Home / Tag Archives: Policy (page 4)

Tag Archives: Policy

Dr. Google, meet Pharmacist Bing

FDA decides whether to allow patients to purchase prescription medications over the counter for many common ailments. This idea is controversial. On one hand, deregulation would remove one of the largest barriers to receiving treatment for some conditions – the doctor’s visit. If no doctor’s visit is necessary to receive necessary blood pressure medications or diabetes medications, then patients don’t have to wait for an appointment and the patient/government doesn’t have to pay for the doctor’s visit. The move would also purportedly cost patients more money for their prescriptions because insurance companies (including Medicaid) don’t pay for over the counter medications. Therefore the costs for medications that go over the counter would be shifted to the patients who purchase the medications. But on the other side, I’m sure that patients will “Bing” what medications they think they need, and the proposed plan would require patients to answer questions online or at a kiosk and then get input from a pharmacist before the prescriptions could be purchased. So there really isn’t unfettered access to the selected prescription medications. According to the article, the American Pharmacists Association is embracing the concept while many doctors’ groups are opposing the idea. Pharmacists believe that their increasing role in a patient’s medical care will be a good thing while physicians see many of their “bread and butter” patients skipping appointments and instead going to the pharmacy kiosk. Some of the conjectures about such a policy should be addressed. Will prescription costs for patients go up? If patients have to pay out-of-pocket, then perhaps they would be paying more money for prescriptions, but I doubt that the amount of money would be much more than the copay they were previously paying. I imagine that most of the medications considered for over the counter use would be generic medications from the notorious “$4 list,” so the financial burden on a vast majority of patients would not be great. However, there are certain medications that have no alternatives. Consider colchicine, vancomycin, and Plavix. Medications similar to these would continue to command a higher price. If patients need such medications or desire name brand medications, then they will keep going to the doctor in order to get their designer medications for a $20 copay. However, medications that do have a generic or over the counter equivalent will see downward pressure on their pricing. Who in their right mind would buy a $300/month name brand medication when the $4 generics (or a combination of $4 generics) work just as well? So pharmaceutical manufacturers would have to justify the price of their expensive medications or would have to lower the price until patients felt that the price justified the benefits over generic medications. That’s free market at work. Will the public be in imminent danger if they are allowed to self-prescribe? I doubt it. The Angry Pharmacist has a different take on the matter (read the post from behind a blast shield because it is rife with f-bombs). He believes that patients who take some medications need to be medically monitored for adverse effects from the medications. For example, patients who take ACE inhibitors may have deterioration in their kidney function from the medication and may even develop renal failure. If patients are worried about the effects on their kidneys, they can see their doctors for such testing. There are also some online labs that will provide direct-to-patient testing. But if we consider the renal function example, we can also look at Mexico where patients can purchase many medications over the counter. The rates of chronic kidney disease are no higher ...

Read More »

Drug Shortages

Just got word that several additional medications have been added to the national list of “drug shortages”. Doctors better start learning more about wilderness medicine at this rate. I can see the management of our next unstable patient now … [Call comes in on telemetry line] “We’re coming to you with a 44 year old male hypotensive and unresponsive. Short transport time.” [15 minutes later, the crew arrives] “Sorry it took so long, our ambulance ran out of gas because we couldn’t afford to fill the tank due to the high gas prices and low Medicare/Medicaid reimbursements. We had to call for assist with transport from the Amish Ambulance Service with its horse and buggy. By the way, do you know where I can get a broom and a very large shovel?” [Patient is hooked up to the monitor. Wide complex bradycardia. Pressure 60/40. Dialysis graft is noticed in his arm.] “Dialysis patient. He may be acidotic and hyperkalemic. Give him an amp of bicarb STAT.” “Sorry doc, we’re out. There’s a national shortage.” “Keep that fluid bolus going. Let’s start some Levophed on him to raise his blood pressure.” “Sorry, doc. We don’t have any of that either. National shortage.” “Well let’s at least give him some Vancomycin in case he’s septic.” “I’d like to, but I can’t. That’s on national shortage, too.” “Well, he’s not responding very well. At least let’s get him intubated. Can someone push some Rocuronium?” “Don’t have that, either. National shortage.” “Vecuronium?” “Nope. That’s out, too.” “Pavulon” “Nope. National shortage.” [patient now loses his pulse] “He’s CODING! Start CPR. Give him an amp of epinephrine, STAT.” “Sorry, doc. National shortage. Don’t have any.” “OoooKayyy. Give him an amp of atropine, then.” “Don’t you know that atropine isn’t part of ACLS protocol any more? Besides, we don’t have any and there’s a national shortage of atropine, too.” [patient is unable to be resuscitated and dies] Six weeks later, the doctor receives a letter from the Arizona State Nursing Board [for those who don’t regularly follow this blog, this is parody — background here] informing him that he is being investigated for failure to properly manage the patient and failure to properly look out for the patient’s best interests, too. He must submit to a psychiatric evaluation, must submit to a genetic test to assess his future intellectual capacity, and must submit to a hearing in front of the whole nursing board to explain himself or else his name will be posted somewhere on the Arizona State Nursing Board’s web site and he will never be allowed to be a nurse in Arizona. “I think I’m going to be sick.” “Hope not. We’re out of Zofran, too. National shortage.” [fade to black] UPDATE Good thing I had extra coffee and some old jumper cables laying around to jolt my heart back into a normal rhythm after seeing the Instalanche! Thanks, Glenn!

