Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: #blue cross of Nc#healthcareblog

My Overstressed Physician (Prior Authorizations, Referrals, Stress, Prescription Assistance Programs, Electonic Health Records and More)

The following video covers just one aspect of my concerns regarding the infringement on Patient Centered Care by the “Business of Medicine”. I have reflected in the past about the cumbersome “Business Process Centered” components of health care delivery that prevent our providers (Doctor, Nurses, Technicians, Therapists ETC.) from focusing on the “Big Picture”. What I am referring to are the dimensions of health that require thorough assessment and attention to detail for the treating provider to accurately judge what is happening in our body, draft a treatment plan and execute the orders. Right Care to me is my team’s full understanding of my biology, culture, mental health and physical health needs, the social roles I play in my community and the support available in my community when it is necessary for me to stay healthy and productive.

During my visits to my doctor the processes’ of assessment, diagnosis, planning, intervention and monitoring are interlinked and any disruption will present a barrier and possibly introduce an error in treatment or missed opportunity to cure a silent condition. These missed opportunities to improve our health are often referred to as Co-missions or Omissions in care. Co-missions occur when our medications interact and cause an exacerbation of an existing illness or cause a new illness to occur. An example might be the treatment of a person with Diabetes who is taking insulin with a Beta-blocking drug such as Metoprolol. This might cause hypoglycemic Unawareness  and the patient will not be aware of a low blood sugar. An example of an Omission in Care  is when a patient is unable to continue taking a medication. The lack of evidence of prescription refills in the patient medical record might create and alert for the doctor to review, but one cannot assume that this is always the case. Beyond being aware of the missed refill the doctor or the clinics Care Coordinators should follow-up with the patient to determine the reason for non-compliance with the patients care-plan. In America financial reasons often prevent us from being able to adhere to our medication regimen and the answer to the dilemma can be as simple as contacting the drug manufacturer and applying for funds through a Prescription Assistance Program. The #partnership for Prescription Assistance is an organization that will help those with financial resource issues. So, what do you do if your doctor doesn’t have the time to spend educating you to look out for hypoglycemic unawareness, refer you to a Prescription Assistance Program or get transportation to the clinic each month for your periodic check of your blood clotting time? Should all of us be self-sufficient with these skills? I suppose in a perfect world this might be the case, but I certainly wouldn’t place this responsibility on the average lower to middle class patient today. We are far too busy just making ends meet and in many cases our health suffers.

Electronic Health Records were our great hope for unburdening the provider and the clinic staff from clerical activities that are required in the day-to-day management of a population of patients. The average primary care provider often has 2000 patients unless they are a concierge practice; which the average Joe or Jame cannot afford. Your referral to the laboratory for routine blood sampling frequently requires the doctor to link the appropriate diagnosis with the lab test or the chart will not close out after the visit and the order will not be communicated to the lab  performing your test. Today, I watched my doctor and his “documentation specialist” carefully navigate several screens in the EMR as the doctor ordered various labs and cross linked them to my problem list. These processes make a lot of sense when they relate to care quality. For example, you do not want a doctor to order tests that are not going to increase his or her knowledge of what’s ailing you.  However, in the cases I see today; and I see a lot since I am a person with multiple chronic illnesses: My doctor is dancing to the tune of the Insurance Company and looking over his back to make sure he isn’t over-utilizing or mis-utilizing his privilege to order expensive diagnostic procedures: When I see my doctor stressed out,  rushing through and missing pieces of his exam: I start to fret that he will leave his present employment and I will lose yet another good primary care physician (I have lost three in the last five years for these reasons).

So my doctor is overwhelmed with filling in the correct fields in a health record to avoid penalties from his administration. My quality of care is declining. The burden in my opinion is a caused by an over-complicated system created by folks interested in the possibilities of Big Data AND the residual business process requirements of a Managed Care Business Model that no longer is valid since our doctors today come well prepared to make high quality decisions based on the published  best practices emerging from the literature accompanied by embedded decision support in their information systems; or has someone been fibbing about what the technology does for us?

Are you willing to step up and work with your doctor to define and deliver the Right Care by the Right People, at the Right Time, in the Right Place?

 

Right Care Action Week Event

Untangledhealth.com conducted a Right Care Action Week Cafe for The Right Care Alliance on October 19th at Elder Path Raleigh; an MKP.org Men’s Group. We discussed, engaged, educated and empowered this group of elders to master their future health through selecting providers and institutions that offer  the highest quality, highest value services with proven integration of clinical services throughout the continuum of care.  I am excited to see this community of men step forward to model active consumerism in Health Care and dedication to teaching their peers the methods consumers can use to evaluate their regional resources. 

Topics covered included the Self Advocacy Process, Selection of High Quality Health Facilities and Providers, The Five Wishes, Transitional Care Hazard Avoidance, Medication Cost and many others. As always, UntangledHeath.com’s desire is to teach patients to advocate for themselves and their families.

We look forward to working with the Right Care Alliance in the future.

The pictures below include slides from our discussion. I will be recording the entire presentation soon!

A Diabetic in Puerto Rico calls out for insulin : Shame on us…

Normal Retina                                                        Severe Diabetic Retinopathy

 


 

I am angry.

Listening to a diabetic in Puerto Rico plead for an insulin delivery this week brought back remembrance of the body pain, insatiable thirst and intractable nausea I experienced when I was broke in 1974 and had to borrow money for medication as I hitch hiked to California to live with my brother Bruce. Feeling helpless I received a $75.00 wire transfer in the nick of time. Fortunately I had a loving brother and Western Express. Thank G-d for a wonderful primary care Doc that taught me to reverse DKA on my own when I was only 13 years old. I can’t describe the misery of Diabetic ketoacidosis with sufficient magnitude. Imagine dying of thirst.

I do not understand where our Army is. It seems we have infinite resources to drop special forces into any part of the world where there is a threat to The American Way. Yet in the time of Trump, and in the Time if Bush I heard the call of The Great Oz.. “We are doing a fabulous job”  or  “Great job Brownie”. Here lies evidence of my claim that we are own our own in this great country: The Country that used to promise opportunity and someone to watch over us when we fall upon hard times. Go ahead, call me a snow-flake…Then walk a mike in my shoes and tell me again “to suck it up”.

