Surgical Diversions » medicine

Baby Steps to Healthcare Reform

Andy — Wed, 21 Oct 2009 15:46:10 +0000

Since I’m sure all members of Congress will have the opportunity to read and comprehend the entirety of whatever is the current healthcare legislation the following small steps to improve the situation will be meaningless. I have 3 simple proposals that could fit on a single page. Heck, it fits in a single post.

Eliminate pre-existing conditions as a reason to deny insurance.
Allow insurance companies to sell in any market in the US.
Malpractice reform — Loser Pays

I think the first 2 are self evident so lets focus for a moment on the third.

Loser Pays

What I mean is that all legal fees will be paid by the losing party to the litigation. This would include naming a doctor in a med mal suit and then dropping them from the suit.

You see, just because a doctor gets dropped from a suit doesn’t mean that his malpractice carrier doesn’t incur costs. In fact, it’s usually about $20K to defend a suit that is dropped.

Interestingly, anytime a doc is dropped from a suit, they must sign a release stating that they will not sue the plaintiff’s attorney. I once tried not to sign this but my lawyer told me he’d never seen it done before.

Yeah, I know, it doesn’t solve many of the problems facing our healthcare industry. But I bet it would improve the situation with minimal effort.

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Nationalized Healthcare and the Free Market

Andy — Thu, 05 Mar 2009 21:33:06 +0000

Nationalized/Universal healthcare will happen. Obama ran on it and he intends to deliver. What’s more, I can see a manner in which the country will flock to it under the current free market insurance system.

First, the federal government will expand Medicaid to cover the unemployed and uninsured. Second, the Congress will pass some law that mandates employers to provide health insurance for not only full-time employees, but part-time employees too.

Oh, by the way, the federal government will also make available a government-sponsored insurance plan to compete with the other available HMO and PPO choices. Of course the government plan will cost you (the employer) 40-50% less than the next most expensive plan.

You (the employer) will offer your employees the government plan as per the terms of the new law and they (the employees) will have the option of spending almost twice as much for a different commercial plan. I don’t really expect many employees to avail themselves of the opportunity to spend more money for little perceived increase in services.

Soon 80-90% of the country will be on the government plan and physicians and hospitals will effectively have a single payor.

Welcome to nationalized/universal healthcare.

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Appendiceal Duplication

Andy — Fri, 13 Feb 2009 23:31:59 +0000

I had a very interesting case the other evening. First, for the uninitiated, it’s usually a bad sign when the surgeon says it was a very interesting case. Generally routine is best.

Anyway, nice 50ish year old female with few days of diffuse abdominal pain now localizing to RLQ. Nausea and vomiting. Anorexia. Acute peritoneal finding in RLQ with percussion. Outside CT reportedly showing acute appendicitis.

I look at the patient. Story is great. Almost sounds like she’s read Cope. I take her to the OR. I feel a mass on exam after induction. Sorry guys I do open appys. 3 cm McBurney incison and mobile the cecum. There’s a 5cm mass but seems to be mobilizing from the superior aspect of ascending colon not inferiorly. Anyway, I deliver what appears to be an appendiceal phlegmon into the wound and fire a GIA-55 across its base. The base is along a tinea adjacent to the ileocecal valve. Doesn’t look like there’s any free perforation so I irrigate and start to close.

I’ve got a couple of clamps on the peritoneum and then I see a relatively normal looking appendix starting at me. Naturally it comes out.

Patient home in less than 24 hours.

Path report shows:

appendix - acute appendicitis
pericecal diverticulum and phlegmon - appendiceal duplication with acute perforating and gangrenous appendicitis

Comment on path report is duplication based upon the presence of circular muscle around the diverticulum, its location and gross appearance.

I’ve never seen that one before. All I can say is I’m glad I saw what I considered to be a relatively normal appearing appendix prior to closure.

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General Surgery in NY

Andy — Fri, 12 Dec 2008 17:11:03 +0000

So here I am in NYC at the American Society of General Surgeons clinical meeting. The program is correctly termed controversies as I’m quite certain many of the described treatment paths would cause you to fail your oral boards.

Of note is that it seems that most of the attendees have been in practice for over 10 years. The lecturers are mostly all teaching faculty at the local ivory tower and they seem to use less invasive treatment and laparoscopy far more than I would.

For example, laparoscopic closure of diverticular perforation with irrigation and drainage but no resection. Not sure I would ever do this open so I can’t see why it’s an acceptable treatment plan laparoscopically. Maybe I’m just old fashioned.

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Doctors Cannot Withhold Care From Gays

Andy — Tue, 19 Aug 2008 00:12:23 +0000

The California Supreme Court has just handed down a ruling. Discrimination is bad, I get it and it shouldn’t happen.

I’m not going to argue the merits of the case but I’m curious to know if anyone else thinks that this decision might be interpreted to mean that physicians no longer can say no to anyone for any reason.

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Saving Medicare?

