Charles Krauthammer’s Provacative Columns on Physicians – Why Doctors Quit

I wanted to post in one location these thoughtful opinion pieces written by Charles Krauthammer.  Do you agree or disagree with him?  The other day on LinkedIn, I posted my thoughts on a proposed Senate bill that seeks to extend independent practice privileges to nurse practitioners, removing mandated physician oversight for them.

I thought it interesting that in one regard, I agree with Krauthammer that bureaucratic mandates from far reaching regulators are stifling physicians from rendering their best care.  I am way too familiar with the glutton of administrative burden that faces physicians and their staffs.  On the other hand, I reflexively hold the notion that physicians must continue to have a supervisory role over the healthcare rendered by nurse practitioners.

Where do we draw the line?  My preference would be that the government NOT draw so many lines that dictate how our healthcare system operates.  Krauthammer is correct.  If EHRs are going to revolutionize the way we deliver healthcare services, then let them be adopted at their natural rate by willing users who can better decide when the proverbial juice is worth the squeeze vs. when big brother compels you.  Let the market work naturally.  If and when EHRs can naturally evolve into the obvious tool that binds the American healthcare system together, you can bet everybody will willingly jump on board.

Maybe it should be the same for nurse practitioners.  If patients willingly want to be treated by nurse practitioners who lack active physician oversight, then perhaps they should be permitted.  Before permitting that, my preference would be that we simply pilot such activity to study the impact on healthcare outcomes.  This might be one of the rare occasions that I actually shy away from my firmly held philosophy of less regulation is always a good thing!

Why doctors quit

By Charles Krauthammer Opinion writer May 28, 2015

Washington Post

About a decade ago, a doctor friend was lamenting the increasingly frustrating conditions of clinical practice. “How did you know to get out of medicine in 1978?” he asked with a smile.

“I didn’t,” I replied. “I had no idea what was coming. I just felt I’d chosen the wrong vocation.”

I was reminded of this exchange upon receiving my med-school class’s 40th-reunion report and reading some of the entries. In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”

As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

I hear this everywhere. Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, “The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”

You may have zero sympathy for doctors, but think about the extraordinary loss to society — and maybe to you, one day — of driving away 40 years of irreplaceable clinical experience.

And for what? The newly elected Barack Obama told the nation in 2009 that “it just won’t save billions of dollars” — $77 billion a year, promised the administration — “and thousands of jobs, it will save lives.” He then threw a cool $27 billion at going paperless by 2015.

It’s 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity.

This hardly stays the long arm of the health-care police, however. As of Jan. 1, 2015, if you haven’t gone electronic, your Medicare payments will be cut, by 1 percent this year, rising to 3 percent (potentially 5 percent) in subsequent years.

Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.

Forget the numbers. Think just of your own doctor’s visits, of how much less listening, examining, even eye contact goes on, given the need for scrolling, clicking and box checking.

The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?

Because banks deal with nothing but data. They don’t listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.

Why did all this happen? Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.

As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

Like my old classmates who signed up for patient care — which they still love — and now do data entry.

Why doctors quit, Chapter 2

By Charles Krauthammer Opinion writer June 4, 2015

I rarely do follow-up columns. I’m averaging one every 10 years. And while my last such exercise resulted in a written apology from the White House (for accusing me of making up facts over its removal of Churchill’s bust), today’s is not a complaint. It’s merely a recognition that the huge response elicited by last week’s column, “Why doctors quit ,” warrants both rebuttal and clarification.

Physicians who responded tended to agree with my claim that doctors are being driven out of the profession by the intrusions, interferences, regulations, mandates, constraints and sundry other degradations of their vocation that are the result of the bureaucratization of medicine. Chief among them is the imposition of electronic health records (EHR).

I’ve also heard from people who notice how much attention their doctor must devote to filling out EHR boxes on a computer screen rather than to engaging with them during an office visit. To the point where a heretofore-unheard-of profession has been invented — the “scribe” who just enters the data so the doctor can actually do doctoring.

On the other hand, my critics, vocal and many, had two major complaints. First, that I’m just a Luddite unwilling to adapt to the new digital world and looking for excuses not to. Second, that while I might have a point about the bureaucratization of medicine, could I not have made it without satisfying my anti-Obama tic and blaming it all on him, and my other itch and blaming it on liberalism?

