Sunday, September 21, 2014

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know -

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

He was blindsided, though, by a bill of about $117,000 from an "assistant surgeon," a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.

"I thought I understood the risks," Mr. Drier, who lives in New York City, said later. "But this was just so wrong — I had no choice and no negotiating power."

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.

The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier's case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion.

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Wednesday, September 17, 2014

Panel Urges Overhauling Health Care at End of Life -

The country's system for handling end-of-life care is largely broken and should be overhauled at almost every level, a national panel concluded in a report released on Wednesday.

The 21-member nonpartisan committee, appointed by the Institute of Medicine, the independent research arm of the National Academy of Sciences, called for sweeping change.

"The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life," said David M. Walker, a Republican and a former United States comptroller general, who was a chairman of the panel. "The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly."

Many of the report's recommendations could be accomplished without legislation. For example, the panel urged insurers to reimburse health care providers for conversations with patients on advance care planning. Medicare, which covers 50 million Americans and whose members account for about 80 percent of deaths each year, is considering doing just that, prompted by a recent request from the American Medical Association. Some private insurers are already covering such conversations, and many more would if Medicare did.

But some recommendations — like changing the reimbursement structure so that Medicare would pay for home health services instead of emphasizing hospital care, and so that Medicaid would provide better coverage of long-term care for the frail elderly — would require congressional action.

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Monday, September 15, 2014

$1.43 of every $100 in America goes toward hospital administration - Vox

America spends a lot of money on the paperwork that makes hospitals run— $218 billion per year, to be exact. That works out to 1.43 percent of the entire American economy is spent on hospitals' administrative costs. Of every $100 spent in America, that means $1.43 is going toward the billing specialists and schedulers that make hospitals here work.

Hospital administration has grown as a percent of the economy over the past decade, from 0.9 percent in 2000 to 1.43 percent in 2012, a new paper in the journal Health Affairs shows.

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Saturday, September 13, 2014

A Life-Saving Salt Binge -

"I can't . . . do this . . . anymore," the young man stammered to his father. The two had been working together in the father's heating-and-air-conditioning business for the past several weeks, ever since the son was fired from his job. His boss said that he never seemed to feel like working. And it was true. He was tired out by the tiniest effort.

The father turned to his 19-year-old son and saw his head slumped on the worktable. His eyes were empty. "My hands," he whispered through blue-tinged lips, "they are so cold." His fingers were also blue, although it was warm in the building. The father hurried over and half-carried him to the car.

At home in their small Oklahoma town, his wife, too, was frightened. "Take me to the E.R.," her son breathed. "I'm scared." By this point they'd been to the emergency room many times. "If they can't figure out what's wrong this time," the man told his wife, "we're taking him to Tulsa."

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Monday, September 8, 2014

When It's the Doctor Who Can't Let Go -

Sometimes it's the doctors, not the families, who can't let a patient go.

My elderly patient had lived much longer than seemed possible at the time of his cancer diagnosis. Ten years later, though, his relapsed lymphoma had become medically unstoppable.

The palliative care team was called in to manage his growing confusion and discomfort, and to discuss what we call "goals of care." That's what palliative care does: It focuses on keeping symptoms under control for the seriously ill and, for patients who can't be cured, addressing how they want to die, including the option of hospice care. Now that this patient's disease could not be restrained, what did he want? He could no longer answer, but his wife and son, sad but cleareyed, chose to stop all treatment aimed at curing his cancer.

Hearing this, his oncologist, standing beside me at the nurse's station, cried, heartbroken that her patient of so many years would not rally one more time.

That evening, though, the patient's primary care doctor came to the hospital, seeing himself, it seemed, as the cavalry. There was hope yet, he said: The patient needed rehab to make him strong enough for more chemotherapy, not palliative care and hospice. So the patient — disoriented and unable to speak — went to an inpatient rehabilitation unit. He died there, a few weeks later.

I'm sure the primary care doctor meant well, but there's no question that his actions made the situation worse because he deprived the patient and his family of comfort at the man's life's end. And this was far from the first time I've seen something like this happen. Such situations arise in part because modern health care still embraces a false dichotomy between curative treatment and palliation, between making a patient healthy and relieving his or her pain.

Palliative care itself suffers from an identity problem, in that many people equate palliation with hospice — i.e., end of life. This mistaken association can make a palliative care consultation feel like a death sentence to even the most open-minded clinicians, patients and family members. Striving for a cure is historically seen as a unique pathway that restores health; easing suffering is a separate, non-curative path that ends with the patient dying.

And it's true that palliative care does offer symptom management to patients who are expected to die soon, as my lymphoma patient was. But it is more than that: It also helps patients with long-term illnesses like congestive heart failure and chronic obstructive pulmonary disease, people who are expected to live with their illness, but need careful managing of their symptoms. If it becomes clear that a patient receiving palliation along with curative treatment will not survive her illness, then the palliative care group works with the medical team to help her make the transition to hospice and help her decide how to spend the last of her time on earth.

Palliative care can extend life, too. A well-known 2010 New England Journal of Medicine paper co-written by Jennifer S. Temel, an oncologist at Massachusetts General Hospital, established that patients with a certain type of lung cancer who received early palliative care not only reported better quality of life and reduced symptoms of depression, but also lived longer than patients who received only traditional oncology care — a result that has since been found with other forms of cancer.

Often, though, the palliative care team is consulted late in the illness, as was the case with my patient. One reason is money: To put it in the crass language of hospital accounting, palliative care is de-incentivized. It saves hospitals money by reducing costly and often futile care at the end of patients' lives, but earns little compared with the expensive drugs and scans used in curative treatment.

But another barrier is the attitude of physicians themselves. Many oncologists, focused on keeping patients alive for as long as possible and hoping, always, to beat the odds, find it hard to discuss what might happen if they don't.

