Posts Tagged ‘Medicare’

Underworked and overpaid

August 30, 2016

The setting in Alaska was pretty

Near eagles and bear’s there’s a city

With specialists plural

You can’t call it rural.

And it paid really well. What a pity.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

I worked a week in a city in Alaska.

Alaska doesn’t have many cities, but it has more than one.

They put me up in a very nice hotel, walking distance from the workplace.

Medicare pays doctors very poorly in rural areas, so badly that a doctor cannot cover overhead if the practice includes too large a percentage of elderly. So a lot of private practitioners refuse to see new Medicare patients, and some will terminate care on the patient’s 65th birthday.

Massachusetts attacked the problem by making Medicare participation mandatory for licensure. The doctors responded by moving away.

(Canada’s system pays a premium to rural practices, but they still don’t have enough rural doctors.)

So in this particular city one of the larger institutions put together a clinic for the elderly to take the burden off the Emergency Rooms. Salaried physicians see Medicare patients; the clinic depends on grant monies to continue operation.  The model lacks sustainability.

But the docs still need vacations.

I confess I said yes to the job because of ego; I liked the idea that they would fly me to Alaska, and put me up, for a week’s work.  I had hoped to work for a week a month and get in some fishing before my return, and I would have, if paperwork hadn’t moved at a glacial pace and my wife hadn’t come down with a benign brain tumor.

So on a beautiful Monday morning, I got two interviews, a name tag, and a couple of pamphlets by way of orientation, and started to work in a large hospital complex.

My previous experience with their electronic medical record (EMR) system came in handy despite the major differences between versions.

With not much on the schedule, I sat down with the first patient and said, “Tell me about your problem.” I listened without interrupting till the word flow stopped, and said, “Tell me more.”  At the next long pause I asked, “What else?”

With never more than 7 patients on a days’ schedule, I could take a lot of time with each patient. I enjoyed listening to the Alaska pioneer stories.  One 72-year-old male patient gave me permission to write that he had biceps a 16-year-old would envy.

Most of the patients of both genders have hunted, many still hunt, and I enjoyed discussion of moose and caribou weapons.

I could access specialty services, including ER, quickly, but, as easy as it made my job, it didn’t fit with my conception of Alaska as the ultimate in rural experience.

And, for me, rural makes the adventure.


Weekend rounds in vignettes

August 5, 2012

This morning I rounded on nine

Three of them now feeling fine

It’s only a slip

That can fracture a hip

An ankle, a neck, or a spine.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

I rounded on nine hospital patients this morning.  The oldest 86, the youngest 19, all of them had more than one diagnosis.  I can’t give identifying information about specific patients because of confidentiality, but drama and irony fill the stories of the people who fill the hospital beds.

Schizophrenia makes a person more susceptible to disease, and the disease process is worse for having schizophrenia on board.  Most schizophrenics smoke, and a frightening number acquire insulin dependent diabetes.  They face problems at the time of discharge, if they can’t take care of themselves and lack financial resources, though most have government-funded insurance.

Anyone unable to care for themselves, with no money or insurance, represents a problem for the hospital.  A lot of nursing homes would go bankrupt if they kept more than one non-paying patient, and some couldn’t afford even one.  Nonetheless, the attending physician has to round on those patients, and has to deal with Utilization Review, a committee that politely and professionally asks why the patient has to stay in the hospital at a frightful cost.

Everyone who smokes knows they shouldn’t, and most intend to quit, but I get a lot of business from people who don’t quit soon enough.  Contrary to popular belief, most smokers die of heart disease and emphysema rather than lung cancer. 

Some people arrive in this world with bad diseases that they didn’t ask for.  Some give up hope at a young age, and bring me a lot more business than those who decide the make the best of a bad situation and take care of themselves as best they can.

Mathematical ability dissolves in alcohol, nobody can count after they’ve had more than two.  Which leads people to think that alcoholics lie, when in truth they’re just lousy estimators.  Continued alcohol use with hepatitis C, viewed by many doctors as an active death wish, leads to cirrhosis and a horrid, stinking death, frequently accompanied by dementia.  The combination affects a disproportionate number of people too young for Medicare, and, again, discharge becomes problematic.

