Get your hot ICD codes on the Health Train

Medicare and other payors are mandating a conversion to the new coding standard, ICD-10 from ICD-9.  Now what's in a number?  Well, the new standard will allow for over 155,000 unique identifiers for diagnostic coding, whereas the current standard only allows for something over 9,000 diagnoses.

Converting from one to the other is a big deal since current fields in computer programs do not allow for the added field size.

What's more important to most providers is that the 'unfunded mandate" will cost a three man physician group 80,000 dollars to convert.  KevinMD and DrVal point out this conundrum in the face of decreasing reimbursement, the push for EMR and the present economic meltdown.

The Dr. House podcast fan club also has as medical consultant extraordinaire, Dr Anonymous, whose weekly show can be seen on Thursday evenings at 6PM PDT or 9PM EDT on blog talk radio.

HealthTrain Arriving from Germany

I participate in SERMO quite a bit (a physician only blog) and I came across an enlightening story about a german OB/GYN who immigrated to the U.S. after falling in love with a woman he met in N.Y. while visiting.  He tells this story on Sermo (ABC1530). Fragments are quoted here, and although his writing crosses much territory not directly related to medicine and health care, here are some of his observations and experience.....comparing, contrasting and teaching what is the difference about U.S. healthcare.................

 

"Flashback a few years, I am 18 and graduating from high school. I am considering architecture, because I would like to "produce something that I can touch, that I can show", but I end up choosing medicine. I trust my ability to study and memorize more than my artistic talent. And the promise of a good life and social standing help to change my mind. At the time admissions to medical school in Germany were strictly by grades and you needed something between A/B or A-. In Germany you have to decide on your career when you graduate from high school, typically at 18 or 19."

In the meantime the admission criteria for medical school have been expanded to include a lottery (based on the thought that performance in school may not be such a great criterion), a personal interview, a waiting list (the longer you wait and the older you are, the more likely are you to be admitted, and finally the good old grade average. They also reserve 2 % for foreigners - e.g Americans and 1-2% for "social cases" where you can be admitted after providing proof that your grades were unfairly diminished or you were impaired by circumstances beyond your control.
There is nothing comparable to the American "college" years where you look around and decide what you want to do in life. Medical school takes 6 years and The first two years are "preclinical", meaning you study medical terminology, chemistry, physics, biology, genetics, physiology, biochemistry and anatomy and histology. You take an exam after the first two years, passing is required for continuation. The following year is "introduction to clinical medicine" and includes pathophysiology, pathology, pharmacology, medical statistics, clinical examination and history taking and some introductory course in internal medicine and surgery. Again exam.
Then two years of clinical courses, which include "bedside teaching" and demonstration of actual live patients. course include all fields of medicine - internal medicine, surgery, obgyn, dermatology, neurology, urology, radiology etc. Another exam. The German exams pretty much resemble the USMLE 1, 2 and 3 in style and difficulty.
Courses usually have a "practical part", small group teaching, where attendance is checked and lectures in large lecture halls, where attendance is not controlled.
Overall there is much less control, supervision and guidance. You are free to do and not to do whatever you want. as long as you show up in the courses, pass the course exams and the USMLE equivalents, you are fine. There is no grading, ranking, no recommendation letters from faculty or from deans. You get out of medical school what you put in in terms of activity, participation, commitment and desire to learn.
You can start in fall and in spring. Medical school is...free.
Suvarov asked me about the expectations when you start?
Could you clarify the question? Expectations of the medical students, the parents, society?
I expected to learn a lot, have a challenging career, work quite a bit later in life and be rewarded with good social status and a stable income which is at least average, if not better.

