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Most hospitals have slim margins, and budgets are set based on anticipated average patient reimbursement at Medicare rates. Some private insurers pay higher rates than Medicare, and the differential is often used to offset the cost of treating Medicaid patients. Medicaid reimburses at about half what Medicare pays, which is usually not enough to break even. Out of financial necessity, Medicaid patients are often given limited access to care and services. This is done in some subtle and some not-so-subtle ways. In a recent conversation with an orthopedist friend of mine, he confided in me candidly:
“Some of my colleagues in private practice can’t pay their office overhead if they treat Medicaid patients. So we see poor people with severely arthritic joints left in pain at home. In addition, with bundled payments, the surgeon gets a fixed amount for the patient’s operation and recovery. What incentive is there to send the patient to a rehab facility? It just takes money away from the surgeon. So the poor have to suffer with very long wait times to see someone who will operate on them, and then afterwards they’re on their own for recovery. Patients who go straight home are at higher risk of falling and may have much poorer outcomes. Surgeons get financial incentives for good outcomes, so it becomes a double disincentive to treat Medicaid patients. You don’t get enough for the operation, and you’re likely to get penalized for their poorer outcomes. Some surgeons I know wont touch a patient with Medicaid for any elective procedure. I have ethical problems with that – so I work at a non-profit hospital where we treat everyone. But I have to do higher volume to break even. I work 90 hours a week and barely see my family. I don’t know how much longer I can do it.”
It is common practice among nursing homes to have a limited number of “Medicaid beds.” The facility simply declines to admit more than 20% of patients with Medicaid. I hear case managers on the phone all day long, looking for a post-acute care facility who will accept a Medicaid patient. For the few non-profit facilities who don’t turn them away, deep financial costs are incurred as they struggle for survival.
The reality is that Medicaid rates are so low that having this insurance is not much better than none at all. As I’ve explained previously in the outpatient world (see an example of an insanely low Medicaid reimbursement for eye care), Medicaid is tantamount to charity care. The news that 21.3 million Americans might receive Medicaid coverage in the next decade should not be hailed as a leap forward. As I see it, that’s just a larger group of people with debilitating arthritis who can’t get hip and knee replacements and are left to suffer in pain at home.
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*This blog post was initially published on the Barton Blog.
When doctors complete their residency training, they are under a lot of pressure to land their first “real job” quickly. Student loan deferments end shortly after training, and whopping debt faces many of them. But choosing a job that is a good long-term fit can be difficult, and gaining a broader exposure to the wide variety of options is key to success. That’s why “try before you buy” can be an excellent strategy for young physicians.
Locum tenens agencies such as Barton Associates work with healthcare organizations and practice locations across the country to offer a variety of temporary assignments for physicians.
These agencies negotiate your salary and call schedule. They also arrange the logistics, covering the costs of travel and accommodations. Once the doctor and the facility agree to terms, the physician simply arrives on the required date(s) and takes on the responsibilities requested. It’s a hassle-free, minimal-commitment arrangement that pays an hourly or daily rate for work.
Locum providers are given the convenient option to receive direct deposits to their bank accounts at regular intervals. Physicians can travel as broadly as they like for assignments, and the agency credentialing team works to efficiently complete any needed paperwork for new licenses and hospital privileging.
I enjoyed “living la vida locum” for six years before I landed my dream job. That’s a long time to be living out of a suitcase, and I doubt that most of my peers would want to do it for that long of a stretch. But an amazing thing happened during those years: With each new hospital experience, I gained insight and knowledge about my specialty. By rubbing elbows and networking with a wide swath of patients and experts across the country, I became a sought-after consultant in my own right.
I experienced different ways of delivering healthcare — from critical access hospitals to bustling academic centers. I learned about best practices and creative solutions that administrators and clinical staff had discovered to improve care quality, given the limitations of Medicare rules and private insurance restrictions.
When I was hired as the Medical Director of Admissions at St. Luke’s Rehabilitation Institute in Spokane, Washington, I came armed with creative ideas and a wealth of experience to draw from. I was a highly seasoned physician who had been exposed to the widest variety of patient populations and practice styles. I knew all about the unique struggles, successes, and solutions of various rehab centers across America. I now leverage that experience to drive change at my institution, and I am virtually unfazed by new problems and challenges.
The career value of locum tenens work is extraordinary. Take the time to look around you at each assignment. Learn what works and what doesn’t work, and file it away for future reference.