First, I don’t oppose going digital. Properly used, it brings many benefits. The gains, however, are coming not from massive databases attempting to cover and extend to all of medicine but from far more narrow and tailored adaptations. In radiology, for example, one is dealing with artifacts — X-rays, CT scans, MRIs — that can be easily categorized, digitized, filed, transmitted and shared in a way impossible in the age of the shadowed X-ray film held up to backlight.

The problem with the EHR, however, is that the pretense of universality leads to information collection that is largely irrelevant to the patient. And, more fundamentally, that the EHR technology, being in its infancy, is hopelessly inefficient. Hospital physicians will tell you endless tales about the wastefulness of the data collection and how the lack of interoperability defeats the very purpose of data sharing.

As for my complaint about President Obama and his fellow liberals: Again, I don’t oppose going electronic. What I oppose is the liberal instinct to impose doing so, giving substance to that old saw that a liberal is someone who doesn’t care what you do, as long as it’s mandatory. Why could they not leave the decision of when and how to go electronic to those who use the technology and can best judge its ripeness and usefulness? Instead, the Obama administration decided arbitrarily six years ago that EHR should be universally in use by 2015. Time being up, doctors who did not conform are now penalized through partial loss of Medicare reimbursement.

In time, we will surely develop more tailored, specific and efficient data-collection systems that doctors and hospitals will adopt if only to keep up with the increasing efficiency of their digitized competitors. Why, then, the punitive mandate?

I was in no way arguing that the bureaucratization of medicine began with Obama. It is the inevitable and inexorable result of the industrialization of everything from cloth making to food service, now extended to health care. My point is that, given the consequent loss of autonomy and authority of doctors, why are we compounding their demoralization by forcing an EHR mandate that robs them of both time and the satisfaction of proper patient care?

Yes, in principle, vast record-collection will create mass databases that in theory could be mined to help administrators, and perhaps even to yield medical insights. But it is somewhat ironic that with incessant complaints about NSA collection of telephone metadata — as of last Sunday, now banned in these United States — as an assault on privacy and civil liberties, we seem not at all disturbed by the current amassing of mountains of medical data about you and your insides, a literal and far more intrusive invasion of the self.

My argument is simple. If electronic records are such a great boon — as I believe they eventually will be — they will be adopted over time as the benefits begin to exceed costs. Let the market work. Let doctors breathe. And while you’re at it, drop the Medicare penalty.

Health Plan Policy Coverage Guidelines Challenged

Background story: Keller family sues U.S. Department of Defense after TRICARE refuses to cover equine physical therapy.

This is an interesting case from a policy setting perspective. It highlights the struggles that providers must learn to more effectively overcome in working with health plans when confronted with the issue of advocating for their patients when coverage guidelines on the payer side are not met for treatments/services that the physician believes necessary for her/his patients.

The final outcome may very well hinge on the argument of whether or not a horse is a tool to aid in the provision of already proven physical therapy vs. a separate modality that is unproven which is the prevalent status of hippotherapy aka equine therapy.  That would appear to be a decision that transcends but is nonetheless foundational to CHAMPUS regulations that seem to be guiding TRICARE’s decision to withhold coverage in spite of the ALJ decision.

The report and the complaint filed with the court for relief from TRICARE’s maintaining its decision to not cover the horse related physical therapy did not appear to address one of the likely primary considerations contributing to TRICARE’s decision. There is an additional federal regulation that requires all covered care to be proven.  If the larger issue of whether or not horses are mere tools in the provision of physical therapy as opposed to being a completely stand alone treatment modality then the issue of it being considered a proven treatment is hanging as a larger looming issue.

Here is the regulation not cited in the complaint:

32 CFR Section 199.4 – Basic program benefits:  (15) Unproven drugs, devices, and medical treatments or procedures. By law, CHAMPUS can only cost-share medically necessary supplies and services. Any drug, device, or medical treatment or procedure, the safety and efficacy of which have not been established, as described in this paragraph (g)(15), is unproved and cannot be cost-shared by CHAMPUS except as authorized under paragraph 199.4(e)(26) of this part.

It appears to be a primary issue of semantics – whether or not Kaitlyn is benefiting from physical therapy that uses a horse as a therapy tool or whether she is benefiting from hippotherapy aka equine therapy.  Here is an article written by a PT who attempts to address the semantics issue.  It’s a compelling argument.