 

The expectations when entering medical school are certainly not as high as here, at least not now. After a continuous decline in income and consequently status and power physicians are just another group of white collar workers. Much like physicians in America if the present trend continues (and, guys, here we go into the "conservative" issues you correctly expected).
Physicians in Germany were making excellent income with fee for service payments by the quasi government Allgemeine Ortskrankenkasse (General Local Sickness Fund), which was established almost immediately after the "Iron Chancellor" Bismarck

passed a law in 1883 to establish such funds and make health coverage mandatory for every German. Some speculate that it was a political move to ward off the socialistic tendencies at the time. The general health insurance worked very very well for almost one hundred years - and then the money ran out. The money ran out due to a combination of rapidly increasing health care costs across the board and the doubling of the number of physicians within a short time - thanks to our friends the lawyers. In the 70s it was one of the main ways to get into medical school. Peoples checked at the bottleneck places in medical school - usually the anatomy courses - and claimed that there were still unused spots. Meaning if there was a group around a cadaver of only 7 students, an additional student immediately sued and got in.

With those tricks the number of medical school students doubled within a few years - with disastrous consequences as you might expect. Within a few years there were unemployed physicians driving cabs and everybody was earning less - the pie, the pot of money available through the AOK obviously never increased, never changed. The pot of money is strictly limited by those 12% health taxes!
Consequently there was less money for everybody.....
The physicians representing the other physicians returned every year from the contract negotiations with a helpless shrug and the comment "we achieved to increase reimbursements for blablabla, in exchange for some cuts at blablabla. The cuts always were much bigger than the small pieces of candy the docs were thrown.

Pretty much the same as the negotiations with HMOs and Medicare (if there are any negotiations with Medicare!).
Those representing physicians were the same breed as the AMA people:

politicos who do not care about those whom they represent, and just enjoying their feeling of "importance", the travel, the cocktails etc.

 

Residents are picked by personal connections. Medical students that are interested in one particular specialty volunteer in that specialty, get to know the attendings, the chief etc.(PANDERING) They might help out on the floor, volunteer for overnight shifts etc. Then they might do a research project in that field, preferably in the hospital they would like to work and train in. (that works very well in university hospitals). Having good grades in the final test, the USMLE equivalent helps as well. Adn the rest is just timing, meaning you apply at the right time and you get in.
There is a significant difference to the US: While here all residents start on July 1st, in Germany you may enter medical school in Spring and fall and therefore people graduate in Spring and Fall and may apply all around the year. There is no such time as the July 1st. People start and graduate the whole year. So you never know when a position is going to be available.
Residences are not as scheduled, they are not as predictable as here. A residency may take you more time than the minimum. Your Department chief pretty much has the power to keep you and to delay your graduation for quite some time.
You can graduate when you have fulfilled your "numbers". For example in ObGyn you have to document 100 deliveries, 35 cesareans, 30 hysterectomies, 20 laparoscopies etc. Yes, these nunmbers are a guess, but they are about right. I do not remember them exactly, but they are VERY LOW compared to American standards.

 

AZdrydoc  Family Medicine

Posted Oct 25, 2008 at 4:28 PM

<The pot of money is strictly limited by those 12% health taxes! > 12% of what? Income? Sales? When you said "medical school is --free" I immediately thought, well, yeah, but who is paying for the "free"?

 

AZdrydoc, it actually is (now in 2008) between 13 and 15% of your income - of the gross (!) income! The employer and employee each pay about half of this. Yet,

this is total coverage, eyes and dental included. You have complete choice of doctors and hospitals.

I obviously have thought quite a bit about the differences between my German and my American residency. Conclusion: you guys are very lucky to have trained here. While Germans tour "academic freedom" - nowadays or at least for me just another label for "laissez faire", the Americans are much more regimented in their training, it is more scheduled, more supervised, more controlled, more defined.
Just one very important point: In Germany you have to fight for your desirable times in residency - in obgyn it is the operative floor. You try to cut your time short in places where you do not learn much, e.g "postpartum". In Germany I actually had a few months where I was responsible only for the postpartum floor. This seems utterly ridiculous for an American obgyn resident, who is used to taking care of the postpartum floor between 5 AM and 7 AM before going to labor and delivery - where, by the way, he or she also takes care of the "emergent Ob Clinic" or triage etc.
German physicians have to draw blood and start iv s in the morning! I can hardly believe it now that I am used to iv teams and respiratory that comes and draws blood gases etc. What a waste of physician time in Germany.
But then, my German Department chief said he did not want to upset the nurse by having them draw blood, because "you can get a doctor any time, but good nurses are hard to find"
The nurses really got on my nerve in Germany. I heard by far too often "You have to do that yourself Mr. (!) Abc1530,