The elderly come to the end of their road with or without dementia; their mental status has little to do with how much their families love them.  Whether beloved or not, the drama of the hospital scene transcends culture and language.

Though most alcoholics smoke, not all smokers drink.  The two most addictive drugs in our culture usually go hand in hand, and the presence of other mental or physical disease brings layer on layer of irony and problems, some of which can’t be solved. 

Bones break, most fractures don’t require hospital care, but while a person heals from a fracture they tend to get illnesses requiring hospitalization, which complicates the fracture care while the fracture care complicates their other problems.

Blog reopened after a year on the job.

July 5, 2012

I find my job a delight

Even when working at night

On this I won’t budge,

I’m a doc, not a judge,

And there’s always something to write.

I have decided to reopen my blog after a year’s absence.  I miss writing, and I miss the immediacy that comes to my life when I go through my day thinking about my post.  I’ve been at my new job a year now.

My workplace runs on teamwork; I’ve never been any place where people seek out so many opportunities to help their coworkers. 

Our patients have few resources; 50% have no insurance, 35% have Medicare or Medicaid, and 15% have commercial health insurance.

I see a lot of schizophrenics, people whom our society has failed badly.   I’m sure if they could push a button and come to a closer contact with reality, they would.  As it is, they hear voices when they don’t take their meds and sometimes even when they do.  An extraordinary number also carry a diagnosis of bipolar.  Almost all smoke, and, given enough time, almost all develop insulin dependent diabetes. 

I find it easy to avoid judging the schizophrenics; they did not ask for their problems.  The less I judge my patients, the more energy I have at the end of the day.

We have so many patients from Ethiopia and Somalia that we have Oromo, Amharic, and Somali translators, and I’ve learned to say Hello, How are you, and Thank you.  Mostly hardworking, family oriented people, they came here after unspeakable horrors.

Many of the people who come to my clinic have been behind bars.  I don’t ask them why.  After all, I did not train as a judge.  Those folks have done their time and my job, as I see it, demands that I focus on what can be done in the future, not what has already passed. 

I start Mondays with hospital rounds till noon, then clinic till 8:00PM.  I’m on call 35 Tuesdays per year.  Most call nights I work straight through till after 9:00 PM.  I start Wednesdays at 7:00AM and finish around 6:00PM. 

I have Thursday off, along with Friday, Saturday and Sunday if I don’t have call.  I still put in 48 hours weekly.

Yet I worked no more than two days a week in the last six weeks, which I found unfulfilling.  I arrive at work Monday mornings cheerful and happy to be back, and I go home on Wednesdays ready for the weekend.

Saturday/Sunday call a year ago ran to fewer than 10 patients between two hospitals, but practice growth led to mission creep, and now a hospital census can run upwards of three dozen.  At any one time, we usually have three patients in liver failure, and three in active alcohol withdrawal.  A surprising number of non-alcoholics end up with cirrhosis.  About half our hospital patients also show up on the dialysis service.  Mental health census averages 5. 

Our patients get sicker younger than any patient population I’ve seen before, which surprisingly, gives me more hope.

Two doctors appointments, two views of the future; agreements about realities

November 9, 2010

Some will be choosing to flee

When Medicare starts cutting the fee

     A trend we are gauging,

    Docs and patients are aging

But no one should be working for free

I had two doctor appointments today.

Dr. Donahue, the podiatrist, confirmed my suspicions that I have posterior tibial tendonitis in my right ankle, and gave me permission to write about our conversation.

About ten years ago, I had a surgery for a similar problem in the left ankle, with mediocre results.   Neither of us  relished the idea of another surgery.  She told me to continue my current course:  rest, rigid orthotics, elevation, ice, elastic bandage, and hiking boots with a lot of ankle support; but I need to get an elaborate hinged brace made for my ankle.

I suspect that the same autoimmune tendency that gives me ankylosing spondylitis makes me prone to tendonitis; I’ve had it now in both wrists, both ankles, both elbows, and one shoulder.

We talked about slowing down.

I told her how I just finished two golden weeks in Grand Island, Nebraska, getting regular sleep, working less than forty hours a week, seeing respectful, hardworking patients.

