Archive for April 2015

Mother Knows Best

My 85 year old patient was brought in from home.  She was cachectic, contracted, minimally responsive to questions, covered in multiple decubitus ulcers on both hips, both knees, both shoulders, and her sacrum.  She had polymicrobial sepsis-bacteremic with two different organisms. She was, in fact, dying. Despite her profoundly debilitated condition,  her son, who cared for her at home wanted "everything" done.  So she was placed on IV fluids, antibiotics, received an infectious disease consult, had a tunneled line placed, was started on TPN etc., etc.  The medical team had a family conference, but could not dissuade the family from the aggressive plan of care to "do everything."  An ethics consult was called.  No decisions to change the plan of care were made.  Ultimately the patient did improve somewhat, but she was stuck in the hospital as it was felt to be "unsafe" to discharge her home, without hospice level…

Do Providers Fear Change or Do They Fear Loss? Part 2

by Dr. Trina Dorrah MD, MPH In Part 1, we discussed the fact that providers are often resistant to change not because they fear change itself, but because they fear loss. In my work as a patient experience physician champion, I am constantly encouraging providers to change. At the Society of Hospital Medicine’s annual meeting in March, Dr. Peter Pronovost challenged us to recognize that resistance to change comes from a fear of loss as opposed to a fear of change. In Part 1, I talked about provider resistance to patient experience initiatives due to a fear of lost autonomy and time. In Part 2, we will discuss the fear of losing professional respect. Respect Historically, physicians have enjoyed a great deal of respect. Although this is still the case, many physicians feel that respect has decreased over time. We devote years to education and training, so we want to…

Getting on the Bus: Hospitalists on the Hill

by Regina Heyl DePietro I sat in the office of a staffer to a Manhattan congressman and waited for the right moment to tell my story about my mother’s experience with advanced directives. Dr. Celine Goetz, a hospitalist from Mount Sinai, and I had practiced our talk in a large atrium a floor below. Our morning meeting led by SHM had prepped us on three points: 1. Address Medicare’s onerous three-day rule 2. Push for doctor funding and reimbursement in preparing advanced directives 3. Discuss the Medicare Sustainable Growth Rate (SGR) Dr. Goetz had taken me under her wing when she learned I was from New York. She had decided that this day was going to be as memorable for me as her first day advocating on the Hill when she was in medical school. Worried that I would fumble, I told her that I was not going to speak,…

Do Providers Fear Change or Do They Fear Loss? Part 1

by Dr. Trina Dorrah MD, MPH At the Society of Hospital Medicine’s 2015 conference, I had the privilege of hearing Dr. Peter Pronovost speak. He is a leader in the field of quality and safety, but the part of his talk that struck me the most was his advice on leading change. During his discussion on change strategies, he accurately noted: People don’t fear change, they fear loss. As I reflected on his statement, I realized he was absolutely correct. We all know change is hard, but Dr. Pronovost identified the fundamental reason why – we’re all afraid of loss. One of my roles as a hospitalist is that of “physician champion” for the patient experience. I’m constantly trying to promote change by asking clinicians to focus on the patient experience. This idea is often met with resistance even though my colleagues intuitively believe the patient experience is important. When…

Your Salary in A Bundled Fee World

I began to think about doctor fee carve outs in the context of global payments approximately five years ago.  At a meeting I attended where the subject came up, private conversations transpired between a group of us and folks in the know from CMS and the AHA.  We listened.  They talked. The discourse led me to two conclusions: one, as compensation goes, any new reimbursement scheme will require members of specialties to do their own bidding, i.e., justify their share, and two, respective delivery systems—be they independent practices, IPAs or hospital organizations—will set outlay policy based on values they establish internally. The government has little interest in venturing into the rate setting game again.  Uncle Sam learned the hard way the last time they tried to codify doctor payment.  The contracted designers of the RBRVS, fee-for-service model did not have a Gordian knot in mind when they implemented the system we have in place today.  Think SGR fix. (more…)
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