Why Health Care Tech Is Still So Bad – NYTimes.com

I interviewed Boeing’s top cockpit designers, who wouldn’t dream of green-lighting a new plane until they had spent thousands of hours watching pilots in simulators and on test flights.

via Why Health Care Tech Is Still So Bad – NYTimes.com.

Let me tell you about my favorite provider. She faces me, each of us at right angles to each other at her computer desk, and writes everything down on a yellow legal pad. She goes system by system, like a quality shift hand-off report. We use the computer to review labs. She never prints out “educational information.” I get handwritten notes and web addresses as needed. She talks and writes fast, with military precision (active Air Force) and maintains eye contact. She pauses and sits back in her chair to look at me when she senses I’m holding back or is working to figure out a complex set of problems.

Her pad is on the table between us, and I can see everything she is writing. I sometimes correct or edit it. It is never longer than a page.

Duplication of work you say! Well, with Alice there is no time lost, no errors made by the anguish of garbage in garbage out. We draft it together. Then it goes in the permanent record.

The big hurdle, the big secret… she works at NIH. Where time and dollars aren’t the exact same thing.

Just a thought. PSST she is also a nurse by training <3.

From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica

Under federal law, nonprofit hospitals must offer care at a reduced cost to lower income patients, a service often called charity care. But crucial details—how poor patients need to be, how much bills are reduced, and how policies are publicized—are left to the hospital. The Affordable Care Act empowered the IRS to set new requirements for publicizing this information, but those have yet to be finalized.

If a patient can’t pay and Northwest obtains a judgment, it’s too late. Hospital policy says once the collection agency has “incurred legal fees” on a case, the patient is ineligible for charity care, regardless of earnings.

via From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica.

I’m breaking my break because this spectacular piece of investigative journalism is really all I wanted for Christmas. This is an issue that makes the individual mandate, as Salt-N-Pepa might say, very necessary.

Charity care/financial assistance is available at my academic health system. Patients qualify for financial assistance based on income and payments are calculated with a sliding scale. They may owe nothing, a percentage of the total, or be put on a payment plan. This article uncovers that the criteria for how a patient finds out about or applies for or qualifies for financial assistance is largely left up to the hospital. As a recent cancer patient with massive bills but good insurance and 2/3 of a graduate degree from the academic health system where I received treatment, I still messed up paying the hospital. Medical billing is incomprehensible and damn tricky. Adding the difficulty of applying for financial assistance on top of your stack of bills from many non-communicating entities is the real cherry on top of the garbage sundae. No, it’s an additional garbage sundae on top of the garbage sundae. No, it’s just a pile of garbage.

Bottom line: Access to aid is limited. Barriers to aid are significant. And, most shockingly to me, once you have been sued successfully by the hospital, you no longer qualify for aid. *MIND EXPLODES*

A complete novice refutes the statements of a qualified professional

Why I oppose payment reform- Alan Weil, Health Affairs Blog

Interesting article but I’ve got counterpoints ’cause I’m a student with more opinions than I have a right to and am cocksure enough to comment on statements made by the editor-in-chief of Health Affairs.

Summaries of his points are in bold. Please read his article regarding opposing payment reform in health care to get his full and well considered arguments.

The current workforce is unprepared for a model that doesn’t reward for filling beds, doing tests:

  • There are tremendous rewards for innovation in the field of health care right now! These folks have seen the model they came up in become more and more of a frustration to them and their patients. Everywhere I look, from floor staff to executives, the feeling is very get on the train folks, we’re heading to the future. Alternately: retire, find a different gig, or learn to cope with the new requirements. People are learning to become successful and you better believe that new leaders are prepared for these challenges.

Any money saved will move its way to the top (health systems, hospitals) and workers on the front lines won’t see any benefit:

  • Maybe. Based on the ones I’ve spoken to I don’t think dietitians, social workers, and community health workers are expecting a huge raise. But many hospitals are dramatically understaffed in these positions to the point that they are unable to perform the core competencies of their roles. As these workers bring forward evidence showing the financial benefit to hospitals of having, say, a full time dietitian to improve nutrition and reduce pressure ulcer rates, hospitals will have a financial reason to staff these professionals.