What’s troubling however, is that as a group of health professionals, PT’s and other healthcare professionals who advocate use horses as tools in PT and OT apparently have failed as of yet to generate the credible evidence that meets the rigid requirements of health payers to accept use of horses as tools in therapy as safe and effective and / or they have failed to differentiate the use of horses as tools from the generally unaccepted modality that is hippotherapy.  Regardless, they have failed to get use of horses to be an acceptable component of reimbursable healthcare under prevailing health insurance practices.

Interestingly, TRICARE does have a hippotherapy benefit under the ECHO program but for diagnoses that Kaitlyn appears not to have. Hippotherapy is not covered under TRICARE basic benefits. Hippotherapy is usually not covered under TRICARE due to the above referenced regulation that excludes non-proven / investigational care outside of TRICARE approved pilot or demonstration projects.

Other insurance payers seem to consider both physical therapy using horses and hipportherapy /equine therapy to be one and the same but stand firm on the side of it being a modality that is unproven.  There appears to be mixed policies with respect to coverage across various health plans, though the vast majority cite it as unproven.  Most look at it from perspective whether it is proven as effective treatment of spastic CP.

Here is a short list of health plans that deem equine therapy as not covered / investigational, though most here do not specifically address it as modality to treat scoliosis:

http://www.aetna.com/cpb/medical/data/100_199/0151.html

Click to access rehabilitative_therapies.pdf

http://www.anthem.com/medicalpolicies/anthem/va/policies/mp_pw_a050176.htm

Here is a plan where it is covered in only very limited / minimal instances  – somewhat similar to TRICARE ECHO program allowance, though I think maybe less generous:

https://www.wellcare.com/WCAssets/corporate/assets/ccg/hs_ccg_hip

A decision by TRICARE to permit coverage of the CPT billing codes as reported about Kaitlyn’s care in the Dallas News blog article linked above seems at face value to be an innocuous decision in light of the fact that Katilyn’s treating healthcare providers report that the therapy using a horse is maintaining her spinal alignment and that the costs to doing so is neutral to therapy provided using other tools that are less effective.

Risk of setting a precedent for allowing arguably unproven treatment tools or modalities is a likely overriding concern that is compelling the decision not to approve coverage. It is a completely legitimate concern as it drives to the ability of health plans to assure that covered care guidelines assure safe, proven, and effective care under the benefits. It is all the more prudent in light of the ever present need to minimize the tax burden to publicly funded plans and assure valuable returns on the investment.  DoD healthcare dollars are not in abundance as policy makers continue to wrestle with sequestration  It is unfortunate that such considerations affect individual patients from getting treatments or services that their treating providers believe are necessary to meeting their individual healthcare needs.  Such fall out is a byproduct of trying to balance the goals of operating effective health plans at a population based level while maintaining a responsibility to meeting the person centered needs of individualized care planning.

It would be ideal and most prudent if the physical and occupational therapy professional community could work to generate the evidence needed to legitimize the use of horses as a reimbursable component of their craft in whatever way the health insurance industry requires.  The bottom line is that if use of horses as a tool for administering physical or occupational therapy is indeed an effective treatment to a generalizable group of patients with similar health conditions such as scoliosis and other musculoskeletal conditions, then it should be provable in commiserate methods and fashion just as other established medical standards of care are.

In the mean time, in light of the cost neutrality and apparent effectiveness of the use of horses as tools in the provision of the actual therapy treatments rendered to Kaitlyn, perhaps some authorized type of waiver can be granted or the DoD Undersecretary of Health Affairs can reverse course and abide by the ALJ ruling to let Kaitlyn resume getting the therapy using a horse so as to prevent further misalignment of her spine that her physicians fear will lead to a worsening of her health – requiring even more healthcare expenditures and hardship to Kaitlyn and her family.  That can assuredly be done with minimal if any damage to the TRICARE program while the issue is worked out of whether or not the use of horses in the provision of PT and OT is proven or not regardless of the semantics of it being a tool used in generalized PT/OT or completely separate modality.