I do not have time". Brought my blood to a boil every time. They would draw blood for the attending though....
When I left in 95, they were just introducing the ordering in the chart.....
Here in the US I write the order and bam, it get's done. If it does not get done, I am not blamed, but the nurse. If I really want, I can write her up. I have never done that though. Nurses are very good here.
Much better system here

 

Level of talent entering the door in medical school.
I am not sure if it differs. There is a study that medical students have an average IQ of 125 in Germany. I am not aware of a similar study here.

But I am absolutely sure there is a gigantic difference in ambition. American physicians are DRIVEN. Holy cow! I could not believe the push, the umpf, the stamina, the energy Americans put into their training.
Sorry, my liberal colleagues, but I believe that this is the result of two things: you have to pay for medical school! It is expensive, so it is dear to you, it is hard to get in, so you have to and you want to make the very best of it.
And, there is the promise of the big reward at the end, a reward to big that it is worth staying up late, going the extra mile, doing the whole 9 yards....
No such thing in Germany. Hey , medical school is free, yes, you heard it, free. So, it can't be worth THAT much, right? At least that's how you feel. And you do not earn that much afterwards, so why struggle! Let's live now, let's go out tonight, let's have a party..residency takes so long anyway, and hours are controlled, so youa re never exhausted, so why work your behind off?
I have seen so many slackers in my German residency, it was disgusting. I was very satisfied (sorry to say that, I aoplogize) to see that a resident who exhibited the typical slacker behavior of too many of my German colleagues in one of the American residency programs - was fired.

You either want good doctors or you don;t.

 

Yes, German physicians are more relaxed and pretty trusting, especially when they hear that someone has trained in the US. American medicine has a great great reputation almost all over the world. Americans and Sermoans may not fully realize the extent of this. You guys are the top, the best, the cream of the crop, welcome and admired all over the world. Not surprising at all that the anesthesiologist handed over the patient to you!
You grew up here, you trained here, you take the American efficiency, quality for granted!
You are the best! Become aware of it!
If I would return to Germany, my future would be secured just by spreading the word that I am board certified in the US and have actually trained and worked there.
Don't underestimate how good American medicine is! How respected it is...

In Germany we say "the prophet is ignored at home".....OUr colleagues are so used to the high quality of medicine here that they take it for granted and consider it "normal". Yes, thank God it is normal, but..... only for the US.
And , thank you for pointing out the probloem with "fixing" health care just to make it resemble the system in those countries that admire us.

On EMRx

Hi Mohican! Guten Tag!
I am using General Electric's "Centricity", formerly know as "Logician". Was programmed 20 years ago, and you feel it. I started using it 1.5 years ago. The part that is most useful is the ability to fax prescriptions directly to the pharmacy

Click-e-ti-clack and the Rx is on it's way, pt does not have to carry a piece of paper around, drop it off, wait, come back, pick it up. Now they drive by the pharmacy on the way home and it is ready.
Besides that it is a big drain on productivity. Everything takes longer, many things are hard to accomplish, such as sending a letter to the PCP that referred the patient to me.
The good side is that all docs in our health care "system" are using it and this actually saves duplicate entries and less things fall through the cracks. I can see the lab reports, the path, the radiology, the ER visit notes on my computer - and - nice too - in the office, at the hospital or at home, with equal ease. Just click and ...wonder...

But the damn thing does not even have a spell-checker! )(&!@^(%#()!

So, it has good and bad sides, overall it takes more time to work with it, but it wil surely get better over the years. When I retire the system will be just as I imagined it to be the first day when they told me about it---- ;-)

 

There is more, much more that you can gain access to on Sermo. Join, log in and search for user abc1350

Technorati Tags: german medicine,american medicine,medical students,high standards

Health Train Blogging

Only I can change my life. No one can do it for me.

