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Demystifying Medicine One Week at a Time

Category: health care reform (page 5 of 13)

Hospice: Mission Creep

Doctors are asked to sign things all the time: Prescriptions, home nursing care plans, death certificates, diabetic shoe forms.

Less frequently, hospice verifications.health_care_spending

Why was I asked to sign hospice orders for Mr. Taylor? Sure, he was old. Eighty-seven.

He’d survived decades of high blood pressure, two major surgeries, unintentional weight loss, chronic pain, headaches, even a benign brain tumor. But I had never referred him to hospice.

I wouldn’t have diagnosed him as “terminal,” i.e. expected to live six months or less. As far as I could tell, he’d just keep on truckin’ for another year or three.

So why was I being asked to sign hospice paperwork for him? How did this come about?

“Mr. Taylor, why are you in hospice? Are you dying?”

-Not that he knew of. He’d just been told that he’d get more ‘home services’ that way.

“Who set this up for you?”

-It was one of those “home doctors.” Geriatric care providers that offer house calls to infirm seniors when it’s too hard for them to come to a doctor’s office.

Thing is, he was still plenty able to come to my office. And did so regularly.

Apparently, though, the opportunity to get more home services was too good to pass up.

The agency that was providing him at-home medical services referred him to a for-profit hospice firm–one that could collect the daily Medicare fee for a hospice enrollee.

Is it any wonder, then, that we’ve seen a surge in hospice enrollments in the last few years?

Finally, someone has written something about it. Thank you, Washington Post.

Internet House Calls

It’s not the first, but it’s generated a fairly big announcement:

A company called American Well has introduced virtual visits directly to consumers in Massachusetts. [They’ve already been doing it in 43 states and the District of Columbia.]

A hand with a stethoscope to give an examThe company has been partnering with insurance companies to provide internet-enabled visits to select populations. But now going direct to the public in the state with the highest number of doctors per capita has increased their visibility.

For the introductory price of twenty bucks (visits usually are forty-nine per), you can sign up and have a vetted medical professional (one that you select from a roster based on background, specialty, and availability) diagnose and even treat you for your problem.

Treatments include e-prescribing of antibiotics or other medications, in addition to advice. Potentially addictive controlled substance pain medications (Vicodin, Lortab, et al.) are not permitted.

Depending on your viewpoint, this is another step forward in technology enabling consumer-driven and consumer-friendly health care. Or it’s another insult to the primacy of the doctor (aka “provider”)-patient relationship and the “Medical Home” model.

Would you confer with a doc online, if you could see her and talk to her “live?”

Broken Dishes

Here’s an idea that seems unfair:

grady

Grady Memorial Hospital, Atlanta.

Hospitals, long searching for ways to minimize their streams of uninsured patients (written off as “charity” or “uncompensated” care), signed on to the Affordable Care Act (“Obamacare”) through their trade associations.

They stood to solve one of their longstanding problems by cooperating with Congress and the Administration to help Americans.

Now, in states not accepting Medicaid expansion (e.g. Georgia, Oklahoma, Texas, etc.), those hospitals are feeling the pinch twice.

Obamacare is in part financed by funds earmarked for hospitals providing a “Disproportionate Share” (i.e. “DSH“) of unfunded care.

Now hospitals in states that aren’t expanding Medicaid not only won’t get payments from newly enrolled Medicaid-eligibles, they’ll be losing their “DSH” payments.

Double whammy.

Here’s the thing, though: Stubborn governors and legislators who will not accept the 100% federal financing of Medicaid expansion will feel the bite. Eventually.

Hospitals will close. Citizens will be angered. Employees will lose jobs.

Those last two in any order.

#9 Dream*

It’s been an interesting week.doc-office-aca_wide-403577f90f9f2aa9fdfb92060c1f512825900d1f-s6-c30

I wrote an essay with some predictions (nine, to be precise) about where health care is headed in the Obamacare era, and it got some attention.

Please check it out: it’s on the NPR “Shots” blog, and it’s called “A Doctor’s 9 Predictions About the ‘Obamacare Era’.” Here’s a link: ARTICLE  [Or just click on the picture accompanying this post.]

I’m really happy with the response the article has been generating. If you scroll down below the article and read some of the comments, you’ll see that some folks think I’m anti-Obamacare, while others think I’m slandering Republicans. That’s how you can know when you’ve gotten it near-right. Critics from both sides!

I’ll say this: people often criticize journalists for bias. I think the comments demonstrate (if you read the article carefully) that respondents inject their own biases into how they see the article.

My thanks to the editors at “Shots” for shaping a solid piece and making it all the more logical, powerful, interesting and attractive.

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*#9 Dream: a song by John Lennon. Click here to see John and Yoko canoodling all over town.

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