It was the same with my patient's oncologist. Hearing about the move away from palliation to rehabilitation, she sounded relieved. "Well, if he goes to hospice he'll just die," she said — as if there were another alternative. She knew better than anyone that our bag of chemotherapy tricks was empty, but facing that reality proved too hard.

Had the palliative care team been consulted earlier, it could have worked with the primary care doctor, the nurses on the floor and the oncologist to understand and communicate the patient's wishes over a period of time, perhaps even when the patient could still speak for himself. Instead, the patient got lost in the back and forth, as did his family, caught between the rock of his imminent death and the hard place of arranging for rehabilitation that was presented as his salvation, but offered no real help or comfort.

Doctors face a difficult paradox: Their job is to keep patients alive, but part of that means keeping at bay the dark awareness that everyone dies. Because doctors are supposed to cure, efforts directed elsewhere, even palliative care, can feel like a surrender. But their job might actually be easier if they found a way to better use what palliative care can achieve for patients, and not only at the end of life.

Physicians also need to recognize that there are occasions when the patient's fate is not, in the end, the doctor's work. Every patient deserves care on his own terms, for each patient's life, and death, is his own.

Theresa Brown is an oncology nurse and the author of "Critical Care: A New Nurse Faces Death, Life, and Everything in Between."

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Sunday, September 7, 2014

Friday, September 5, 2014

Why Do Doctors Commit Suicide? -

Two weeks ago, two medical residents, in their second month of residency training in different programs, jumped to their deaths in separate incidents in New York City. I did not know them, and cannot presume to speak for them or their circumstances. But I imagine that they had celebrated their medical school graduation this spring just as my friends and I did. I imagine they began their residencies with the same enthusiasm for healing as we did. And I imagine that they experienced fatigue, emotional exhaustion and crippling self-doubt at the beginning of those residencies — I know I did.

The statistics on physician suicide are frightening: Physicians are more than twice as likely to kill themselves as nonphysicians (and female physicians three times more likely than their male counterparts). Some 400 doctors commit suicide every year. Young physicians at the beginning of their training are particularly vulnerable: In a recent study, 9.4 percent of fourth-year medical students and interns — as first-year residents are called — reported having suicidal thoughts in the previous two weeks.

Hospitals and residency programs recognize the toll residency takes on the mental stability and physical health of new doctors. In 2003, work hours were capped at 80 hours a week for all residency training programs. Residents are provided confidential counseling services to help cope with stress. My residency program offers writing workshops and monthly reflection rounds. We have a wellness committee that organizes social events such as bonfires on the beach and visits from therapy dogs.

But despite these efforts, people still fall through the cracks. While acute stress, social isolation, pre-existing mental illness and substance abuse may be obvious factors to consider, we must also ask if there are aspects of medical culture that might push troubled residents beyond their reserves of emotional resilience.

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Wednesday, September 3, 2014

Humiliation tops list of mistreatment toward med students | MSUToday | Michigan State University

Each year thousands of students enroll in medical schools across the country. But just how many feel they've been disrespected, publicly humiliated, ridiculed or even harassed by their superiors at some point during their medical education?

Recently, researchers at Michigan State University were the first to analyze 12 years worth of national survey data from the Association of American Medical Colleges, or AAMC, questioning graduating students about their medical school experience during the clinical portion of their education.

They found that up to 20 percent of students reported some form of mistreatment each year.

Additionally, only an average of 31 percent of those who indicated they were mistreated actually reported the incident to faculty or university administrators.

Public humiliation or belittlement topped the list, with sexist remarks and requests to do personal favors coming in second and third, respectively.

The research can be found online in the journal Academic Medicine.

Although the survey definition of mistreatment has evolved over the years, more recently, the meaning has focused on specific behaviors such as being disrespectful or humiliating others, as well as sexual, racial/ethnic, gender and sexual orientation mistreatment.

"The goal was really to uncover the nature of the problem and better understand what needs to be done to change these experiences," said Marsha Rappley, dean of the College of Human Medicine at MSU. "The feeling of mistreatment often happens in stressful environments like a clinical setting involving patients, and it's up to everyone to respond in ways that are respectful."

Recently, both the AAMC and the American Medical Association have acknowledged that mistreatment is an issue and should be addressed.

"If our students are experiencing these negative feelings, then everyone else is probably feeling uncomfortable as well," Rappley said, who is also the chair for the AAMC Council of Deans. "Not everything is polite and clean all the time, but if we think of the whole notion of education as treating people respectfully while giving them good feedback on their work, this could help build resiliency in moments where tempers may flare."

Rappley also said that proper safe reporting mechanisms are needed to ensure that students feel protected when reporting an incident.

"Across the country, med schools continue to look at ways to improve safe reporting practices whether it's using an ombudsman or implementing an online system," she said. "We all may be using different approaches, but ultimately it's about what makes the students feel safe."

By having serious discussions about specific behaviors that are perceived as disrespectful and offering up tools to help manage conflict and feedback, Rappley said that resident physicians and students could work even better as teams and help each other in intense situations.

"Collectively, we can figure out a solution," she said.

Saturday, August 30, 2014

What Doctors Can't Do -

Mary White makes house calls. She's a senior community health worker in Philadelphia in the IMPaCT program at the Penn Center for Community Health Workers. She has 25 of the University of Pennsylvania Health System's toughest patients. It's her job to help them set health goals and, step by step, carry them out.

One of her patients is Grover Wilson, an engaging man of 56 who weighs 515 pounds. Wilson had long been athletic and sociable, the organizer of a long-running community volleyball game. But depression and an injury led him to gain weight. Now he lives in a tiny basement apartment packed floor to ceiling with boxes of his possessions, and is trapped and isolated by his weight.

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