Andy — Mon, 07 Jul 2008 22:02:18 +0000

I’ve been getting to the point lately that the system needs to undergo some catastrophic collapse before it will get better.

As the Happy Hospitalist says:

Here’s my position. It’s time to let the cuts stand. Congress should not reverse the 10.6% cuts that began in July 1st 2008. And here’s why: The financial mess we are in now is entirely a result of third party interference of the doctor-patient relationship.

He’s absolutely correct in the assessment that the doctors are to blame. If only we didn’t prostitute ourselves by signing some of these outrageous contracts it might be better.

I say let the cuts go through. Then soon, both doctors and hospitals will soon realize that they cannot afford to take care of patients for the contracted rates and might actually grow the brass ones to cancel all of their contracts, including Medicare.

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QuickClot

Andy — Fri, 25 Apr 2008 17:18:49 +0000

Boy I’d really like to try some of this QuickClot stuff in the OR. I think it would be great to use for a planned second look.

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Ambulance Chaser

Andy — Thu, 24 Apr 2008 22:48:52 +0000

Yes Virginia, they really do exist.

So here’s the story. The family of a trauma victim, a motor vehicle collision, is met outside the ICU by a lawyer saying that the particular vehicle in which they were traveling has a defect and he and his firm would be happy to represent them. The family never contacted this lawyer, or any lawyer for that matter. He just showed up out of thin air.

Does it really matter if the driver of the vehicle is intoxicated and the vehicle is traveling at over 100 mph?

Apparently not to this attorney.

Minh T. Nguyen
Jeffrey S. PoP & Associates
Beverly Hills, CA
minhnguyen@poplawyer.com

By all means, send him and email and let him know what you think if his ethics and behavior.

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Never Events

Andy — Fri, 18 Apr 2008 21:52:46 +0000

In October, 2007 CMS (Medicare) proposed a list of eight preventable conditions that result in a prolongation and increase in cost of care to the hospitalized patient. These are what CMS terms never events. CMS is trying to couch this in terms of patient safety but if you look at the list, there are only a few of these items that are 100% preventable. It’s really less about patient safety and more about how CMS can cut reimbursement. Medicine isn’t an exact science and expecting it to act as one is irrational.

On April, 14 2008 CMS proposed additions to their never event list…

The HAC provisions in Medicare regulations required hospitals to begin reporting on their Medicare claims on October 1, 2007, whether certain specified diagnoses were present when the patient was admitted. The first eight conditions, which were selected last year because they greatly complicate the treatment of the illness or injury that caused the hospitalization, resulting in higher payments to the hospital for the patient’s care by both Medicare and the patient, were:

Object inadvertently left in after surgery

Air embolism

Blood incompatibility

Catheter associated urinary tract infection

Pressure ulcer (decubitus ulcer)

Vascular catheter associated infection

Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery

Certain types of falls and trauma

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later this year. The list in the proposed rule includes:

Surgical site infections following certain elective procedures

Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)

Extreme blood sugar derangement

Iatrogenic pneumothorax (collapse of the lung)

Delirium

Ventilator-associated pneumonia

Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)

Staphylococcus aureus septicemia (bloodstream infection)

Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

Some of the biggest problems in this list are twofold.

Who’s to define things like derangement and what constitutes delirium?
If these are never events can someone please tell me how to avoid them 100% of the time?

All invasive procedures, and I include having a foley and being on a ventilator as invasive, carry risk. The risk is small but it exists and it is not zero. I seems what CMS is seeking to do is to transfer the risk from the receivers of medical care to the providers of medical care.

Personally, I think this list will ever expand and eventually hospitals and physicians will cease to be paid for any care arising out of these never events. When that starts happening, watch out. All of a sudden it will not make financial sense for hospitals and doctors to participate with Medicare.

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Immediate Breast Reconstruction and CMS

Andy — Tue, 15 Apr 2008 00:40:41 +0000

OK, first off this part of my practice is over and I’ve moved on. But let me relay a story of how CMS (that’s Medicare for the uninitiated) works.

I was asked by one of my local breast surgeons if I would see a patient for immediate breast reconstruction with implants. The patient was to undergo bilateral mastectomies. No problem. I see the patient. Surgery scheduled and goes fine.

I submit my claim forms to CMS and I only get paid for the consult. They say the surgery (immediate reconstruction with implants) is only billable as an add-on to a procedure done by me. This is absurd. I didn’t do the mastectomies. It seems that CMS can write their own rules along the way. My coder followed all the proper rules according to the CPT Code books.

It’s now over 6 months later and it looks like I’m going to have to write off the $400 that Medicare is usually willing to pay for this procedure. Yep, you read that correctly. No offense to all those women with breast cancer needing and wanting this combination of procedures but I can tell you now that at this fee schedule and with this ease of reimbursement I surprised that anyone is willing to do immediate breast reconstruction. This clearly has not been worth my time and energy, even to get paid.

Side note: If you think the solution to healthcare is to let the government run it; I wish you luck in getting any doctors to care for you.

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