Today I am ashamed of the indifferent , arrogant attitude of Donald J Trump and want our Global Friends to know that we know how to care for our own, we have the resources to care for our own and that the Real America is currently on the mat in a twelve round championship fight against Master Blaster. Let me be clear; Master Blaster doesn’t run this part of town!

The retinal photo above right is an actual photo of a person with diabetes who has not had access to primary care. She lived in a rural area of North Carolina, had no insurance and died one year after this photo was taken. She was in her thirties. Medication, a treatment plan and adequate nutrition go a long way.

Hey DJT, stop worrying about what people think of you and send some helicopters in with the supplies that are piled up a few miles of the shores of Puerto Rico.

Awe Nuts! I am really pissed.

Time to pull the sheet out from underneath healthcare in America. In one step. Eliminate Insurance, Medicare, Government Programs, and see what we come up with. Please leave a note on my grave as to the outcome.

someone-to-watch

Thank you friends from LinkedIn today. Those discussing our frustration and describing a need to sit down and discuss the disaster that was and the disaster that will be.

Without action that-is!

Rephrased: My friend states our Medical system is far to complicated and polluted with bad ideas to resolve through a bunch of silo business meetings of silo organizations who define for us consumers exactly what health is, what we need to consume to maintain it and how much we should pay!

My point was to provoke: Strictly because I have similar judgments. I recently have seminar to senior men on functional decline over life for avg American male. Then overlay of possible interventions and services through death. Then described business layer and regulatory layer.
Your point Bruce Pisetzner is precisely why we need to define the pain for all stakeholders. When I say “stakeholder” I include consumers from all socio-economic classes as well as the professionals who treat them and the “business opportunities” created between 1965 and today that supposedly state a clear value added to the system of care.
Spent my career sketching iterations of your shell games. It seems to me: and I hold a straw-man judgment; that 1) as a country we have no agreement on what “health”is e.g. functional status, emotional status, absence of disease, bio-psychosocial well being etc. Far too much room to allow a free-market enterprise to explode without revisiting what is necessary to achieve healthy population goals.
Then of course we have the employer – employee entanglement.
Then of course the Government – Defined Benefit issue.
As patient with chronic disease, provider – admin acute care for 8, provider-admin post acute for 10, HIT product architect for 10 and community healthcare integration consultant for 10; predictive analyst for 8: I have watched the money flow. Oh how I have watched the money flow. Some even into my pocket. $25K a year out to stay alive and well with diabetes.
Perhaps it is time we all tell the truth. Insurance company, Large Employers, Small Employers, Provider Types, Patient Types and so on.

I created this blog post on the fly but thought it important to get out here now!

cropped-stcroix-jeff.pngsevere retinopathy

An advocate gets busy while every politician and “talking head” takes credit for healthcare model ideas published long ago.

Reconciling data in my six health portals

Reconciling data in my six health portals

I watched Barbara Starfield again last night. She passed away in 2011 but it seamed as though she was sitting in my living room telling me everything will be alright but many of us will never get our way. Barbara spent several decades studying the characteristics of health systems all over the world. Her final conclusions were simple and easy to implement as long as social agreements were made between consumers of healthcare services and their providers. The contract (sort of) is that my primary care doctor will be available when needed if I promise to contact his or her office before going to the ER for an earache or other non-emergent condition; my doctor also agrees to follow my care as I transition through life stages and address all mental and physical health conditions as they arise by assuring I connect with the correct specialist if required. The specialists in return are in constant contact with my primary care doctor so the primary care clinic is coordinating continuous and comprehensive care and reviewing all interactions between myself and other medical environments. Like I said earlier this week. Someone to watch over me. I first learned of Dr. Starfield in 2001 and followed her publications. Funny, she was never accepted to sit on any best-practice boards but the scientific community considered her work to be spectacular in terms of statistical approach and quality. In other words, she looked for the null hypothesis also.

Again…concerns over repeal and replace.

Some more diatribe with hope at sarcastic humor is written for you below. Please follow through to the end as I pasted a really cool graphic pointing you to a new society of consumers and professionals that might fix the system over the long run.

The conversation doesn’t stop at my dinner table, on my phone, through IM or Facebook. It seems as though my popularity index took a healthy bump after November 8th, 2016. I wish I could be happy about the reasons for the traffic.
“Jeff, you are on Medicare are you concerned?”