Carol Burnett
US actress & comedienne (1936 - )

What blog subjects are the most popular? My recent review of the Blog Catalog, in order are:

1. Blogging

2. Arts & Entertainment

3. Technology

4. Humor

5. Health

So health is in the top five, but just barely. It is tied with Politics, and ahead of all the rest, law, business,financial,beliefs, social, and believe it or not social media.

At this time Health and Politics go together, entrenched in the economy as top talking points in the presidential campaign for the world's most powerful office.

An interesting observation from the Wall Street Journal by Robert Carroll points out the tax realities of each candidates. It gives a clear endorsement to John McCain's health policy proposals.  Would I put it in the arena of Health Care Reform?

NO.  This is merely a poorly conceived financial manipulation to have more people in the 'insured category'.  Both Obama's and McCain's Health Reform amount to a wallet biopsy.

Other issues, such as propositions in Arizona would ban programs such as universal payor or universal health plans.  Would Federal  law pre-empt  state law??

Technorati Tags: health refrom,universal payer,tax breaks,blogging,state law

Health Train Dining Car

They aren't talking to one another, while they chew their food.

Sometimes a whisper is more powerful than a shout. Here's a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

American primary care is a shambles, and it is now clear that it will not be viable in the future unless significant changes occur in our national attitude about its value and in the way we pay for it.

So what should we do?

The National Committee for Quality Assurance proposes a plan

Another interesting, and perhaps more far-reaching proposal (Download finalpcppaper.doc) has been made by Norbert Goldfield MD and his colleagues. Dr. Goldfield is a highly respected health care innovator,

The articles go on to elaborate how this would work, and how PCPs would be rewarded for acting as the fiduciary and patient advocate, unlike the gatekeeper model, which fails miserably.

Collapse, a book which discusses how societies choose to

suceed or collapse is a worthwhile read.

 

Given the current crisis, and quick fixes proposed by both Presidential candidates it becomes patently obvious the internal mechanisms of patient care  need to be 'fixed'' before any more money is thrown into medical care.  Physicians and educational programs need to climb on board the new Health Train.

Health Train Committees

 

Quote of the day:
Committee--a group of men who individually can do nothing but as a group decide that nothing can be done. - Fred Allen

************************************************

KevinMD..................

The High Points:

A family physician shares her ideas on fixing our health care system. Someone better put Elizabeth Pector in charge of something, because her ideas need to be instilled stat. Like this one, explaining why physicians deserve equal rights:

When it comes to equality, doctors get the short end of the stick in our health-care system.....duh !!!

In short, as part of restructuring the health-care system, physicians need to be put back on a level playing field with the rest of the health-care players, so they can provide input prior to implementation of supposed cost-saving measures that often only transfer costs to doctors.

Another must read from KevinMD---how about just writing it out?

Point of Law  (you best believe it)

Health Train Express International

 

Perhaps we should emulate the Chinese in revising our health care system.  Long considered primitive regarding health care, China is taking a bold step toward caring for it's billion or more people.

The Chinese however may have an advantage that much like building a home, it is much easier and less expensive to start from scratch.  The United States is faced with disassembling a system that has grown over the past 100 years or more and transitioning to a better means of financing health care.   We see that a large barrier to transitioning lies in the financing. Converting to a new system will be disruptive financially, and  old habits are difficult to break.

The Wall Street Journal reports that China is aiming for universal heatlh care.

The proposed plan would be quite a shift for China. The draft plan’s overall goal is to cover 90% of the population within two years and achieve universal care by 2020. It aims to return to non-profit national health care, an idea that was largely abandoned in the country 1980s.

This all stands in contrast to China’s current system, which provides little government funding to government hospitals and requires patients to pay heavy out-of-pocket expenses. The WSJ notes that out-of-pocket payments made up more than 60% of health spending in China at the end of the 1990s.

The plan — drafted in consultation with groups including the World Health Organization, the World Bank, consultant McKinsey & Co. and a few Chinese university-based public health experts —-----The government also aims to set pricing standards for medical services.