There is no current evidence to suggest that payment reform will achieve the goals we need it to achieve, and there is some evidence to the contrary.

  • Okay, your evidence is good here, but early days! There is evidence showing smaller programs put into place are already saving money such as reduced re-admissions with heart failure transitional care (article unfortunately not open access, DOI: 10.1097/JCN.0b013e31827db560).

The original rationale offered for payment reform doesn’t match the current objectives.

  • I think it does match that original rationale (to pay for quality rather than quantity of care). Health systems do not have an incentive to stop a practice for which they are getting reimbursed. We know patient falls are bad thing for a patient, but more days in the hospital to recover from your now necessary hip surgery is money in the hospital’s pocket. Why would you spend money reducing falls to stop yourself from making money? When hospitals are told they won’t be getting paid for the consequences of that fall innovations in care happen and adverse event rates go down. Of course we need metrics to quantify success and failure, and because these rule changes are rolled out in a way that intends to give health systems time to introduce new measures without sinking the rusty old tub. And certainly hospitals with higher acuity patients are getting the shaft, hence even more complex models to try to even the playing field.
Payment reform poses a risk for the growing understanding of the importance of patient-centered care (What is an appropriate value formula when patients differ in their goals for recovery).
  • The value formula is simple: “Patient, are you satisfied that you have reached your stated goal of x?” If your 95 year old patient states his goal is successfully completing the Marine Corps Marathon pain-free then you’ve got to use your negotiating skills to get him back on this planet. The point is to set patient centered appropriate goals before undertaking invasive or potentially harmful interventions.

How Obamacare Lowers Your Property Taxes – Forbes

How Obamacare Lowers Your Property Taxes – Forbes.

Key point:

A snapshot of this trend can be seen in Cook County, Illinois, where the public hospital system has seen a decrease in patients who cannot pay their bills thanks to the law’s expanded Medicaid health insurance for poor Americans.

Long and short–Medicaid expansion offers insurance to people in poverty, which is a means to provide payment to public hospitals and health systems that are mandated to give care regardless of an individual’s ability to pay.

Here’s the AHA reports on uncompensated care through 2012 for those who want numbers (before Medicaid/marketplace).

PS- I love working for a public health system because it is the closest thing I’ve seen to fulfillment of that phrase under Lady Liberty’s feet. That’s corny as hell, right?

Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola — NEJM

Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola — NEJM.

Please read this because we have to remember our history to learn from our history.

Various politicians called for quarantining of anyone who tested positive for HIV, and commentator William F. Buckley infamously penned an op-ed in the New York Times saying that “everyone detected with AIDS should be tattooed.”

Let us pump our collective brakes.

I mentioned in an earlier post that as an infectious disease, Ebola is a slam dunk for a country with a robust public health system. It poses far fewer challenges then, say, a really bad respiratory virus. This technically-but-really-not-an-epidemic has shown that there are some weakness in public health. Particularly in leadership. I’ll leave you with a parting tweet:

Mississippi, Burned – Sarah Varney – POLITICO Magazine

The previous post is mostly head, but this story is the heart. Atul Gawande, to whom I have a small altar in my closet, says it is essential.

Mississippi, Burned – Sarah Varney – POLITICO Magazine.

Falling into the gap.

Midsummer 2012 the supreme court upheld the majority of the provisions of the ACA, and people like me who had made every major life decision since turning 22 based on where I could get health insurance (hello preexisting conditions) breathed a deep sigh of relief, wept one tear, and took a long nap.

Fast-forward to now and the part of the decision that made it optional for states to decline to expand their Medicaid programs is taking it’s toll. In states where Medicaid was not expanded, the majority of adults making under 100% of the federal poverty level have no options for health insurance. They do not qualify for the incentives available through health insurance exchanges. They cannot afford private coverage. Unethical.