Well yes; you see, as we become older the likelihood of needing assistance from case managers, specialists, short stays in skilled nursing or rehabilitation facilities increases. Same with home health services which is always the preferred place to recover from the self-inflicted fractured hip that occurred while my masculine ego informed me of my capacity to clean out my gutters.
One of the most important changes to the clinical language coming from Obamacare is the right for all patients cared for by primary care doctors with Medicare contracts to receive “Coordinated, Comprehensive Care”. Lately you might have heard the terms: “Patient Centered Care” or “Medical Home”. You probably heard President Elect Trump mention “Patient Centered” or a new commercial by Humana presented by a handsome young doctor stating that Humana’s system of Patient Centered Care is superior because of their capacity to coordinate your care within their “medical community”. Then you will watch a local conservative pundit state: “those stupid narrow networks tried through Obamacare didn’t work: here is a toast to repeal and replace.
This stuff cracks me up for the same proponents of patient centered care realize that closely collaborating narrow networks can provide you with clinical personnel that understand your needs better than anyone else! In fact, they have the same attributes of a Patient Centered Care Team using a single medical record and plan of care to increase safety and minimize mistakes. Yet you will hear no one (perhaps save me and a few of us that are tired of scraping the poop off our boots) tell you that the words Patient Centered, Narrow Network, Accountable Outcomes, Value Added Payment, Medical Homes, and all other terms implying a tightly coordinated, error free clinical team surrounding all patients are not original concepts. In fact, they are in place in many of our successful neighbor nations who provide universal enrollment and have always demonstrated lower reliance on emergency room services for basic medicine, better health outcomes and no difference in treatment effectiveness for cancer, diabetes, cardiovascular disease and other leading causes of premature mortality. Our own CMS (The Centers for Medicare and Medicaid Services) have published the policy here July 2016:
So all of a sudden the administration of 2017 will be using terminology invented by others to describe care models that work after years of academic surveillance by healthcare policy analysists and already written into The Patient Protection Affordable Care Act or what the opponents call “Obama-Care”.
My prediction is we will keep the new payment systems for coordinated care and chronic disease care management. However, the credit for the success will fall under a new Trump label. My fears is that the same three insurance companies comprising the oligopoly of payers for American Healthcare will recoup their lost profits of mandated care without premium inflation for the chronically ill by shifting the premiums higher for those with pre-existing conditions. So here is another question from the week:
“Jeff, what will I do now I couldn’t get covered because of my history of cancer before the ACA?” “What if “Trump-care” requires coverage for pre-existing illnesses but allows insurance companies to include the illness in the premium pricing model? “ My response to this question was “not sure, my cost in the NC High Risk Insurance Pool for my diabetes prior to Obamacare was $1200.00 per month not including co-pays. Today it is $350.00.
More on Patient Centered Care AKA Medical Homes AKA Integrated Care AKA Chronic Illness Care.
I discussed the integrated care model and its payment adjustments to my Men’s group on Thursday night as they requested a primer on planning for their last ten years of life. Their hope was that our system of care had evolved and they would not have to lose their homes to cover the long-term care charges. Many of the guys in my group neglected to buy long term care insurance when they were young and healthy, had since suffered a chronic disease diagnosis and episode of treatment and no longer qualified for long term care insurance. They could however place $10 K per month into an account to pre-pay up to one year of long term care. This is what my father did: In 2006 he entered into a contract with a transitional care organization. He paid them $350,000 for full access to assisted living and long term care until his death. They also allowed him to live in the attached apartment complex for independent seniors for an additional rent of $3200 per month including one meal per day. Not a bad deal eh? Oh yeah…one more oversight: My friends ; all retired upper middle class professionals had no idea that Medicare didn’t pay for long term custodial care either in home or inpatient facility.
Now, like I said the other day, I am a bit tired of shouting the truth to those who were unfortunate enough to buy into the following promise: “Oh we will have the most wonderful healthcare system in the world” and “We promise to repeal the expensive policies and replace with something better.
We were on our way folks: The biggest mistake, President Obama’s team was denied the necessary Medicaid expansion for ALL not SOME States by our supreme courts. If you don’t understand the math I will be pleased to describe it in another column. Basically when the folks that would have had access to Medicaid don’t receive the insurance they still consume services. The loss of revenue winds up on the balance sheets of hospitals and providers and they respond by increasing their cost per service. The insurance companies pay more and your premiums increase. So… my neighbors policy (55 year old male) in NC costs $11,000 per year. The very same policy in New Hampshire where they expanded Medicaid costs $5,500 per year. As Mr. Obama leaves keep in mind that the rate of increase in health costs since the inception of Obama Care is the lowest it has been in 40 years.
Somehow, someway; we need to cover everybody. If we do not we cannot cover the losses incurred in the private sector without the Magical Thinking that has been sold you for so many decade. Hide the losses, get others to pay for the losses through modest increases in cost of living and blame the doctors, and hospitals who give away more free care than you could ever imagine.
What would happen if our incredible consumer driven internet harnessed the decision support technology that we use daily on Amazon and instantly brings the right service to you when needed should you or a loved one become ill? What if we harnessed IBM Watson to make the diagnosis thereby reducing error rates and reducing unnecessary utilization of expensive diagnostic procedures?
What if we didn’t need insurance companies any more to assess population risk and perform preauthorization services while we waited for our new medication?
Since we have all of the data connecting lifestyle, culture, nutrition, infection and the human genome can anyone appreciate where we are headed with our capacity to discover the cause of disease and effect of treatment? This is not decades from now my friends; it is within the reach of our children’s lifetime. I have wonderful friends with incredible scientific minds that are creating open source technologies to accomplish human collaboration like humankind has never witnessed. The only barrier to their success is a loss of priority to cure disease, increase well-being and expand the functional-years of human life.
Or…we can keep these technologies secret, forget those we have developed through the natural sequestration of competing private enterprise and traditional silo thinking. If this is where we are headed then the best investment to assure a painless end of life if you are not surrounded by humanitarian friends is my undying support for the second amendment. If you catch my drift.

Check out Right Care Folks!

Right Care Now

Right Care Now

From Obama to ObamaTrumpCare

someone-to-watch

Someone to watch over me…….
Dear Doctor, will you please make sure I receive the RIGHT CARE!
What do you know about me Doc?
Do you have time to spend with me today; perhaps discuss who I am in the world, what my goals are and what I think might help me feel better?
Are you interested in my Well-Being? Do you and your staff ever discuss Well-Being or is it all veiled in a pile of healthcare acronyms; where Well-Being is described by absence of symptoms and disease?
Do you have the opportunity to discuss my goals and interventions with my other doctors? Sometimes I am not sure you folks talk because my information: from religion and employment history to list of medicines varies between practices. I thought someone was fixing all of the electronic health record issues ten years ago?
I noticed that all of my personal physicians that I have chosen over the last fifteen years are selling their practice or merging into some sort of healthcare system that appears to be managed by the local hospital; is this a good thing? I am really not sure you see me because the person at the registration desk doesn’t recognize me and your Medical Assistant told me that you only had time for 10 a minute appointment today.
Actually, to be honest with you; I am concerned for your Well-Being Doc because you have dark circles below your eyes and tell me that you are up until 10:00 PM each night completing your records at home. I realize that the new electronic health records are cool but shouldn’t they increase your quality of life as opposed to drain any remaining discretionary time you have with your family?
Ya know Doc, I have learned allot about healthcare in my life: Yeah, some because of my training and work but mostly because I have these….”conditions”. The “conditions” have presented adequate challenge to require me to understand the “bits and pieces” that string this system together. I’ll bet you don’t learn much about being a patient in medical school. I am not sure how you could do it without adding another two years to your fourteen years of post-grad education.
Did you know that I have spent ten hours in the last month trying to get a prescription authorized? You know the prescription that makes living with RSD and diabetic neuropathy tolerable! It appears that someone didn’t install your e-prescribing system correctly; something to do with prescription received and filled acknowledgments? I don’t know Man; it seems like the fax machine and pharmacy calls worked better than this e-Rx stuff. The long and short of it is that between your practice, my insurance carrier, and my CVS pharmacy the most efficient transaction I can hope for when I am in pain is 48 hours. My “Well-Being” wasn’t so “Well” this month…..
BUT my A1c is 6.5, my blood pressure is 124/78, my immunizations and other measures of health process and management outcomes are all great. I am pleased to be one of the good data points on your quality report and certainly testify to CMS and Blue Cross that you deserve an extra 5% for your hard work. Might be nice though if I received a discount on my insulin copay for the snappy A1c that has kept my feet attached to my legs and my body out of the hospital these last 50 years.