A Problem with non-FDA Approved Lab Developed Tests Under the Federal Government

Here is a link to an update on the DoD Lab Developed Test Demonstration (LDT) Project written by syndicated columnist Tom Philpott.

http://www.military.com/benefits/2014/02/06/dha-ops-chief-vows-relief-from-surprise-lab-fees.html

I first blogged about this demonstration project back when it was initiated in 2012.  As an occasional pundit of government waste, I was and maintain a troubled opinion that an entity working under the umbrella of the federal government would utilize regulatory red tape to guide healthcare policy decision making that would seek to limit patient access to likely proven medical care that could save lives.  If other federally run health plan programs such as Medicare and Medicaid and other health plans operating under the FEHB program ALREADY utilize LDTs that are not FDA approved and these tests are found NOT to be unsafe while possibly saving lives, then I struggle to relate to how in good conscience, TRICARE can use bureaucratic red tape under the guise of a timely and costly demonstration project to try and prove their appropriateness for use in practice.

Rather than force patients to wait for the outcome of its DoD study (potentially wasting precious time needed to get an early jump on a diagnosis) at the very least, TRICARE should seek to utilize already existing healthcare utilization data analytics derived from CMS and other data warehouses to do a case control look back as to the effectiveness of any LDTs in question.  There is likely a whole repository of experience under CMS using LDT’s.

Why force current TRICARE beneficiaries to do without are deemed standard of care tests unnecessarily?  I am glad to see that the issue of the direct care aka Military Treatment Facility (MTF) managed sector having the ability to use its own operation and management funds to pay for LDTs is being examined.  In the end though, if federal tax dollars are still being used to cover the cost of LDTs is on the MTF side or the purchased care side, then is it really a matter of FDA approval and effectiveness or is it just really a matter of where DoD MHS dollars are being spent?  The whole problem is borne from bureaucratic red tape entanglements.  So to a patient who needs the test to survive, it is easy to see the frustration of bureaucratic red tape getting in the way of good medicine.

It is time that congressional lawmakers get involved and set some legislative requirements to streamline data sharing for health programs and plans that operate under its jurisdiction using federal tax dollars.  A good place to start would be to recognize regulatory inconsistencies under ALL federal law, such as the use of LDT’s not yet cleared by the FDA and to begin requiring department and agency heads to work together to eliminate legislative barriers that do the public harm.

While congress is at it – (God willing) some additional  regulatory alignment type house work certainly be done with respect to who under TRICARE can prescribe Durable Medical Equipment and how much physical, occupational, and speech therapy is actually medically necessary.  That and ABA Therapy are huge expenditures that would appear to be requiring reigning in.  The courts have not done TRICARE any favors in that regard and DHA to its credit is trying to work out a practical solution.  I sure would hope to see capitated benefit limits on utilization of those services as in the private sector.  But all of that is a blog post for another day.  Hopefully they can get LDTs on track for less nonsensical management under federal control.

#Healthcare #Policy Impact: #PPACA & State #Medicaid Expansion & #Hospital Budgets

Here is a report on the funding challenges that are being thrust upon Hampton Roads, VA hospital and healthcare systems in relation to the Medicaid expansion aspects of the PPACA aka Obamacare.

The cost of increasing access to care for all the people previously not covered under health plans is going to be born by either taxpayers or those already paying the premiums – which really are the same people.  If the hospitals have to cut their services in the absence of Medicaid expansion in order to recoup the costs they already paid up front, it could precipitate the death spiral of the entire complicated scheme.

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dailypress.com/news/politics/dp-nws-medicaid-expansion-0119-20140119,0,1276182.story

dailypress.com

Hospitals fear service cuts, layoffs without Medicaid expansion

By Dave Ress, dress@dailypress.com

Daily Press

January 19, 2014

Beds could close, nurses could lose jobs and it could be tougher for Hampton Roads families to find a place to have babies or get mental health care unless Virginia finds some way to pay for the hundreds of millions of dollars a year hospitals give the area’s poor and disabled, hospital executives say.

With the quid pro quo of the Affordable Care Act fractured because the General Assembly won’t move to expand Medicaid, almost $200 million will be drained from Hampton Roads’ health care system by the end of next year, estimates from the state hospital association suggest.

Hampton Roads hospital executives fear that layoffs and painful service cuts are the only way to keep their doors open without the $2 billion a year that Washington has promised to fund an expansion of Medicaid to cover more than 375,000 Virginians living below the poverty line.