Read More »

“Safer” Conscious Sedation

I’ve performed conscious sedation dozens of times. Never had a problem. Not once. Until now. For some unforeseen reason, our hospital has now decided that there are multiple additional hoops through which physicians must jump in order to be credentialed to perform conscious sedation. We have to be certified in ACLS. We have to sit through a course on conscious sedation so that we know the difference between light/moderate/heavy sedation and general anesthesia. Then we have to take a test on the medications we prescribe to make sure that we know that the medications may … make patients drowsy. There are several “pre-procedure” forms that we have to complete to determine how difficult a patient may be to intubate … if intubation is needed. And, while the patients are in their sedated state, there is a six page form that the physicians must complete – in addition to another several page form that the nurses must complete. Looking through all the additional proposed paperwork, I’m not really sure how there will be time to do the procedures when all of the paperwork is required to be filled out and medical care will obviously just get in the way. Yup. Conscious sedation just became a whole lot “safer.” I’m glad. But I just don’t think that the paperwork is appropriate, and I think the overwhelming focus on paperwork is bad medicine. Because of that, I withdrew my privileges for performing conscious sedation. I’m not the only doctor who has done so, either. Now, if patients need conscious sedation performed while I’m working, the hospital has decided that I am no longer competent to perform the procedure. From this point forward, patients who need conscious sedation in the emergency department will get an anesthesiology consult and the anesthesiologist can deal with the hassles if every last one of the multitude of checkboxes hasn’t been completed make sure that the conscious sedation is performed properly. That will cost substantially more money be safer. And from this point forward, if the anesthesiologist is busy in the operating room (which is likely during the day) or is gone for the day (which is likely at night) and can’t come to administer the same medications that emergency physicians administer all the time, the patient will have to be admitted and the procedure will need to be performed in the operating room. That will be even more expensive and time consuming safe. Patients with dislocations or other painful conditions who need procedures performed will have to wait. I’m competent to give them IV pain medications (we’ll see how long that lasts), but just not IV sedation. Patients who need IV sedation will need to speak to the anesthesia specialists. I’d like to help and I’m able to help, but I’m just no longer certified to help. Everyone is just looking out for your safety. Now the Medical Marijuana Advocates (nee “the Joint Commission”) has further justified its existence because it can now REVIEW the stack of charting required for every patient that has received conscious sedation and threaten the hospital with decredentialing if every last check box on every last form hasn’t been completed correctly make sure that things are safe. It might even be able to create a booklet to describe how to pass inspection for said paperwork which will cost $595 per year be made available to hospitals. Hospitals will then be able to hire advanced consultants to look over all the paperwork and make sure it is complete before JCAHO comes to visit. But patients will be “safer” … at least on paper. Isn’t ...

Read More »