So what is Right Care? How do we know if we get it? Is it through the Diabetes DM report? Is it through the patient satisfaction survey that I take at each and every service provider I see? They all are very similar, I wonder if anyone has ever considered a “whole system measure”; at least something better than the Service Excellence Survey that reminds me of the material sent to me by American Airlines after every business trip. By the way, I always give my providers 5 stars with the exception of the conglomerate that bought up the primary care practices; their employees seem miserable. I find it amusing that their employees all where buttons that say “Ask me about the “Name of Healthcare Institutions” WAY. I guess they all have some kind of culture that is supposed to make my experience less painful as a consumer? Perhaps more like Disney Land I suppose.
What I really long for is my diabetes pediatrician from 1965. Dr. Lipmann. He always asked me to discuss how I was feeling about school, whether I had enough to eat at home, did I have any dreams and whether or not my diabetes would prevent me from achieving my dreams. Heck, he called me on Sunday night to as how I was feeling when my urine sugars were running 4 plus. When I left his care at the age of thirteen he had illuminated an interest in human biology that has carried me through my life. On a darker side of my childhood life he also notified “Children’s Protective Services” when he discovered I was living in an alcoholic flop-house!
My friend Tony is from another country. His mom had a CVA last year. She was transported to the ER, hospitalized, transferred to a facility with real rehabilitation specialists and doctors on staff daily, discharged home with visiting nurses and therapists and returned to society as a healthy 75 year old woman who is now completely independent. Her cost? Well there was no cost to her and the average cost per person for health services in her country is 1/2 of what it is in the USA.
In meeting with my insurance adviser the other day I was informed that my healthcare cost will be more than $500,000 between now and my death; with my diabetes, RSD, neuropathy etc. I wonder how we will cover the services. I really don’t want to be one of those patients that I cared for early on in my career. You know….like the old man and WWII B17 Aviator that looked up at me shortly before he died and said “Ya know Jeff; I used to be somebody once”.
The end of his life was no different than my fathers. Dad died last year from pneumonia at the age of 87. We had just celebrated Memorial Day. He called me complaining of a chest cold and 48 hours later I found myself sitting at his bedside with new onset dementia, consolidated breath sounds, a temperature of 101 degrees and abdominal cramps. I asked the Nursing Assistant to get him a bed pan and she informed me that he “just got off the pan”. A few minutes later I overheard her complaining to her supervisor that she had no intention of getting my Pop out of bed because he was a difficult transfer due to his combativeness. Pop was angry for sure but not combative. Then I witnessed the IV nurse insert a 18 gauge catheter into my pops wrist. She never registered IV access and proceeded to deliver 500 cc of solution into the sub-cutaneous space. This was the only vein he had left since they had made the same error the night before in the opposite hand. By 6PM his hand was as large as a soft-ball and this was hours after I complained about her technique.
So the following day Pop got a PICC line. PICC lines are infection risks!

Three days later I took him to the SNF with his PICC line and met with the therapists. Dad was becoming more lucid but I had concerns. I met with the Charge Nurse and facility director to assure his good care. I was concerned about the additional risk for infection from his new PICC line. You see, this facility was part of his life-long $450,000 investment in a continuing care environment; supposedly the best available in Huntsville Alabama. I used to direct clinical services departments in these facilities earlier in my career and was aware of their financial strain as they attempted to deliver hospital level care for 1/3 the cost.
I saw Pop the next day while he was cycling on the recumbent bicycle in the rehabilitation department. He had 20 minutes of therapy to go but as soon as I showed up to watch his work-out the therapist terminated the session and quickly wheeled Pop to his room so we could chat. Dad looked horribly sad, I knelt down to say good-bye kissing him on the forehead I said “I love you Dad!”; he looked up and said “And I love you Jeff”. These were our last words.
Three days later I received a call at 3AM from a person who could not speak English. He mentioned my father’s name and I asked for someone who could speak more clearly. The second person I spoke with also could not speak English. Finally a paramedic picked up the phone…”Mr. Harris, your father is unresponsive and we are taking him to the hospital”.
After a quick dialog I was able to determine that Pop had explosive diarrhea several hours earlier and simply lost consciousness. I called ahead to the Emergency Department to inform them of my father’s forthcoming arrival and that I was worried he might be septic. I told the doctor that Pop was a DNR patient and he should call me when he arrived. When Pop was evaluated the ER Doctor called me with his lab results and it was quite evident that he was dying and most certainly had been allowed to dehydrate while at the Rehabilitation Hospital OOPS I mean Skilled Nursing Facility OOPS I am not sure what I mean. God did I weep as the ER doctor and I discussed his DNR.
I wrestle with the fact that I might have been able to save Pop if I had pushed for re-hydration, antibiotics and other therapy but I couldn’t help think about Pops state of well-being. You see my brother and I had spent years shuffling him around between neurosurgery in Birmingham and other clinical facilities. At one point I had imitated a physician to keep my father from being discharged prematurely after his brain tumor operation. He had been in the hospital for a week. The Medicare Prospective Payment was going to pay for eight days and the hospital was pushing him out to a skilled nursing facility. I watched my Pop eating and realized he had an aspiration problem. Fearful of aspiration pneumonia I asked to have him discharged to the rehabilitation beds at the University Medical Center. I wanted him to receive a speech language therapy evaluation for aspiration risk and rehabilitation services. To get the transfer to rehabilitation where a doctor and therapists would be available; I had to retrieve every clinical skill I had when meeting with the staff to justify his case. When they assumed I was a doctor, I let it ride. Feeling shame the next day I convinced myself that I would do whatever I needed to protect my father.
You know, to make sure he would receive the
Right Care.