“We’d have to be looking at reductions in force,” said Peter Bastone, chief executive of Chesapeake Regional Memorial Hospital. “I would have to reduce my beds … that means you don’t have as many people and you can’t serve as many people.”

The problem, said William B. Downey, president and chief executive of the eight-hospital, 400-physician Riverside Health System, is that “hospitals paid up front for the Affordable Care Act, Obamacare, call it what you will. Medicaid expansion was supposed to offset that.”

Without it, hospitals don’t know where to turn.

The commercial insurers offering coverage through the new Affordable Care Act insurance exchanges are pushing for cuts to hospital fees, Downey said. They’re seeking rates even lower than the deep cuts to Medicare and Medicaid fees hospitals agreed to in order to make the Affordable Care Act affordable. The legislation cuts other federal support for hospitals, too.

Medicaid expansion was supposed to pay hospitals for care to the indigent that those federal payments and the hospitals’ own charity had covered.

The idea of asking Virginia taxpayers to pay for care that a federally funded Medicaid expansion would cover doesn’t make sense to Hampton Roads hospital executives — not with Virginians set to pay $1.1 billion in Affordable Care Act taxes and fees this year and more in years after that. By 2022, the bill for Hampton Roads alone from Affordable Care Act cuts in payments to hospitals and doctors and in the taxes and fees everyone else pays will total $4.4 billion, according to a state hospital association estimate.

“We’ve already paid for this,” Downey said. “It’s like we would be triple-taxed.”

In any event, the budget now before the legislature calls for nearly $60 million of cuts in state payments to hospitals over the next two years.

If legislators don’t expand Medicaid, or find a way to hit up Virginia taxpayers for funds to offset a quarter billion dollars of Affordable Care Act cuts this year, the only alternative for hospitals is to cut costs, Downey said. That means fewer beds and services.

Large and small hospitals at risk

Big hospitals like Riverside Regional Medical Center and Chesapeake, which serve large numbers of indigent and Medicaid patients, and small community ones, like Riverside’s hospitals in Gloucester, Tappahannock and the Eastern Shore, are particularly vulnerable.

Riverside Regional is squeezed because Medicaid, which takes a notoriously tough line in setting fees it pays hospitals, now covers about 60 cents of each dollar of the cost of caring for its patients, Downey said.

Virginia limits Medicaid coverage to children from low-income families and only a small number of working parents or the disabled, earning just a few thousand dollars a year. Coverage for kids includes birth and prenatal care — but doesn’t pay the full cost of obstetrics, which has long been one of the biggest money drains for hospitals.

Mental health services are also tough to support financially.

“We can have people TDO’d who need to be at Eastern State, but there aren’t beds for them, so they stay with us for months with no payment,” said Downey, referring to the temporary detention orders that are a first step toward an involuntary hospitalization.

Trauma care, too, is costly.

“You need to staff 24 hours a day, seven days a week, with skilled nurses and specialized physicians,” Downey said. Many of the people who need that care don’t have insurance, and Riverside relies on income it gains from other services to pay for its trauma service.

Bastone is worried about how Chesapeake will maintain the same level of charity care it now offers — it provided $22 million of care to low-income Hampton Roads residents in 2012. Riverside, which provided $44 million of charity care at its main Newport News hospital and millions more at its other facilities, also provided support for five independent free clinics, with X-ray, surgical and other services those safety net facilities can’t offer, Downey said. Those community efforts will be tougher to afford at a time when, without Medicaid expansion, legislators are looking for a larger role for free clinics.

By the end of this year, Hampton Roads hospitals will have taken a $65 million hit from Affordable Care Act cuts to their fees and federal support, according to data gathered by the Virginia Hospital and Healthcare Association.

By the end of 2015, those steadily deepening cuts will add up to more than $120 million.

Even if the General Assembly votes this year to expand Medicaid, so that hospitals could tap the program in 2015, area hospitals still would have lost more than they gained.

And it’s far from certain the legislature will act.

McAuliffe versus Howell

While Gov. Terry McAuliffe said Medicaid expansion is a top priority, Speaker of the House William Howell is firmly opposed.

