. However, readmissions can often be prevented. So the crux of this movement is to prevent COPD readmissions.

So, should you ever find yourself admitted to a hospital with a diagnosis of COPD, what changes should you expect to see? Based on successful programs already created, here is what you might find.

1. More questions: Health care providers are going to ask you a plethora of questions to learn more about you and why you were admitted or readmitted. Questions may include: Do you understand your disease? Do you understand your medicine and why you need to take it exactly as prescribed? Do you know how to use your inhalers and nebulizer properly? Do you understand why you need to take your medicine? Do you understand how to prevent lung infections? Do you understand why it’s important that you quit smoking? Do you know how to recognize your COPD signs and symptoms? Did you wait too long to come in?

2. Better education: You will literally be the center of attention for health care providers, who will visit you often, not just to treat you, but educate you about your disease. You will learn basic lung anatomy, and how COPD affects your airway. You will learn about pulmonary function testing and how COPD is diagnosed. You will learn the stages of COPD and what one you are in. You learn that, while there is no cure, COPD can be controlled. You will learn about COPD medicine, how they work, and why it’s important to take them exactly as prescribed. You will learn the difference between maintenance and rescue medicine. By the time you are discharged you will know this disease inside out and upside down. By the time you go home you will feel confident and competent about how to effectively manage your disease.

3. Caregiver involvement: In many instances you will need help managing your disease. This person could be a spouse, parent, child, other relative or even a friend. If you have a caregiver, this person should be involved in the entire process. Every time there is a scheduled teaching opportunity, your caregiver will be strongly encouraged to be present.

4. COPD Action Plan: This is a plan that teaches you to recognize your COPD signs and symptoms, and what action to take. Ideally, you will learn to recognize when your breathing is just starting to flare up so that the action you take stops it. The idea here is to help you treat yourself at home so you do not need to seek help. However, should you need it, the plan will also help you decide when to call your doctor, and when to call 911.

5. Bronchial Hygiene: Since COPD is a condition that may result in increased and thick secretions blocking your air passages, you will need to learn methods of clearing these from your air passages.

6. Breathing techniques: There are certain breathing techniques that may help you to keep your lungs open. One technique commonly taught is pursed lip breathing, where, when you are having trouble breathing, you purse your lips and slowly exhale. You may also be taught some methods that should help you create a better cough.

7. Pulmonary rehabilitation: This is a program made just for COPD patients to help you keep in shape. It is a proven fact that if you keep your heart and lungs strong, you are more likely to stay healthy. Upon discharge, arrangements should be set up for you to participate in such a program, with transportation arranged.

8. Follow-up interview: This might include a visit to your home or a phone call by a caregiver. The purpose is to make sure you are feeling okay, but it is also to answer any questions that might have developed since your discharge. For instance, there have been instances where patients kept returning to the hospital with a COPD flare-up, and upon visiting the patient's home it was realized the nebulizer or oxygen equipment wasn’t working right. So, this is our opportunity to keep an eye on you, making sure you’re doing alright post-discharge.

9. Follow-up doctor visit: Not only will staff schedule you a follow-up appointment with your doctor in 2-10 days, they will make sure you have transportation. This is the type of thoroughness that is essential to helping you control your COPD.

10. Discharge instructions: Last, but not least, you will be discharged. In the past this may have been the only education you received during your visit, but no more. Now, by the time you are ready to go home, you will have already been presented with any wisdom you need to live with COPD, and had time to hash it over in your head and review it with your caregivers. Ideally, anything you hear at the time of discharge will simply be a summary of what you already know.

Bottom line: It’s surprising it took a government initiative to focus on preventing COPD readmissions, as studies clearly show they are both unnecessary and costly. Likewise, it’s impossible to know what methods individual hospitals will create; although, one might imagine that any efforts in this regard will help COPD patients live better lives.

What do you think of Obamacare?

The Patient Protection and Affordable Care Act (PPACA), a.k.a. Obamacare, has forced upon hospitals a new program that will punish hospitals as far as reimbursement is concerned for any COPD patient who is readmitted within a two week period of being discharged. This does not include emergency room visits, only hospital admissions. 

This provision of the law was made with the idea of giving hospitals an incentive to pay special attention to their COPD patients to make sure they are educated about their disease, are on all the best medicines, and their are follow up appointments made to make sure the patient is taking his or her medicine. 

Other people disagree with that claim. They say that the provision was implicitly placed into the law to give CMS an excuse not to reimburse hospitals for said patient.  There is some credibility to their claim considering it does not matter what the patient is readmitted for: heart failure, COPD exacerbation, high blood pressure, low blood pressure, rickets, a hand nail, or anxiety.

These patients have a high rate of morbidity, and it's nearly impossible to know, even if the physician is being proactive, what ailment might plague that patient in a day or two.  Our hospital, and every other hospital I've ever worked for, has had a steady flow of COPD patients, many who are admitted often enough to become good friends with the hospital staff.  With this law, there are many hospitals that will go under. 

There is also a stipulation in Obamacare to make it easier for hospitals to merge, and many hospitals in the geographical region where I live have merged since Obamacare went into effect.  Some of my friends claim that these provisions, and the entire Obamacare law, was implicitly put into place with the intention of causing the health care system to fail.  When the health care system fails, people will come calling to the government to bail them out with universal health care. 

With most hospitals already joined into large conglomerates, taking away competition and the incentive to lower prices, the government will have fewer companies to combine.  When Obamacare fails, they say, so too will the health care system. 

I think it was worded best by a physician friend of mine:  "The government caused the mess with health care by becoming involved in it in the 1960s, before that time it was a pay for service system, and the cost of health care was low.  Since the 1960s, health care costs have increased, making it so most people cannot afford it.  So then career politicians, the same people who caused the problem, purported to fix it with even more government. This is a system set up for disaster." 

I personally, as my regular readers already know, am among the 54-58% of Americans opposed to Obamacare.  What do you think of it?  Be nice. 

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.  

My solution to fixing the healthcare industry

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

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

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

What is the current trend?

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

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

1. Order sets
2. Protocols

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

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

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

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

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

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

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

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

Advantage of protocols:

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

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

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

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


Reasons your hospital might choose not to use protocols:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What are the current trends? 

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

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

The result of this is the following:

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

What is the best approach to take in the future?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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