Archive for February 2015

Bad to the Bone

I came to hospital medicine from the land of pulmonary/critical care. I had spent ten years dealing with septic shock, respiratory failure and acute renal failure. I had intubated, withdrawn life support, placed central lines, performed thoracenteses, and even placed a couple of chest tubes. I had changed tracheostomy tubes, I ran codes. In short I was a critical care bad ass. I thought I was hot stuff. But I tired of critical care, so I went to hospital medicine. And died. Just died on the vine. It turns out that the skill sets necessary for critical care are different from those that are required for inpatient care of general medicine patients. So despite a DECADE of inpatient care in a 24 bed ICU, I was woefully unprepared for hospital medicine. I felt like the stupidest bad ass in the world. Because I was! I tell you this for a…

10 Scripts Never to Write

by Dr. Charlie Reznikoff, MD A few months ago while attending the general medical floor I met a 60-year-old patient in a tragic situation. She was holding her household together -- cooking for, cleaning up after, and parenting her granddaughters, managing the family finances, and trying to reform her two twenty-something daughters who preferred partying to raising their kids. One day she just collapsed. In the emergency room she was diagnosed with widely metastatic cancer of unknown primary. Liver. Bones. Lung. She had less than six months to live. She had pain. Prior to her diagnosis, her pain was unmedicated. She had dealt with the pain because she prioritized her family over her needs. With the diagnosis of terminal cancer, she learned she would never see her granddaughters grow up, or help her daughters mature. She was comfortable in the care-taking role, but the roles would reverse, as she would…

If Congress Plans on Fixing the RACs in 2015, They Need To Read This First!

The recent increase in observation stays has led to a surge in federal oversight and scrutiny.  We have covered the dispute on the blog before. And yes, as the facilitators of the process, the recovery audit contractors (RACs) continue to receive the lion's share of critical attention—especially with congress. In our attempts to resolve  the issue of appropriate in versus outpatient hospital stay designations, pressed inpatient facilities endure overwhelmed administrative law judges (ALJ) and employ hospital FTE resources they cannot spare. The RACs get the spotlight for what they do, or if you need reminding, don’t.  Moreover, we can only speculate on the veracity of the data and how their auditors perform.  Previously, we possessed only aggregated, somewhat filtered information released by the government. Until now. The Journal of Hospital Medicine has released a first of a kind paper exploring the above. Given the importance of RAC auditing pressure in the growth of hospital observation care, the study investigators conducted a retrospective descriptive…

Value-based Payments: On the top of CMS’s List and Yours, Hospitalists

The Department of Health and Human Services (HHS) announced a bold new goal to rapidly enhance the adoption of value-based reimbursement for all payors in the medical industry. The Medicare goal is to tie 30% of payments to ACOs or bundled payments by the end of 2016 and 50% by the end of 2018. HHS also set a goal to tie 85% of traditional payments to quality/value by the end of 2016, and 90% by the end of 2018. In order to stretch these goals beyond Medicare, they will set up a Health Care Payment Learning and Action Network, in order to get other payors to live up to the same value-based payment goals (the Network will hold its first meeting in March 2015). It is obviously easy to support such a notion that the health care system needs to move from fee-for-service payment models to those that drive value…

My Interview With Capt. Sully Sullenberger: On Aviation, Medicine, and Technology

The story of Chesley “Sully” Sullenberger – the “Miracle on the Hudson” pilot – is a modern American legend. I’ve gotten to know Captain Sullenberger over the past several years, and he is a warm, caring, and thoughtful person who saw, in the aftermath of his feat, an opportunity to promote safety in many industries, including healthcare. In my continuing series of interviews I conducted for my upcoming book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, here are excerpts of my interview with Sully, conducted at his house in San Francisco’s East Bay, on May 12, 2014. Bob Wachter: How did people think about automation in the early days of aviation? Sully Sullenberger:  When automation became possible in aviation, people thought, “We can eliminate human error by automating everything.” We’ve learned that automation does not eliminate errors. Rather, it changes the nature of…
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