As the ACA (Obamacare) was implemented I began to have hope. You see, this year 2017 is the beginning of Medicare’s observation of how well inpatient hospitals and post-acute care facilities integrate. One important measure they are watching is the frequency of readmission to acute care for the same diagnosis. This combined measure of how well institutions, nursing homes, home health networks and primary care communicate regarding a patient’s process as they are handed off between facilities is to prevent patients from becoming ill and requiring re-hospitalization. Trust me folks, it used to be horrible: I can remember turning patients around as they arrived at our rehabilitation hospital and sending them straight back to the Medical Center that had just discharged them. You see, some were still in heart failure and semi-conscious; not only could they not participate in rehabilitation; to attempt rehabilitation might have killed them. But you see, the hospitals were not linked to the rehabilitation and skilled nursing facilities through a common therapeutic goal and reimbursement mechanism. The hospital in Boston just wanted to discharge the patient prior to exceeding their Medicare reimbursement allotment. We however had marketing nurses out in the field accepting any warm body with a heartbeat that just might survive a 21 day Medicare stay in a Skilled Nursing Environment.
My friends had no idea why I never lost my job by reversing the trajectory of these patients. What they did not know was that I had a compassionate family owned corporation employing me who trusted my clinical intuition.
Alas… as of today….Obamacare is being repealed and we have yet to be informed about “TrumpCare”. My guess us that we will return to the past with the exception of mandatory care for persons with pre-existing conditions. Then we will see just how much our policies cost and what our end of year out of pocket expense will be.
For my wife and I,
We are searching once more for our peeps. This week I have looked at my well-being through the end of my life if we ex-patriate to Canada. My cost will be $0.00 for healthcare. My waiting time for a CAT scan will double but Canada’s outcomes for Cancer and Cardiovascular Disease and diabetes are slightly better than in the USA. So what do we have to lose? In fact, Canada doesn’t amputate many diabetic limbs. You know why? Because all of their diabetics have access to care!

Fondly thinking of you fellow patients and consumers;
Jeffrey Halbstein-Harris
• An advocate for those who feel lost
• Always watching
• Harnessing the compassion that surrounds you in a time of crisis
• Connecting you with the best science available
• Minding your pocketbook
• Working to return you home safely

Doctor Price? Should we run for the hills?

A serene day in St. Croix

 

His history might clue you in.

Tom Price on healthcare: What should we expect?

What happens when you strip coordinated care incentives through repeal of the PPACA. One outcome is certain: orthopedic surgeons like Dr. Price perform more amputations for which they receive several thousand dollars for a fifteen minute procedure.

What happens when you strip coordinated care incentives through repeal of the PPACA.
One outcome is certain: orthopedic surgeons like Dr. Price perform more amputations for which they receive several thousand dollars for a fifteen minute procedure.

Click link above to access Dr. Price’s priorities. First please read my fears, doubts and insecurities below?

 

 

 

Pres. Elect Trump hired Rep. Tom Price as the new Director of US HHS today.
Mr. Price is a vocal supporter of Mr. Trump when other republicans were not. It appears Mr. Trump continues to hire loyalists.
Dr. Price is a successful physician having authored numerous bills to replace PPACA. When hired he stated his objective is to repeal and replace.
The bills authored by Price do have language that sounds attractive e.g. Patient Empowerment but when read…show a clear intent to remove the most important economic controls on health cost escalation in the PPACA. These include: DME competitive bidding for items such as prosthetics, motorized wheelchairs etc. Competitive bidding on drugs purchased by Medicaid and Medicare, Removal of our veto on using genetic data to derive insurance premiums for individuals and many more.

I have long thought that it is weird that Americans who place so much emphasis on pure free market tactics in all industries vote for politicians that author bills to veto competitive pricing virtually eliminating 100 million people from hiring a government payer to reduce the cost of medicine.

Now, I always suggest we follow the money.
Dr. Price’s three leading PACs and individual campaign contributors fall within these industry’s.
Physician Membership Organizations
Hospital Systems including HCA ( brought to testify on anti trust and fraud several times in front of congressional committees)
Pharmaceutical Industry
Insurance Industry

Where I have worked for HCA, consulted to the American Academy of Family Practice, Anthem Blue Cross, NY BC, and State Government I am confident in my conclusions about their business objectives. If you trust me and want more info please feel free to call on me.

I highly suggest that everyone who voted for PETUS look at who has been appointed to lead US agencies and fill important cabinet posts. My prediction and I hope to eat my words is that the middle class is about to be dealt a final death-blow that will eliminate any hope of having enough left over at our death to pass on to future generations.
I am suggesting people like myself: aging with chronic illness describe what they hope for quality of life in their final years and make preparations. The only way to do this is to understand how necessities are priced and determine individual bargains strength.
We had Price transparency tools created through the PPACA. My guess is they will disappear in short order .

My colleagues who believe in universal enrollment for defined evidence based public health and personal health interventions will be fighting any changes that do not provide consumer-facing competitive shopping tools that dispense with confusing terminology commonly used by healthcare institutions and insurance organizations. I also look to the millennial to jump in since they have a future at stake.
Tony Antony Williams may be right in his suggestion that PETUS is a liar.

