The Happy Hospitalist

Italian Greyhounds Wagging Tails, Waiting For Treats (Cute Video!)

2012-01-26T15:02:00.002-06:00

Watch Marty and Cooper, our cute little puppy Angels, wait patiently for their treats. Their tails tell their story. Every day it's the same thing. Like uur own little Groundhog Day.

You can also view the rest of Marty's and Cooper's beautiful slideshows, videos and blog posts.

CT Contrast Causes Thyroid Damage Says Study (and Heart Caths Too). What Are The Implications?

2012-01-26T11:11:00.006-06:00

We order a lot of CT scans in this country. Why? Because we can. We likely have more access to immediate CT technology than any country in the world. Go to any ER in this country (including any tiny county critical access hospital) and complain of a headache, abdominal pain or chest pain and chances are pretty good that someone, at some point, is going to order a CT scan on you.

We already know about the potential long term dangers of CT scan radiation exposure. Go to this link and have your eyes opened to the dangers of frequent CT scan exposure. Some studies suggest one CT scan of the abdomen is the equivalent of 2000 xrays of radiation, or 30 years of background radiation. What does this have to do with your risk of developing cancer? Go read all about it.

Now comes reports out of the Archives of Internal Medicine that CT contrast exposure may cause thyroid damage leading to higher rates of incident hyperthyroid and overt hypothryoid states. CT contrast (and any contrast used on angiographic studies such as heart catheterizations and other invasive arterial and venous studies) is a form of iodinated contrast media. In other words, they contain iodine. Contrast is used to enhance CT and angiographic imaging and is required to make certain diagnostic determinations.

Thyroid homeostasis is dependent on complicated iodine metabolism. I couldn't even begin to remember the complex physiology behind the association. Suffice to say, while cause and effect hasn't been definitively proven, this study raises the possibility that the thryoid of some folks are incapable of handling the large iodine load associated with CT contrast and other angiographic studies.

This appears to be the first study suggesting the possibility of long term thyroid dysfunction with the use of iodinated contrast media. What does this mean from an informed consent stand point? Should all patients receiving CT or angiographic contrast media be required to sign documents detailing the growing list of complications and potential complications from these medical tests?

Should all patients who have received iodinated contrast media receive thyroid screening tests before and after, like we do with creatinine levels? And if so, when should those test be performed? One week out? One month out? Should they be repeated in series? And who should pay for them? How much does a TSH cost? Does the risk of long term (and even short term) thyroid disease outweigh the potential benefits of the CT scan? Should greater weight be given to the pre-test probability of finding an abnormality on CT? Should ordering a "just to make sure" CT scan to avoid being sued for failure to diagnose give doctors second thoughts about the potential dangers present on the other side of the equation.

Untreated thyroid dysfunction can lead to a whole host of other medical problems too including weight gain, heart disease lipid metabolism dysfunction, depression and anxiety. Lots to think about. I don't know what the right answer is. But I'm sure, eventually, the lawyers will tell us.

By the way, some folks may ask, "Does MRI contrast have iodine in it?". The answer is no. Most commonly, gadolinium is the contrast of choice for MRI. It is not an iodine based medium. MRI is rarely used in the evaluation and treatment of diseases screened or followed by CT. The two technologies are simply not interchangeable in most circumstances.

Source article: Connie M. Rhee, MD; Ishir Bhan, MD, MPH; Erik K. Alexander, MD; Steven M. Brunelli, MD, MSCE; Arch Intern Med. 2012;172(2):153-159. doi:10.1001/archinternmed.2011.677

Changing Observation or Inpatient CPT® Codes To Match Hospital Billing

2012-01-25T11:46:00.000-06:00

A reader asked an astute question that comes up frequently in the debate on defining observation vs inpatient status for hospital admissions.

I have a question for you. I am getting really bogged down with this obs vs inpatient business, specially with admissions that are not so clear cut to me and stay more than a day. First of all, the initial observation vs inpatient is often decided by the ER doctor. Sometimes, if it is obviously wrong I change it. But often times that is missed, especially if our super busy nocturnist is admitting the patient. So I bill subsequent obs stay charges the next couple of days. And then the case manager comes and tells me on day 4 that the patient met inpatient criteria from day 1. Can I go back and change my codes to subsequent inpatient follow up charges? I have been told I can't. Do I need to educate myself more on what meets inpatient criteria? Again, I am talking about cases that are not clear cut. Thank you!