Like a bumblebee cross-pollinating hospital or medical practice “flowers,” locum tenens providers have the potential to drive change like no one else. When you’ve seen it all, your insights become invaluable, and you gain the maturity to know when a full-time job is the right cultural fit. Choosing the right job, on your terms and in your time, is the key to finding happiness in healthcare.
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Hope is a tricky thing. On the one hand, false hope can lead patients to opt for painful, futile treatments at the end of life. On the other, unnecessarily bleak outlooks can lead to depression and inaction. When health is at stake, presenting information with the right amount of hope can guide patients away from both suffering needlessly and/or succumbing to treatable disease.
I was reading a sad story about a patient whose physician had made her feel hopeless. She was an elderly widow with some real, but not immediately life-threatening, medical conditions. His attitude led her to believe that she was sick and useless – with little to look forward to but ongoing testing, disease progression and eventual death. His professional opinion held special weight for her, coloring her entire outlook. It wasn’t until a friend reminded her of the doctor’s fallibility that she began to question her diagnoses, treatment options, and even prognosis.
When faced with concerning new medical diagnoses, even the most educated among us tend to imagine the worst case scenario. Knowing this, physicians should take care to offer reassurance and optimism whenever it is warranted. Hope provides the energy to course correct, to fight battles that can be won, and to hold on to trust in a brighter future. Why be stingy with it when it is so easily given?
As a rehab physician I have regularly encountered bias on the part of healthy people in regards to certain injuries. I hear them whisper, “I wouldn’t want to go on living if I couldn’t walk” or “That poor man’s life must be ruined.” And yet, these feelings are not shared by those fighting the battles. In many cases, losing an ability focuses the mind on what’s important – and on all the things that can still be achieved and enjoyed. Life is a gift, and while we all still have breath – we can make meaningful contributions.
It breaks my heart to see patients lose hope, and it is sadder still when physicians facilitate the loss. What we say carries psychological weight, and we should recognize the duty we have to deliver information with kindness and respect – focusing on the possible, dispelling unreasonable fears, and emphasizing that inner peace is attainable no matter the circumstance.
In healthcare we ought to always have hope – not for perfect health, or longer life – but in our ability to overcome obstacles, to make good come from bad, and to have a positive impact on others. The choice to live our best life is ours to make, no matter the disease or condition. Never let a doctor steal your hope, but adopt the rehab mission: to add life to years.
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Most of my patients think about pain medicines in terms of the symptoms they treat. “This is my headache medicine, and this is my arthritis medicine,” they often say. Healthcare providers are more likely to categorize pain medicines by the way they work: some are anti-inflammatory, some affect nerve endings, and others influence how the brain perceives pain. But the truth is that no matter how you classify pain medicines, there is no way to know if they’ll help until you try them for yourself.
Most people don’t realize that pain management is personal. Research is beginning to help us understand why people respond to medicines so differently, and one day we will probably be able to personalize treatment plans more successfully. For now, there are several known genetic reasons why pain medicines are more or less effective for one individual over another. Genes affect:
The number of enzymes that break down medicines and remove them from the body. Some people have larger numbers of these enzymes and therefore require more drug to feel its pain-relieving effects. Others may be strongly affected by even small doses of drug.
Pain medicine receptor variations can make one medicine effective and another (nearly identical medicine) ineffective in relieving pain.
Differences in carrier molecules that transport pain medicine across the blood stream and into the cells that are triggering pain sensations. Some people have fewer carrier molecules to bring the medicine to the site of pain.
The number of “middle man” neurotransmitter molecules that pass along the pain response. Too many of these molecules can reduce drug binding and mute the pain relief effects of some drugs.
When pain is severe, prescription medications may be necessary. However, mild to moderate pain may be effectively managed with over-the-counter (OTC) medicines. I believe in the start low, go slow approach to finding the smallest effective dose of pain medicines. I always recommend that my patients read and follow all the instructions on the Drug Facts labels to make sure that they don’t accidentally overdose on active ingredients.
When I choose a pain reliever with my patients, the first thing I think about is potential side effects. Some medicines (such as non-steroidal anti-inflammatory drugs like ibuprofen and naproxen sodium) can be hard on the stomach lining, or cause bleeding in people who are at risk for it. Other medicines (such as acetaminophen) can harm the liver if used in excess, while prescription pain medicines can cause constipation and drowsiness. The best pain medicine to start with is one that is least likely to cause harm to the specific person.
