I. Funding for Residency and Internships
Upon graduation from medical school a medical student is not able to practice medicine. They must fulfill additional training as internship (first year out), and residency program. Students apply, and are placed at various programs through the match, a very complex process. Some students do not place. They are notified the day prior to announcements on match day and have to scramble to find a place to train.
All of this training is funded by a federal grant to pay the salaries of all these individuals in training. The amount each year is graded according to level of training. There are small pay raises, but the salary is low and the work hours long enough to casually be considered slave labor. In my day, I worked seven days a week, sometimes forty hours straight with no sleep, two to three times a week. One hundred twenty hour workweeks were typical, although eighty was the norm. The eighty hour workweek has been put in place as a direct result of the Libby Zion case in which an over-tired resident gave demerol to a woman who was on an antidepressant that has a fatal reaction when the antidepressant and demerol are mixed.
There are no work hour restrictions on graduates of the training, attending physicians, the working doctors you see every day who have completed the training.
II. DEA and Schedule II and III Medications
All physicians must apply for a federal DEA number from the Drug Enforcement Agency. This bureau assigns a DEA number to each doctor, allowing them to write prescriptions. There are triplicates, special prescription pads for the dispensing of controlled substances such as dilaudid or morphine. Triplicates used to be actual pieces of paper but now they are an entire computerized system that goes straight to the pharmacy. All controlled substances must be accounted for drop per drop in the hospital. I have a balance sheet with all of my anesthesia narcotics and agents that can make someone high. If my records and the balance sheet do not match, I have to write a note in the medical record. A pharmacy that does not correct miscounts will get a twenty-five thousand dollar fine.
Medicare is the kingpin of all insurance around. Medicare pays competitive rates to just about all specialties besides anesthesia. Anesthesia reimbursement is twenty cents on the dollar that we bill. Despite the high rates members pay into the Medicare system, the doctors are not seeing that much. A long case on a fragile senior that takes much vigilance and is a technical challenge will pay less than a quarter of the value that is being given by my services. A healthy D&C with good insurance will pay two to three times as much, and there is very little risk to the patient from the anesthesia.
Another unusual thing about Medicare is that it stipulates direct payment to the provider. It gets wired into a bank account, but it also has authority to withdraw money without notice to adjust a payment. I still have to pay a seven percent billing fee to my company on all funds given. It just comes out of the other insurance reimbursements. It feels like total Big Brother to me.
However, despite the low reimbursements, Medicare makes up in volume. Hospitals will do everything to get accredited and win a Medicare contract. Unfortunately, Medicare is playing hard to get. For example, a major component in primary care is capitated care. Medicare will pay one lump sum to a provider for all primary health care coverage for a year in advance. It is like a game--if the doctor keeps you healthy, the doctor gets to keep the money. And, to raise the challenge, payment is contingent upon key words in all medical documentation. It is not enough to say, 'massive blood loss'. The physician must write the words, 'symptomatic hemorrhagic anemia'. It is this way for just about every disease state. And there are billing and coding specialists combing through all of the paperwork making sure the physicians are in compliance, in other words, writing those special words to be awarded payment for their services.
And the latest? Any and all medical complications not reimbursed. That can be a lot of care for free. Complications happen--medicine is not perfect, and some patients are more at risk for them, for example, smokers...
IV. JAHCO --Joint Commission
This organization runs the inspection process for all hospitals to be eligible for Medicare contracts. The week that JAHCO comes to the hospital, a transformation takes place. Extra equipment and furniture disappears. It is like a realtor would do staging to sell a house. All the employees are prepared phrases to say in case they are questioned. I hide in the O.R. on a case, but if asked, I will state, 'I will ask my supervisor. I don't know.' In my work, if a case finishes on the hour, the nurse and I alter it by one or two minutes. We call it JAHCO-time, because the inspectors get suspicious if the times are neatly rounded off in the record. Now all anesthesia carts have to lock, no drugs can be left on top of the anesthesia cart. The O.R. is a restricted part of the hospital, and having to go through these steps takes extra time. But some inspector decided unilaterally, 'this would be safe' and now everyone has to do this. It is this way for all parts of the hospital, minutiae in the name of safety, just more regulation to slow you down in your day. Some safety parts are important, but ninety percent do not have the kind of impact on patient care that the inspectors hoped.
Inspectors get rewarded for the changes they bring about. Not if the changes were needed in the first place. Signing charts at medical records is grounds for suspension if you are past a certain time. Delinquent charts after that charge the physician a fee, in hundreds of dollars, just like an overdue library book. It adds up.
V. End of Life Care (TBA)
The are the things Sarah Palin shot down. The implication of government intervention on is far-reaching: the decision as to who lives, and who dies. In the hospital, I have seen countless resources wasted on terminal care, where the family seeks cure when hospice would be more compassionate. The family is just not willing to accept that death is inevitable. I have also seen ICU patients kept alive until a family member could fly in and be present when termination of efforts is done (unplugging from life support). There is room for improvement in this area, but no actual practices have come into the arena. The only difference that the government was proposing to do, is to reimburse the physician for having this conversation with the family. Currently it is not billable. But it is a delicate issue indeed.
Privacy. Now if a staff member goes into the hospital they work, other caregivers have to log into the computer under break the glass security function and state who they are and exactly why they need access to the records.
If you ask me, this is another area of control, where lawyers stand to gain a great deal over infractions.
Now we have a whole layer of administrators on privacy and HIPAA compliance, monitors and officers, in charge of everything. When I was starting out, at the VA, we used social security numbers for identification of patients. That WAS their medical record. We used the first letter of the last name, and the last four of the social security number, to look up patients and to keep notes on who was who. Those days are no more.
This is another one of the alphabet soup policies. The Health Care Responsibility Act is a statutory requirement placed on every County. I am not sure what all of these acts and things mean. There are so many of them. There was another one that had letters, and hospitals had to document time of administration of antibiotics prior to incision, or risk a negative measure. It had requirements for patient temperature in recovery room too. That explains all the little blowing blankets in pre-op holding. They are used in surgery and also in PACU too. The average clinician is barely aware of these, and it takes special administrators to decipher them, and give recommendation to caregivers on how to 'toe the line' on the latest things we have to do.
VIII. Work Hour restrictions
Your doctor can work more than twenty-four hours without sleep and still do your surgery, anesthesia, or medical care. There is a disparity between trucking, commercial airlines, and medical care on mandatory rest periods After sixteen hours of work, it is like being legally drunk, as far as impairment measurements are concerned.
Yes, I have worked those hours. I do not enjoy them. And the next day at home, I am a mess. It takes two days to recover from this, but sleep debt adds up. Frequent vacations, about five weeks a year, is helpful in counteracting this.
State of the art organizations have four-hour rest periods built into the call system, with one anesthesiologist assigned to give respite to the Labor Deck anesthesiologist and then the O.R. on call anesthesiologist back to back.
IX. Affordable Care Act
So what? Is this another way to decrease Medicare reimbursement for services? Is it really going to help? Does anyone really know the over one-thousand page law? What will the judges decide? You tell me. As I see it, it is just another step down the slippery slope that leads to less autonomy and less financial reward for my work. Yes, it is good to get the insurance industry in line, and also to give healthcare to others who are in need of it. But who gets the final say? Does medicine have a chance to give input? Or is it unilateral decision-making again?
X. Reiki in the Health Care Industry
Do you want this to happen to energetic medicine and complementary medicine? How to handle it? I don't trust The Establishment on it. My recommendation is this, invite Higher Powers that Be, for Divine Assistance in the merging of the Healing Arts. And to have the money-changing icky part to stay way out of it.