Other news about Chinese health care, Pharma,Western style hospitals is in the Wall Street Journal. And what does Heparin have to do with hot dogs?

In China as in the United States reform has it's skeptics.

Technorati Tags: china,healthcare reform,world health,pharma,public health

Health Train Express Roundtable

Today's Health Train Express takes us to

The View from Here...my other blog.

Click Here

Post II

Financial Analytics vs. Health Analytics

Health Train Reform

I have reviewed the proposals of McCain and Obama.

Frankly I do not think either proposal is going to do much to improve health care, reduce costs, or satisfy anyone for very long.

1.The proposals do not address internal problems with delivering health care wisely , or efficiently

2.Both  proposals use tax policy to create change, and campaign issues revolve around tax credits and/or deductions.

3. Neither proposal addresses the increased utilization from baby boomers

4. Both proposals do not address medicare's approaching insolvency.

5. Each proposal is bound by partisan politics

6. We should not decide upon health care issues during

a heated political debate.

We should step back, and allow the financial crisis to cool down, assess the impact of the financial bailout program.

No one can make an educated guess until we see how our economy shakes out from the financial crisis.  There are many unknown factors operating in our free market system.

We do not know how, when or where the financial bailout will be distributed.  Initial funding has made most prudent planners skeptical as to whether the banks (the ones who perpetrated the crisis) will  judge correctly how to use the funds for the good of all of us, or probablly just go on playing the same game....save their own behinds. One obvious warning is the admonition from GWB that they need to 'loan the money" and not hoard it.  Bankers don't give a rat's  a-s about customers...only what their shareholders think and do. They have no motivation to change their game, and we have rewarded them for their incompetence. Their excuses are lame.

If you are a big banker, or insurance company the rules are different than those for you and me.  This 'bailout money" had better be a loan and not an outright gift to them.  Foisting this debt off on the American Public is an outrage, and  probably justifies throwing out the vultures at the top of the predatory feeders. Why would anyone want to appoint executives from Goldman Sachs, and other financial institutions in charge of the hen house  to these positions again?

The manner in which this is being addressed should alert anyone with common sense that this is what will happen to health care financing as well.

For more information link to my other blog

Out of the Fog

The fog lifted quickly this morning. It burns off in mid morning and things become clearer as I head off , not on call, not worrying about seeing 40 or 50 patients with itchy burning eyes, floaters, flashing lights, computer vision problems, chldren referred for evaluation of dyslexia referred by a  school psychologist for eye exercises. Mixed in with that mix are the retinal detachments, acute narrow angle or undiagnosed chronic glaucoma, the ocassional herpes dendritic keratitis, zoster, macular hemorrhage, vein occlusion and central artery occlusions. and the bread and butter for most ophthalmologists....that cataract !

But as I said I am not going to be doing any of that for awhile.....perhaps never.  I have made my mind up to become 'cognitive' again after several decades of assembly line medicine seeing 50 or more patients a day. I sometimes lie awake at night, and also during the day (between naps). It must be the sleep apnea as well as my antidepressants and meds for bipolar spectrum disorder.  Now that you know the 'truth' about me you will understand the reason(s) for the nature of my writing.

I had always attributed my sense of anxiety and apprehension as well as occassional irritability and impatience to my sense of superiority in all  things medical and surgical. I mean I survived college, med school, internship, residency, military service in a combat zone, with several episodes of moderately severe depression which I always attributed to my meager financial resources,  and family responsibilities and seemingly endless nights on call and moonlighting to survive residency. Early on my anxiety would bring me to a therapist. It felt good to ventilate. So after 30 years or more my last therapist told me that I sounded 'bipolar'.   Well, shit yes...!! How else would any normal human be able to have normal SSRIs with little sleep and staggering hours and workload without a bit of an imbalance in vital neural brainwash.??

Now, I don't know what bipolar sounds like.

There, I have exposed myself.... my hidden vulnerability.