Howell says Virginia can’t count on Washington to stick to its promise to fund the whole cost of the expansion through 2016, and then phase in a state contribution capped at 10 percent by 2021. Other Republicans say Medicaid’s costs are already ballooning out of control, and say it makes no sense to make what they call a failing system even bigger.

But business groups, including the Virginia Chamber of Commerce and commercial insurers, fear not expanding Medicaid will mean higher costs for people with insurance.

“One way or another, we all contribute to subsidizing that care — either through taxes or increased insurance and provider rates. We definitely need to fill the gap in coverage and find a path moving toward extending coverage, whether it’s expanding Medicaid or Medicaid reform,” said Phil Wright, chief executive officer at Southampton Memorial Hospital in Franklin.

“We have restructured and found creative ways to become more efficient in the way we deliver care,” Wright said. “We review operations and staffing daily, by shift, and sometimes hourly to ensure staffing matches patient volume. If anything, these challenges have certainly heightened the emphasis on those processes already in place.”

Some Virginia hospitals have taken more drastic action.

Last fall, Wellmont Health Systems closed Lee Regional Medical Center in Pennington Gap, in far southwest Virginia, saying Virginia’s failure to expand Medicaid to make up for Affordable Care Act cuts meant it could not keep the 70-year-old hospital open.

In Winchester, Valley Health laid off 33 employees this month and decided not to fill 25 vacancies.

“This is a very difficult decision we had hoped to avoid,” said Valley Health CEO Mark H. Merrill. “Federal deficits, payment cuts included in the Affordable Care Act, declining volumes, the decision by the Virginia legislature not to expand Medicaid, and other factors have impacted our financial position and we must respond.”

Ress can be reached at 757-247-4535.S

Copyright © 2014, Newport News, Va., Daily Press

Clinical Errors and Patient Safety in Healthcare

Patient safety in healthcare is on my mind.  Whether as a patient, the loved one of a patient, or as a healthcare professional, I hope that by reading this, you will be compelled to take purposeful action to address the issue of medical care errors and patient safety in whatever way you think you can.

I became an registered nurse in 1994.  One of my family members is currently in a fight for his life battling stage 4 colon cancer with metastasis to his bones and stomach.  I am deeply concerned that he suffered from 3 clinical care errors in the past month.

The first was several weeks ago.  His assigned oncologist was out of town for some time and he was due for chemotherapy.  As is the norm, he was treated by another physician in the practice.  The chemotherapy cocktail that was mixed and administered was an older prescription that had been used and abandoned sometime in the past due to ineffectiveness and extreme negative side effects it had on my family member.  Within days of this errant administration, he was admitted to the hospital with neutropenia, severe dehydration, and low blood calcium.

On Thanksgiving Eve, my wife and I paid my family member  a visit. He asked me to look at his portacath because he was concerned that something did not seem right.  He said he had a routine follow-up visit at the oncologist this past Monday to include a lab draw from his portacath.  To my astonishment, the nurse errantly left the huber needle accessed to it, unsecured and just sticking out with a capped butterfly infusion set attached and dangling with a flimsy dressing.  Not knowing whether or not the portacath was appropriately flushed or not, I had him call the oncologist on-call (not his treating oncologist) who told him to go to the local ER to get it removed.  The on-call oncologist said he would call ahead to the ER.

I accompanied him (along with my brother in law) to the ER, where we understandably had to wait due to triage.   A nurse conducted a quick assessment and said she knew what needed to be done, but that she had to wait for the ER physician to conduct the cursory assessment and write the treatment  order.   The physician eventually rounded after the nurse and he too performed a very brief initial assessment and history and physical.  He acknowledged the obvious error of the needle having been left inserted as it was. He then bid farewell, stating that the nurse will come back, extract the old needle, reinsert a new one, perform the portacath flush, pull that new needle out, and that we would be on our way in quick fashion. In short order, the nurse came in and completed the portacath care and said she would be back with discharge papers.

When she came back some 20 minutes later, she casually and without great detail reported to us that our patient was accidentally given too much Heparin just now.  She said that they called the oncologist on-call and he said that everything should be okay despite the error and that there was nothing to worry about.  Surprised at the news of an error when we were here due to an error, I asked the nurse  (who at this point knew I was an RN from our previous discussions related to the error that brought us here) if he was given an IV bolus of 5,000 units of Heparin for anticoagulation instead of an IV line “keep clear” dose of 100 u/ ml with just 3-5 ml.  She said yes, that is what occurred. I then asked if it was due to an errant physician order or a matter of pulling the dose from the wrong Heparin vial. She said the wrong vial was used.