Dr. Donahue has a three-year-old and works 30 hours a week.  We discussed the joys of rational hours.  She gets the best of both worlds; she looks forward to going to work, she looks forward to coming home and she gets regular sleep.  “So,” I said, “THAT explains your clear complexion and your shampoo commercial hair.”

Doctors’ life expectancy runs seven years behind the rest of the population because of stress and sleep deprivation.

If all the doctors do what I’ve done, I said, we won’t have enough doctors.  We can increase the number of doctors going into primary care by democratizing the first two years of medical school, and letting anyone who can pass Part I of the Boards go on to a clinical program.  We would get a lot of docs who would work fewer hours for less money.

A few hours later I talked to a doctor while he took care of a premalignant condition.  One of the few people who has read the whole health care bill, I asked him how he plans for the future.  “I’m stockpiling guns and ammunition,” he said. 

I filled him in on what I’d been doing (see my previous posts), and we talked about medical economics.  He pointed out that Congress will soon cut Medicare reimbursement by 29% and another 11% cut will follow a few months later. 

Most family practice offices run 60% overhead.  Where Medicare reimbursement falls below the cost of seeing the patient, many practices have stopped accepting Medicare.  If payment goes down, the trend will continue.

Then, we agreed, we’ll come to a situation where medical care is rationed.

One fourth of our doctors are over the age of 60; the more onerous the regulationsand the lower reimbursement, the earlier the doctors will retire.   Trying to get smart young people to give up seven years out of their ‘20’s is a tough sell now, and will only get harder.

Hyperaldosteronism, Medicare pay cuts, and a good night’s sleep

March 3, 2010

A patient depressed will cry

I said I didn’t know why

            But, I will mention,    

            There was hypertension

And the aldosterone level is high!

A good night’s sleep is a gift directly from heaven, and one of those graced last evening, making for a euphoric morning.

A patient, after being shuffled from doc to doc, came in last week on a new patient visit with high blood pressure disproportionate to age.  Non smoker, non drinker, and two hundred pounds overweight, an elective surgery was delayed for a pressure of 158/116. 

I see a lot of obese people and a lot of high blood pressure, but I don’t see hypertension this high in a person this young who doesn’t drink.  There were other problems, with more lab pending.  I already started vitamin D and booked a follow-up appointment for Friday.

But the aldosterone level came up high in this morning’s lab queue, 30 with normal being less than 16. 

Aldosterone comes from the adrenal gland and usually gets ignored because this hormone rarely goes bad.  I have never, not once, seen a case of hyperaldosteronism before.  On the verge of ordering spironolactone (an aldosterone blocker), I stopped and asked for further blood tests.  On her way to the endocrinologist I wanted to present my consultant with a thorough work-up.

Over lunch, one of the transcriptionists says, “Look at that Medicare cut, 21%.  What do you think about that, Dr. Gordon?”

“Like I care,” I say, “It’s not my problem.”

It’s a national problem in that people reaching Medicare age will not be able to find medical care if the rates get cut.  As it stands, the government pay for patients over the age of 65 is an insult and doesn’t cover the overhead.  But I’m not worried about it bringing down my income because I’m going to be doing Something Else.  I’ve also found that worrying about the government is a waste of time.  I will still enjoy taking care of the elderly, but in short order I’ll be on salary. 

It will be a problem for our oldest daughter, Jesse, currently in her Family Practice residency in Chicago.  She’ll inherit a lot of problems, and Medicare is only one of them.  

I inherited a lot of problems from my father’s generation of doctors.

Every generation of doctors fixes some problems and generates others.  I have never seen a case of polio or smallpox, but HMO’s still seemed like a pretty good idea while I was in med school.  I’ve had to deal with the rise of the Resource Based Relative Value Unit and the pharmacy review board.  As Jesse progresses there will be more and more faceless bureaucrats pushing her around.  I don’t see a remedy for it.  Medicine will still be the most honorable way to make a living.  Chances are she’ll never see a case of measles or mumps.

The quality of medical care keeps getting better and better and consequently the cost keeps going up.  As life expectancy increases, the rewards for not dying young spiral up and up, and the demand for health care keeps increasing.

I don’t think I’m going to solve the problem, but I’m having a blast taking care of patients.