The next thing I ask is whether or not the medicine has worked for the patient in the past. Previous experience is one of the best indicators of future success. Since I know that my patient has a unique, genetically determined number of enzymes, transporters, and receptors, previous experience with pain medicines will give me a good idea of how well they will tolerate it again, and if it will be effective.
Finally, I consider the type of pain that they are experiencing. If the pain is caused by inflammation (from an injury, surgery, or arthritis) I’ll consider a medicine with primarily anti-inflammatory properties. If the pain is caused by tension (such has headache) or complicated by fever, I may consider acetaminophen first. If the pain is coming from a nerve (such as sciatica or neuropathy) then I’ll use pain medicines that work for nerve pain specifically. If the pain is complicated by depression, I may discuss additional medicines and approaches.
Sometimes, combinations of medicines are significantly more effective than one medicine alone at treating pain (this is why some prescription pain relievers are combinations of an opioid and acetaminophen). When using more than one pain relief medicine, it is important to compare active ingredients in both prescription medications and OTC products to make sure that accidental overdoses do not occur. I also recommend consulting with a healthcare professional if there are concerns about drug interactions or if the patient is already on a significant number of prescription medications that could interact with his or her OTC pain medicine choices.
The bottom line is that science is still catching up to pain management. Perhaps one day a simple blood test will help us to determine the very best pain medicine regimen for a specific patient at a given time. But until then, adopting a strategy of careful trial and error (avoiding unwanted side effects, using the lowest effective doses, and consulting a physician when pain is severe) is the only option. Don’t worry too much about whether a specific medicine is “best” for your pain. Pain management is very personal, so you will need to discover your own best solution.
Disclosure: Dr. Val Jones is a paid consultant for McNeil Consumer Healthcare Division.
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Hospital culture is largely influenced by the relationship between administrative and clinical staff leaders. In the “old days” the clinical staff (and physicians in particular) held most of the sway over patient care. Nowadays, the approach to patient care is significantly constricted by administrative rules, largely created by non-clinicians. An excellent description of what can result (i.e. disenfranchisement of medical staff, burn out, and joyless medical care) is presented by Dr. Robert Khoo at KevinMD.
Interestingly, a few hospitals still maintain a power shift in the other direction – where physicians have a strangle hold on operations, and determine the facility’s ability to make changes. This can lead to its own problems, including unchecked verbal abuse of staff, inability to terminate bad actors, and diverting patients to certain facilities where they receive volume incentive remuneration. Physician greed, as Michael Millenson points out, was a common feature of medical practice pre-1965. And so, when physicians are empowered, they can be as corrupt as the administrations they so commonly despise.
As I travel from hospital to hospital across the United States (see more about my “living la vida locum” here), I often wonder what makes the pleasant places great. I have found that prestige, location, and generous endowments do not correlate with excellent work culture. It is critically important, it seems, to titrate the balance of power between administration and clinical staff carefully – this is a necessary part of hospital excellence, but still not sufficient to insure optimal contentment.
In addition to the right power balance, it has been my experience that hospital culture flows from the personalities of its leaders. Leaders must be carefully curated and maintain their own balance of business savvy and emotional I.Q. Too often I find that leaders lack the finesse required for a caring profession, which then inspires others to follow suit with bad behavior. Unfortunately, the tender hearts required to lead with grace are often put off by the harsh realities of business, and so those who rise to lead may be the ones least capable of creating the kind of work environment that fosters collaboration and kindness. I concur with the recent article in Forbes magazine that argues that poor leaders are often selected based on confidence, not competence.
The very best healthcare facilities have somehow managed to seek out, support and respect leaders with virtuous characters. These people go on to attract others like them. And so a ripple effect begins, eventually culminating in a culture of carefulness and compassion. When you find one of these gems, devote yourself to its success because it may soon be lost in the churn of modern work schedules.
Perhaps your hospital work environment is toxic because people like you are not taking on management responsibilities that can change the culture. Do not shrink from leadership because you’re a kind-hearted individual. You are desperately needed. We require emotionally competent leaders to balance out the financially driven ones. It’s easy to feel helpless in the face of a money-driven, heavily regulated system, but now is not the time to shrink from responsibility.
Be the change you want to see in healthcare.