Doing my best to stay healthy enough to escalate beyond the occasional battle into a Full Blown War against Wall Street.

The War in DC is for campaign reform and term limits.

“Oh what a drag it is getting old”

Hello Darkness My Old Friend…

I am witnessing an illogical social rage emerge that “if we are not steadfast to our principles of tolerance and acceptance” could ignite into a civil crisis even greater than what I (we) witnessed in the 60s and early 70s.
The content displayed on the Internet is usually present for a single purpose: to sell an idea.
So now we have evidence of dishonesty and amoral behavior.
As I chase material down to its source I find frequently that the information is genuine but stretched beyond its context. Meaning: a video purporting to expose poor security architecture of a 10 year old vote tabulation computer is released from a blog that claims a vast conspiracy to undermine our election process. However, the machine tested was studied through “real scientific procedure” by Stanford years ago and found to be defective, thereby causing the vendor to lose its contracts with election management authority’s .
The video published within the last few days had a single intent: convince the public that we have a crisis in our voting apparatus and a probable conspiracy.
On the same blog the moderator claims our support of foreigners in need is far greater than our effort to support those of us on Social Security. ” How can our Government support thousands of Syrian refugees when it can not give a raise to Soc. Security recipients!”
These words are meant to do nothing but divide us.
On another blog I find the video of a silly man embarrassing himself by making petty comments regarding his power over women. The guy was 59 years old and behaving like an adolescent braggart. Ask me if I care. I think I am intelligent enough to not consider him suitable for public office through listening to his speech alone; let alone some silly dialog he had with a Hollywood “Child” .
Now Most of my friends and I are not content with our choices in this election cycle. However, we know we can survive another 4 years waiting for another leader to emerge if we vote for Sec. Clinton.
But the generation below me: the folks that didn’t experience the Cold War, Vietnam, Students being shot on campus, the pictures in Time of beautiful men hanging from trees by their neck throughout the South. The beginning of and final failure of the war on drugs, Project Apollo.
They can’ t seem to realize that corruption is everywhere but reflected by genuine love and collaborative effort in the very same moment.
The candidates in our election today are simply warning lights on our social dashboard : bringing our attention to our fear of powerlessness, loss of faith in humanity and capacity to understand how each of us is perfectly imperfect. From George Washington to Whoever wins this election ; all of our leaders , all of our heroes have nasty moments along their life-path; They were and are human also.
I think it is time to silence our voices, lay down our pens and video recording devices and sit down for a discussion. Perhaps a discussion that will illuminate our fears, doubts, insecurities, desires, hopes and dreams. Through this work we might once again find our commonalities and work together to re-form our nation.
We are broken…..I think, but not irreparable.

Enjoy

What is important! Life, Death and Taxes

Hopeful

Hopeful

The most important messages I carry are personally empowering. They are seldom original but channeled through the “bright spirits” I encounter in life.

To be empowered in this confusing world requires a grasp on reality. I will be 60 next week, a milestone I never cherished; even less so today with recent memory of the loss of my father, mother, brother and best friend of 30 plus years.
I was so freaking sad today when I woke that I found it hard to make a cup of coffee. I preferred to sit in my armchair (nicknamed the neurotic’s spaceship) and discuss the meaning of life with Bodi my loyal canine friend.
When I opened my social portal into the virtual world I discovered a friend’s post. A warm soul I met in a business conference two years ago, April Koontz had posted an important message; another piece of wisdom that I find to be a blessing for all of us.
I have chosen to teach about how to survive in America if one is ill perhaps it is time to focus on the ultimate reality for my lifetime. I will not witness a fix. We are far from agreement on the definition of health and well-being and human rights in American Society to imagine anything close to a satisfactory solution in my generation.

 

So perhaps I will continue to post interesting tidbits and ideas with hope of enlightening those who did not work 35 years in healthcare; but most importantly I will re-state my agreement with the video below; a presentation by @Michael Hebb, the founder of Death Over Dinner’s Ted Talk below – a must see!

A great thanks to April for bringing this to my breakfast table this morning.

Wait, Wait, Don’t Kill Me; I have my data and you don’t! A Chronic Disease Patients Point of View Part 1

 

A 33 year veteran worker from the US HealthCare Industry who was diagnosed with type 1 diabetes in 1966 describes his  realization that health care efficiency solutions must first address social and business barriers prior to implementing technology and hope for the future.

Reconciling data in my six health portals

Reconciling data in my six health portals

Keeping our eye on the ball: Let us not forget why we showed up over these last few years and started shouting out!

A small sample of issues that we learned about in the last fifteen years:

  • Disproportionate Growth in Healthcare Costs (greater than GDP and growing as a multiple of consumer price index) with poorer health outcomes
  • Disparities in care and care outcomes directly related to personal income. (as family income falls so does family health)
  • Lack 0f availability of critical, decision influencing data when and where we are treated (The Patient Information Gap) arising from lack of governance of data exchange between industry segments, physicians and payers at local, State and Federal levels, (often hidden behind well intentioned efforts to secure the privacy of patients).
  • Reliance on antique point of care exam model: Patient and family as historian.
  • Poor price transparency due to confusing and always changing industry syntax such as: Facility charge, Allowed amount, Deductible, Co-Pay, Co-insurance, Patients responsibility, Cost Sharing, Plan Type, Episode of care; Discharging to next lower level of care;  Medical Savings Account appeared to us as a shell game where we would always find our total cost out of pocket living under a different shell!
  • Certification processes: JCAHO Ambulatory, JCAHO Hospital, NCQA, URAC, CARF, Insurance Company’s Center of Excellence! What does it all mean! 
  • Questionable ethics of pharmaceutical industry: Tiers level 1,2,3,4. When our doctors told us they prefered a brand drug because of evidence that the drug was more effective but the insurance company required we pay 4X cost of their PBMs generic who do we trust! Will I die because I spent $200 less per month on my medication than my Dr.Recommended?
  • Numerous Business to Business relationships that supposedly have value for payers but only decrease the size of the consumers wallet. What is a PBM anyway? A Pharmacy Benefits Manager! You mean my medical insurance company needs another company to manage the medications!!!!
  • Disease Management Companies: Nurse calls me monthly who works for Depression Institute LLC who evidently subcontracts (like the pharmacy benefit manager) to my insurance company or my employer. She asks me if I am” downhearted and blue.” I say “yes” and she sends me some uplifting books and websites to look into. Meanwhile I would like to see a therapist because I am loosing function at work due to diabetes and am very sad and can not concentrate. My primary care provider sees 10 patients per hour and is empathetic but can only refer me to a psychiatrist associated with his institution. The institution psychiatrist places me on multiple medications to address my depression and the nurse from the DM company calls me monthly. I feel no better. Months later I begin having heart palpitations which turn out to be a side effect of the antidepressants. I am now afraid to work out.