How Time is Spent During an Emergency Department Shift

During one shift last week, I felt as if I was spending too much time doing computerized charting, computerized order entry, and computerized admit orders [contractually required to write them – don’t ask] and not enough time with patients and their families. This week, I decided to account for every minute of my time during a 12 hour shift in a moderately busy emergency department where I was the only physician working. I had to scrap the first time I tried it because I kept forgetting to write things down. The next shift, I put the notes where I wouldn’t forget – right next to the computer keyboard with portable clock sitting on top of them. There is a little bit of overlap between categories when I was multitasking. For example, if I was speaking to a doctor on the phone while charting, I counted the time as only speaking to the doctor. Out of a total of 720 minutes in the shift, I calculated that I spent the following amount of time performing the following tasks: Seeing patients: 247 minutes Time on computer: 365 minutes including … –Charting/entering orders and labs to be done: 219 minutes –Looking up old medical records: 42 minutes –Entering discharge instructions/prescriptions: 41 minutes –Entering admit orders/completing transfer forms: 63 minutes Discussions with other physicians: 69 minutes Researching medical issues: 13 minutes Eating lunch: 5 minutes Personal phone call: 4 minutes Miscellaneous down time: 12 minutes Sign out to oncoming physician: 5 minutes Longest time between patient exams: 47 minutes Involving: 24 combined minutes charting patient’s condition and entering orders, 13 minutes discussing the patient condition with three physicians, 10 minutes completing transfer documents and giving report to medics I probably write more than most docs on my patient charts. Even so, more than half of my time was spent making sure that the charts were documented sufficiently to satisfy hospital administrators, to please governmental payors, and to smite plaintiff attorneys. I’ve had some nurses tell me that I spend too much time with patients. My shift averaged 7-11 minutes per patient, with a few outliers. In total, I spent only one-third of my 12 hour shift with patients and their families. That’s too much? Kind of disappointing to realize how the practice of medicine has “evolved.”

Read More »

Pay Up or Leave

Want non-emergency care in the emergency department? Pay up first. After performing a federally-mandated screening exam, many hospitals are now charging an up-front fee of $100 to $150 to be treated for non-urgent complaints. Don’t want to pay? You’ll get a list of other health care resources and can leave. And it is happening … all … over … the … country. ACEP is against such a policy, arguing that 2 to 7 percent of patients determined to have “nonemergency” conditions are admitted to a hospital within 24 hours and that a vast majority of patients have conditions requiring urgent treatment. I don’t think the policy is a bad idea, provided that patients have an alternative source for routine care. Medical care costs money … a lot of money. The problem is that when the practice becomes commonplace and a public outcry occurs, I can only imagine what new laws that will be created to force hospitals/providers to provide treatment to all emergency department patients.

Read More »

Legislative Fixes

Washington State drops its plans to limit Medicaid patients to three emergency department visits per year. Instead, Washington plans to institute a policy of refusing to pay for any emergency department visits by Medicaid patients that are deemed “unnecessary.” What effect will this policy have? Medicaid patients can’t/won’t be charged for the “unnecessary” visits. Washington state will no longer pay for the “unnecessary” visits. Therefore, hospitals and medical providers take a financial hit if the state makes a retrospective determination that a visit is “unnecessary.” In order to make the determination whether a visit is “necessary” or not, Washington State officials must rely upon what is written in the patient’s chart to determine a patient’s complaints, diagnosis, and workups. Who controls what complaints are emphasized on the charts and how the complaints are worked up? The same providers that will be financially liable if the visits are deemed “unnecessary.” If this policy survives the legal challenges that are being mounted against it, look for a sharp increase in the number of patients diagnoses that Washington State does not deem “unnecessary.” The funny thing is that when you pay for a result, you often get the result. Remember when Medicare started docking hospitals that had central line related bloodstream infections? When hospitals don’t get paid for patients with central line related bloodstream infections, the incidence of such infections plummets. But the incidence of bloodstream infections in general goes up. It’s all in how you define the issue. With emergency patients, the demographics won’t change. The patient complaints won’t change. The diagnoses will change a lot – especially if patients know that they might be triaged out of the emergency department without receiving care and sent to a medical clinic if they have certain “unnecessary” complaints. If I was running a hospital, I would even put a sign up in the waiting room stating which complaints/conditions that Washington State would pay for and telling patients that after they receive their federally mandated triage exam, they may be sent to a clinic for their care if they do not have one of those conditions. Because reimbursable diagnoses are usually paid at a higher level, I think it’s a safe bet that Washington State will end up paying out more money for emergency department visits by Medicaid patients. Your baby needs to be seen for a cough? Coughing is an “unnecessary” complaint. But, that cough could represent RSV pneumonitis or pneumonia. Those aren’t “unnecessary” diagnoses. Instead of giving you some cough medication and discharging you, we should probably do some blood work, a chest x-ray, and get a nebulizer treatment going just to make sure that there’s no pneumonia or RSV present. When legislators try to fix a system that they know nothing about, they often just make the system worse. And then they need to create more regulations to try to fix the problems they created with the initial regulations. We’re from the government. We’re here to help.

Read More »