How ironic that there would now be third patient care error occurring for this gentleman. Just moments earlier, while we were waiting there at the ER for the portacath care, I explained to my family members about the ongoing need for the leaders working within and across our healthcare system to devise a plan to reduce the dangerous and costly patient care errors occurring in the delivery of healthcare. I shared how the industry is looking to adopt similar redundancy type safety checks before rendering care, similar to how the airline industry performs pre-flight checks (both mechanically and procedurally).

What is particularly unnerving is that the IV bolus dose of 5,000 units of Heparin was given with a most shallow knowledge of the patient’s coagulation condition and risks for bleeding. The care to be delivered during this encounter was understood to be nothing but a routine IV access device flush.  The care encounter for all intents and purposes was innocuous and without risk.  It is clear now that this is where the danger lurks in healthcare. No patient care, even supposedly routine care,should ever be assumed to be without risk. As a cancer patient, my family member’s platelet count was already low due to myelosuppression.  Rapid anticoagulation is not what this patient needed. The act of administering an injectate directly into a large bore access device should ALWAYS prompt precision and accuracy on the part of the people providing the care.

It is alarming that this vulnerable patient suffered numerous healthcare delivery mistakes in such a short span of time.  I hope the hospital is following its rules for incident reporting in medication administration errors so that an analysis of what went wrong can take place. The oncology practice similarly should have a procedural look back as to what led to the two mistakes that took place in its rendering of care.

It is critical that health care organizations maintain a due diligence when as it relates to patient safety.  They must adhere to incident reporting standards that permit a retrospective analysis of the factors that lead to mistakes taking place in the delivery of patient healthcare services.  Mistakes may occurs a result of failure to follow established procedure or from a lack of systematic safeguards not yet evident in procedure.  Regardless,  healthcare system leaders across the continuum must create a culture that encourages open reporting of acknowledged clinical errors so that similar mistakes are not repeated.

Health plans and accrediting bodies have clinical quality standards relating to healthcare provider’s ongoing efforts to improve patient safety through the reduction of clinical errors.  The above noted three errors occurring to this one patient in just one month’s time is an indication that much still needs to be done to try and reduce these risks to patient safety.

When I started graduate school in 2001, the Institute of Medicine released the landmark report, Crossing the Quality Chasm: A New Health System for the 21^st Century. Relatively recent updates of the work have the initiative moving in toward the adoption of technological safeguards, such as the use of programmed medication dispensing systems and electronic health records that can detect dangerous drug interactions.  The nature of all of the above noted errors appears to involve some process that could have been aided by use of technological safeguarding as an adjunct to human process control.   It is incumbent upon all healthcare providers to embrace a mentality of “patient safety comes first” in all care that is rendered in a leader led effort that provides the tools and resources necessary to effectively reduce the risks of patient care errors.

Patient Protection and Affordable Care Act and Morals

October 1, 2013 came and went as the first day open enrollment began for the Patient Protection and Affordable Care Act, or more commonly known as Obamacare.  Problems with accessing the enrollment website at http://www.healthcare.gov have been widely reported and commented by pundits pro and con.

I read today that the health insurance industry giants have partnered up (yet again) to offer aid to the embattled Obama administration to see if they can lend their expertise in getting the http://www.healthcare.gov website off the ground as bipartisan calls are starting to be made to hold senior government leaders accountable to the debacle.  Besides power lusting progressive politicians, the health insurance industry stands to lose the most with the government’s prolonged inability to corral the “sheeple” into its health insurance holding pen.

Mine is a moral and ethical objection that an industry(in this case mine) has partnered with the government to enact a tax penalty against all citizens simply for being alive and not wanting to purchase health insurance.  Who could have ever imagined that America would ever see a tax on the living imposed on its people?  The government does not care if there are segments of citizens who opt to live healthy and practice wellness in their daily living outside the prevailing healthcare system – making a conscience decision to not purchase something that they do not want nor need.  Instead, masking as a parent, it coerces them to buy something that they otherwise might not want to buy simply because the it has the might of the IRS to enforce penalties.  Might is not always right.  Countless polls show vast numbers of Americans (tens if not hundreds of millions) do not want this healthcare mandate to purchase insurance.  While the PPACA may be the law of the land, ushered in by a political party majority that obtained power via elections, it still does not make it a just law – even if the Supreme Court upheld it as some bullshit taxing power interpretation.