Then we approved the HITECH ACT, ARRA and ACA all of which contain system enhancing improvements that are to address our concerns and help us feel safer, have better health outcomes and have better consumer capacity to analyze the state of our own health, determine our care needs. plan for our care needs and finance our care. Because as we all know: We are all temporarily able-bodied individuals; that is unless we are delusional.

My mission with these next series of posts, articles and perhaps a self-care book is to frame America’s Healthcare System as it evolves in front of you. How is it that I can do this when others can not? Well many, more qualified people can. Most will not due to the shackles of our industry and survival instinct. Ezekiel Emanuel will lay it all out for you if you listening to a compassionate physician who gets the big picture. For now: I am no longer dependent on this industry to support me. I have no fear of exposing the truth including those elements of my past that cause me to carry shame, anger, fear and a substantial amount of JOY. The truth is; all of the commentary I have heard at cocktail parties attended by physicians, employers, patient rights groups, hospital administrators, nurses, mixtures of all levels of worker-bees is beautiful material and quite humorous. If you are a healthcare worker and are reading this than you know this material is true. If you are recently graduated from your professional training venue whether it be nursing. medical school or other and you find my words a bit offensive then please forgive me and disengage 

So for now: Let’s get started, I welcome all feedback as this material comes belching forth from my repressed memory and will try to frame my words with ego disengaged.

 

My first experience with accidental death bordering on murder:
In 1982 I experienced one of three medical errors in my career that culminated in a person’s death. I was 26 years old so I took it less seriously than I do now: but it was the start of a change in consciousness regarding my thoughts on communication breakdown within the care delivery system. Ultimately this one focus would become my life’s pursuit.
Setting: A beautiful, crisp fall day in New Hampshire, My duties that day were respiratory therapist ‘on call’ for code blue (resuscitation events): A man of about fifty walked into our emergency room noticeably distraught. “I can’t catch my breath he said, it feels like my heart is coming out of my chest”. We took him immediately to our trauma room where all of the equipment would be available should we need to perform complex procedures (temporary pacemakers etc). Laying him down on the gurney the EKG technician hooked him up to the monitor and I reached up to turn it on. My job was to assist the team if the patient arrested and then intubate and ventilate him upon order of the physician. What I saw on the EKG appeared to be a life threatening rhythm yet the physician ran into the room and announced the rhythm to be less threatening  which requires a completely different treatment approach: So I figured “well he is the doc and knows much more than little old me”. This was back in the days when a patient’s personal physician could deliver direct care in the ER as opposed to a board certified emergency room physician. This Navy Dr. was quite sure of himself and demanded respect. At the time the Dr’s diagnosis called for electrical cardioversion with a defibrillator to establish a normal rhythm so I began preparing the defibrillator. However, this was 1982 and we had a new cardiologist on staff so the Dr. in charge thought it best to ask the cardiologist if there was a less traumatic way to correct the patient’s rhythm. He yelled out Hey Dr. XXXX; what is the standard for cardioversion for intraventricular tachycardia? Now keep in mind that the nurse and I were concerned that this was a missed diagnosis and that the patient was in-fact having a heart attack.  We spoke up at this point but were dismissed due to our lower level of credentials RCP and RN vs. MD. The cardiologist said “there is a great new class of drugs that have been used for years in Europe they are Calcium Inlet Channel Blocking agents. Give your patient 4 mg of Verapamil! So our esteemed leader –without running the EKG to show it to the cardiologist pulled up 10 mg of verapamil –not 4 into a 3cc syringe and handed it to the nurse. “You will be okay in a minute Mr. Smith said his doctor, we will take your shortness of breath away shortly by giving you this drug”. The poor man was terrified and his horror made worse when my nurse friend refused to push the drugs into the patient’s IV. Dr. (Navy Save the Day) said “Fine I will do it”; injected the medicine, looked at the patient and then up at the EKG monitor. Mr. Smith sat straight up in bed, grabbed his chest and fell unconscious. As we looked at the monitor we could see that there was a clear EKG rhythm but the patient had no blood pressure nor could we feel a pulse. He had stopped breathing and his eyes were wide open with pupils dilatesd.We worked on the poor man for almost an hour. I intubated him and started ventilating while the nurse began chest compressions. The cardiologist had come into the room to take over the resuscitation effort. As soon as he looked at Mr. Smith’s first EKG he knew that he and the other doctor had made a terrible mistake. Had he looked at the EKG before recommending verapamil he would have labeled the rhythm as acute myocardial infarction with ventricular tachycardia and suggested defibrillation immediately.  What confused the patients doctor who had little clinical experience in cardiology was the fact that his patient was walking and talking.One is taught in school that a person usually loses consciousness when in “V-Tach” however, those of us who spent hours our lives reading 24 hour EKG recordings knew that many patients with good strong heart muscle can be in this rhythm while having coffee with a friend and simply complain of some shortness of breath. So this was an old-school clinical decision support error: the wrong diagnosis (bad data) given to the cardiologist (software decision support engine) caused the report (feedback loop) to the patient’s doctor to recommend the wrong therapy. Taking the advice the physician administered verapamil caused the patient’s cardiac muscle to stop contracting due to the lack of exchange of calcium across the cell membrane.