Just for fun, here’s the states by political party in 2013 (source):

governors 2012

Uninsured people will still use emergency departments and be inpatients, putting hospitals in a tough position as part of the ACA takes away the pre-ACA measure of DSH (disproportionate share hospital) funding (federal dollars) that hospitals needed to account for the absence of reimbursement from these uninsured folks. DSH dollars were supposed to be replaced by payments from Medicaid insurance dollars. In states that did not expand Medicaid, DSH dollars are being replaced by zero dollars. IMHO this is on the state–but Obamacare takes the knock. From the patients denied access to affordable care, the hospitals that are in dire straights financially, and the communities that are losing their hospitals (and often largest employers) as they just can’t stay afloat.

I’m working up posts describing how one qualifies for Medicaid in non-expanded states, the state incentives offered by Medicaid expansion, and the burden on local communities with large numbers of uninsured people in poverty. This is a mire, but I can’t think of one more worthwhile to wade through. PARTY TIME!

Women in medicine

Consider this post one of innumerable on women in the medical field.

via www.envisioningtheamericandream.com

The MD-RN dynamic is old saw (sidebar–the no. 1 problem with RN retention at my health system is “I need to move to find a man.” Take heed undergrads, the be-a-nurse-marry-a-doctor plan is not working out). As health systems move toward the team model of care we nursing pups are told that the doc is not your boss. Administratively speaking this is true. In practice getting chewed out by a doc is one of a new grad’s greatest fears. The power differential is entrenched.

One of my classmates brought up a super prescient question this past semester while we had the ear of an old school doc who battled it out in the 1960s as the only female member of her med school class. What is going to happen to MD-RN relationships now that near 50% of med school grads are women? The doc sidestepped the question (which was, of course, a landmine), but did share a thought worth repeating: in the US, as the prestige of being a doctor declines the number of women entering the profession increases. This isn’t coincidence. Either as prestige drops more women are viewing medicine as something that they are capable of OR as more women become doctors the stock price on an MD drops (see teachers, secretaries). To both of those possibilities I give a big eye roll-y OH BROTHER.

Ebola, Epidemiology

So far this semester of nursing school we’ve spent less than an hour talking about Ebola in America. There is legitimate concern for good guidance on PPE. CDC guidelines have been in evolution, which makes health care workers nervous.

PPE(NY Times)

BUT, epidemiology views the population as the patient. And right here right now we are looking pretty healthy. Ebola is an epidemiologist’s dream since you are not contagious until you are showing symptoms (no latency), and the course is long (outbreaks spread from patient to patient relatively slowly). It is fairly easy to find people who may have been exposed and quarantine them before they have a chance to pass along the virus. Contrast these characteristics with those of the flu, and you can see why the CDC isn’t sweating too much.

Also, what does this even mean? No.
cnn ebola

Communicating Electronic Medical Records (EMRs)

So you’re going to need to sign this release and we’ll send your records over to the specialist!

Sure. Cause that works ever.

There are any number of reasons why the health care industry has been painfully slow to adopt electronic record keeping (1-25 are money). Since 2009 and the passing of the HITECH act, which gave back $26 billion in incentives for implementation of EHRs with “meaningful use” the majority of hospitals and health systems have gotten on board with the tech. This is a good thing.

But back to you trying to get your god forsaken medical records from your primary physician across the street to the orthopedist. Here is the current option:

Nice.  Meaningful use mandates the EHRs COMMUNICATE WITH EACH OTHER as of 2014. Which would have been great. The mandate has been pushed back year by year,  but in the fullness of time we will get there. The barriers are many (1-25 also money) and the rest have to do with creating the tech that will bridge these records using a multitude of platforms. I will get back to you on this after I get my IT degree. As a nurse I would appreciate having the prenatal records of a laboring woman at my disposal. In the ICU it’d be nice to know if my patient is allergic to penicillin, had a stroke last week, or is a type 1 diabetic.

The stakes may be lower in the clinic but for heaven’s sake let me take a bat to the fax machine.