From Chief John Robert’s Ruling:.

“The Affordable Care Act is constitutional in part and unconstitutional in part. The individual mandate cannot be upheld as an exercise of Congress’s power under the Commerce Clause. That Clause authorizes Congress to regulate interstate commerce, not to order individuals to engage in it. In this case, however, it is reasonable to con­strue what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance. Such legislation is within Con­gress’s power to tax.”

“The Framers created a Federal Government of limited powers, and assigned to this Court the duty of enforcing those limits. The Court does so today. But the Court does not express any opinion on the wisdom of the Affordable Care Act. Under the Constitution, that judgment is reserved to the people.”

Mr. Chief Justice, let my judgement be known that I deny my consent to this government requirement/tax shakedown on the grounds that it is morally and ethically wrong to coerce a person to purchase something simply because they are alive, regardless of their income or wealth status or lack thereof.

Legal Argument: Use of Case Law or Refer to the Constitution as Supreme Law of Land in Analysis of ACA

Here is an amazingly thought provoking argument against the Affordable Healthcare Act that uses the Constitution and not established Commerce Clause case law as its underpinning.  Several blog posts ago, I wrote that I wondered how much of my rights were left due to erosion from bad court decisions serving as precedent such as Wickard v. Filburn or Gonzales v. Raich before I actually became a full fledged ward of the state. In my amateur judicial mind, new case law appeared to just keep being based and built upon errant case law that was centered on politically expedient court decisions rather than constitutional interpretation.  If every new or subsequent challenge of unconstitutional law was brought before the court and weighed by the court only against established case law that was – to be frank, a bad opinion, then I postulated that our freedoms are quite doomed.  Supreme Court case law of the early to mid 20th century is not exactly a bulwark of pro-Constitutional rulings.  Fortunately, true legal scholars and professionals who understand the Constitution thought the same thing and banded together to write this argument as to why the Affordable Healthcare Act is unconstitutional. These friends of the court include one of my favorite organizations that support Liberty, The Downsize DC Foundation and DownsSizeDC.org

Amicus Curiae – DEPT. OF HEALTH AND HUMAN SERVICES, ET AL., Petitioners, v. STATE OF FLORIDA ET AL., Respondents.

The analysis in this amicus urges the Supreme Court Justices to discard the bad habit of relying on Commerce Clause case law since much of the key decisions were from a politically packed court during FDR’s administration.  Instead, the respondents urge the court to look at the health mandate with a fresh new perspective, going back to the actual textual law that is the Constitution – The Supreme Law of the Land.  It really is an argument to behold with awe and great appreciation.  Hopefully a majority of the court will see the wisdom in this argument and overturn the low courts upholding of this constitutional abomination.  The Congress does not have free rein to do what it wants under the Commerce Clause.

Former Ronald Reagan solicitor general Charles Fried, now a Harvard Law Professor, thinks the opposite and that the current Supreme Court led by Chief Justice John Roberts should follow the bad precedent set by previous Supreme Courts and not overturn the ACA law as unconstitutional. “It would be plainly at odds with precedent, and plainly in conflict with what several of the justices have said before.” Here is a link to this opinion of the former conservative lawyer who served under Ronald Reagan.

It would be my hope that a fresh check against the text of the Constitution take place.  I don’t understand exactly what Fried is worried about if today’s court makes its own assessment of the Constitutionality of the law.  What is exactly is wrong if this court abandons the poorly thought out decisions from its predecessors?  Are not mistakes permitted to be corrected?

Waiting on the Supreme Court Decision Regarding Obama Care

The wait on the Supreme Courts ruling of whether or not the Affordable Health Care Act (ACA) is constitutional is akin to waiting for the surgeon to come out of the operating room after having just performed surgery to remove a cancerous tumor from a loved one’s lungs.  Only the surgeon can say whether or not the patient is going to live.  The ACA is the tumor. The deathly ill patient is a country once known to be a Constitutional Republic that went by the name of the United States of America.