I have not changed, but the world around me has changed. All the things I studied for and worked for are gone. (but not my family) So it's not my fault and it is not my responsibility to adapt anymore.  I now have a new fundamental understanding and gestalt for those 'old eccentric folks' walking around babbling and seemingly inappropriate....

During my 'seeking'  a career transition (a euphemistic saying to cover up boredom, burnout,or whatever) I visited a local Starbucks near a UC campus.  There it was....the future of the world, a lot of Apple Macs (all white) and lots of Asians. (no insult intended).

I  am not certain what the p.c. term is for those of asian descent.  It seems many Asians excel into getting into the UC system.

This is a wonderful that they  move to the U.S.to keep our universities full, since our own public school system cannot keep up feeding the greater University system.  The unemployment of college professors would be much greater without Asian participation.  What goes around in the business world also comes around in education.  So our educational institutions also participate in the global economy I am just concerned that our balance of education is negative. We need to export more students!!

If you haven't applied for a job in the normal workplace in the last ten years, you will be in for a shocker. 

You have to do most or all of it online....No face to face

unless  you can penetrate the software algorithms screening for key words in your resume.

I am even suspicious that you do not have to write coherently, just put the correct keywords, or tags in the appropriate fields.

Guess the correct combination and your resume does not get filtered into some giant resume spam file.....

presto it appears in the 'incoming resume file for some lower level flunkie to bring into the dean's office, or the human resource filter to be forwarded to the appropriate department in whatever business you will be hired to continue your financial plans.

del.icio.us Tags: fog,flashing,keywords,resumes,interview,finances,nest egg,burn out

Health care vs. Health Care

Yesterday's posts were truncated by some other important issues.

Today I am a bit overwhelmed by what to post. The issues are legion.

Our first great event is the State of California being held in contempt regarding funding of Prison Health Reform  The issue is that  the courts are insisting that California write a bad check to initiate planning for the new prisons. (when I do that I get charged for overdrafts, and possible criminal charges.)

Our second great event is the State of California v. the County of Santa Barbara.  The state claims it overpaid Santa Barbara in Medi-cal funds. 

Just what I love...my government using my tax dollars to fight with one another...net gain less than zero...pure stupidity, audit it and report it, and don't make the same mistake again.

We need more government involvement in healthcare (sarcasm)

 

del.icio.us Tags: prison reform,healthcare lawsuits,santa barbara,Schwarzenegger,medi-cal overpayments

Health Train Express Travels through the Cloud, or should we say Fog??

What's in a name? Is it a cloud or fog? It depends upon your altitude.....and the dew point....

Sublimation....the transformation of a solid directly into a gas, ie dry ice to vapor.

Microsoft has announced it's new "Azure" platform...it's answer to Google's online microsoft look alike solutions available on the internet. They are calling this "Cloud computing".  We'll see if it a cloud or fog (vapor)  soon. Cloud Computing according to Wikipedia

This announcement reveals a major shift in software development applications for health solutions in both business and clinical applications.  Look here for more information at a later date on specifics about cloud computing and healthcare.

Our medical practices have gone from being solid business platforms into vapor at times. Is this sublimation? At one time our medical practices were a sublime portion of our daily lives.

Happy Hospitalist Express

 

from THE HAPPY HOSPITALIST VIA GRUNT DOC

For most of you out there, I will never meet you. You will live long, prosperous, healthy lives. You will raise families, remain gainfully employed, go to church, give back to the community and generally live. You will play by the rules. You will have your ups and downs and life will go on. What I describe in my blog and experience in my life as a hospitalist represents a very skewed representation of America. I am often lambasted by others for being unHappy and distressed with my situation. That couldn't be farther from he truth. What I try and present to you on the Happy Hospitalist is the gross abuse running rampant in our health care system. The abuse, I believe, entirely the result of third party rules and regulations, has become intolerable for many health care providers. Enough to make many quit. The abuse running rampant by the few has also had the effect of driving up prices for everyone looking for health care security.
So I ask the question, what type of patient are you? Are you contributing to the demise of the third party model so ingrained in our current culture.

del.icio.us Tags: health care abuse,patient,hospitalist,third party model