The patient’s wife arrived 30 minutes later to be informed that her partner had died from a heart attack. It’s hard to forget the screams of agony one hears throughout a career in the hospital ER. There was no incident report or mortality round on this case. The nurse and I were dumbfounded as the patient’s physician took off his gloves, through them on the patient’s chest and said “that’s the last time I ever take advice from a cardiologist”!

What I have just illustrated is a failure to communicate and validate; even in the presence of communication technology. Years later we would have computerized EKG interpretation algorithms that were often ignored due to as lack of trust in the computer. After a decade or so the interpretation algorithms became spot on and many stopped arguing with the machine.

I always wondered after this event “would this happen to me?”

Our time has come: In my opinion we have some brilliant people speaking to the topic of healthcare reform and its multiple components today. The same personalities have formed organizations that bring patients into the fold of healthcare transformation such as the Society for Participatory Medicine and its Sister E-Patients.net.

Furthermore research has confirmed that some basic tenants of care are major correlates of lower cost and higher health outcomes. These are ease of access to a primary care physician, assurance that the primary care physician treats the patient with comprehensive techniques; assurance that the primary care physicians practice coordinates the patient’s care as he or she develops new conditions and problems and requires interventions from other providers or facilities such as hospitals. Furthermore there is evidence that if the primary care database is queried on a regular basis to identify patients with chronic disease that have not been seen or are experiencing a deterioration in health status that populations can be identified and engaged well before they show up in the local emergency room. This type of procedure is titled Population Medicine.

So here we are with all this knowledge and interest. On top of that we approved a National program for the expansion of electronic medical record technology under the Bush administration. This HITECH bill was primarily a jobs creation bill but it was to create something of immeasurable value for us patients, doctors and our loved ones. A single record or location on the internet called a portal where any one clinician that might have an interest in caring for us would be presented with a thorough historical record of our problems, diseases, interventions, therapeutic outcomes, medicines etc. This alone was worth the billions spent since it could make our safe at a time in history when the institute of medicine was quoting over 100,000 deaths per year due to therapeutic misadventure. I call this permanent record “the life-long plan of care”

This engineering feat was not rocket science: it required technology that we had in place and a social infrastructure that we did not. By social infrastructure I mean an agreement among industry providers, provider specialities, hospital organizations, employers and insurance companies to settle on a standard clinical and business syntax defined by the context of the workflow or data flow and not interfere with the transfer of information between organizations holding information and their competitors since patients are transient. Metaphorically speaking it is similar to my exchanging the service records on my car between competing car dealerships and then downloading a copy for myself at home. In fact here is evidence that it is not happening while the private eHR companies selling their wares are owned by CEOs worth billions! Doctors challenged by data exchange

Crap! We still don’t have it! I am reading about campaigns “give me my data!” #gmmdd because evidently patients are having trouble accessing their records, test result etc.

My friends all tell me that they have been told by their providers and doctors that they have their own portal access their records, talk with their docs and download records. In fact they do. Here in the RTP area of NC I can count seven clinical portals that a patient’s clinical information may reside in. I have tested them all and have no problem downloading my personal or a friend’s personal information from each portal. This leaves me wondering if the campaign should be labeled Give Me My Data or “Wait Wait Don’t Kill Me” ,#WWDKM “I have data and you do not.” This is a much more succinct description of the problem in my world anyway. (credit to NPR for paraphrasing their wonderful show “Wait Wait Don’t Tell Me”)

What scares me is that I understand the cost of sharing information and it is not just some random charge made up by vendors. You see the vendors were given three guidelines to meet for interoperable data. However, during implementation it is possible to modify the system templates thereby creating artifacts as data cross the street from hospital A where Blood Pressure means Blood Pressure and Hospital B where Blood Pressure means Respiratory Rate. These are the CCDA documents that your physicians patient portal allows you to download either in the form of a pdf document or .xml document adhering to CCDA guidelines. So where you and I can download our information, good luck uploading it into another facilities records. So, once again…I am doing what I did in 1981 and hand carrying my test results and visit summaries to each specialist and each hospital that performs surgery. From the surgery perspective it is important because I am diabetic and have a family history of hyperpyrexia; a condition where in reaction to an anaesthetic agent your body heats up to 105 degrees and starts to melt on the OR table.

So as we riot against the machine because we are afraid for our very own lives remember who the villains are: No body! The manufacturers have certified their ability to interoperate. The ONC did not consider a standard where it is suggested that you document your capacity to exchange data in all contexts: Administrative, Financial, Result Observation, Continuing Care Document Architecture Record between every known vendor of eHR software that has received the same level of accreditation. This is an oversight or someone was paid off I am not sure. All I know is that the Epic enterprise EHR is deployed in three hospital systems that I use including their partnering physicians and I am unable to transfer my data between systems without a download and manual entry of results which never make it to my medical record because patient entered data are considered unreliable. Such arrogance! Don’t you think?

Below I illustrate and describe my current processes which include the use of MS Healthvault for data consolidation. This will be part 1 of a series that I construct with the objective of embarrassing an industry that has been playing a shell game for three decades with our private and taxpayer dollars. In the end you will hopefully have more clarity on why it has never worked, why it won’t work without a change in societal attitude toward health care as a right vs commodity and how we might change the future by getting clear with our healthcare business leaders and policy wonks now about our understanding of their special interest controlled industry.

I have been reading the same complaints for three decades; I have worked in provider industries and taken advantage of others in accordance with corporate doctrine, I have struggled to get my long-term needs met as well as those of friends, neighbors and family members. I have seen us come around now through three complete cycles of “novel idea that will fix medicine” followed by “new opportunity for new industries to form and to get wealthy on the suffering of patients and the majority of the workers who provide the most nurturing experience while they earn $15.00 per hour. I have had 45-year-old physician friends throw up their hands and walk out the clinic door with tears in their eyes as they dropped their career while still paying their student loans. It goes on and on but I do not. So now, with neuropathy advancing, fingers aching from arthritis as I type I say to you: I might need to rest and bleed for a while but I ask that you carry me to the next gathering to continue the fight.