Thats a great question. As a physician, how should you bill your CPT® codes when the hospital pulls a switch-a-roo (which by the way requires an order from you) and changes either inpatient to observation or observation to inpatient?

To understand my answer you have to understand the rules. Let me lay some ground work to help you. There are two major types of status a patient can enter into the hospital as. Either they are considered inpatient or they are considered outpatient. Which status they are defines how hospitals get paid by Medicare (at least if you are not admitted to a Critical Access Hospital) AND how you as a physician will get paid.

In general, inpatient stays are paid to hospitals as a diagnosis related group (DRG). With some modifying conditions, whether the patient is in the hospital for two days or two weeks, the hospital will get paid the same amount, based on the diagnosis you carry and any major complicating conditions (MCC) and complicating conditions (CC). However, soon, hospitals may not get paid at all with 30 day readmission rules coming shortly on the horizon. Until then, all supplies, inpatient xrays, medications, daily hospital labs are bundled into a DRG and paid for with Medicare Part A benefits.

If the patient is considered outpatient (such as observation status), hospital charges are paid for through outpatient benefits, which are generally paid for through Medicare Part B (except home medications which may or may not be even be paid for by Medicare Part D benefits). Hospital charges incurred during an observation stay are often billed out separately or bundled with ER charges and often include room and board charges in blocks of time as well. If a Medicare patient is in the hospital for less than eight hours, often, the observation stay itself will be denied and that means they won't pay the doctor charges either. So doctors, round last on your early morning observation admissions or you won't get paid for work provided. Why? See the next paragraph.

Medicare Part A does not cover any physician services provided during your stay in the hospital. Medicare Part A will not cover any charges submitted by any physician that sees you in the hospital, including your family medicine doctor (if they still round in the hospital), hospitalists, ER doctors, anesthesiologists, pathologists, radiologists, surgeons and any medical subspecialists. It won't cover the charge you will receive from a physician who never saw you but provided interpretation of a billable CPT® charge (such as interpreting a cardiac echo, noninvasive vascular studies, EKGs, PFTs, xrays, etc...).

For Medicare patients, physicians submit their charge (defined by a CPT® code) to Medicare Part B. Medicare Part B is not an automatic entitlement. Medicare Part B will cover 80% of submitted charges. Many Medicare patients buy an additional supplemental plan that covers the uncovered 20% of Part B charges.

In a nutshell, hospitals get paid under Medicare Part A and physicians get paid under Medicare Part B. The paperwork submitted by the hospital to get paid under Medicare Part A must match the paperwork submitted by the physician for payment under Medicare Part B, or, I presume, fraud detectors go off. That means if the physician saw the patient on days 1,2,3 and 4 and billed outpatient observation CPT® codes, but the hospital ended up submitting a single inpatient DRG request for payment by Medicare Part A, even if done retrospectively, red flags will fly everywhere. Why would Medicare pay for your outpatient services on days 1, 2, 3 and 4 if the patient was admitted to the hospital according to the submitted hospital charges. Are you committing fraud doctor? How could you possibly be billing for outpatient services when the patient was being paid a bundled inpatient DRG on the same days, doctor?

This is the Medicare fraud Obama refers to.

Your billing as a physician must align with the billing of the hospital or you won't get paid. What do I do? If I bill a patient observation and the hospital retrospectively changes the stay to a full admission from day one or they start with inpatient and changes to observation (code 44) I always align my billing with the status of the hospitals paperwork. The hospital has their ways of getting paid for changes in status (from inpatient to observation or observation to inpatient). I want to make sure my billing status (inpatient or outpatient) always aligns with the hospital's status. That way I'm not billing for outpatient services when the hospital is billing for inpatient services and I'm not billing for inpatient services when the hospital is billing for outpatient services.

I haven't heard of any problem from our billing company about getting paid for services provided. Is it right? I assume it is. The initial CPT® visit codes for inpatient (99221, 99222, 99223) and observation (99234, 99235, 99236) require the same respective elements. The note itself has nothing to do with defining inpatient or outpatient status. The same goes for the hospital inpatient follow up codes (99231, 99232, 99233) and their respective observation follow up codes.

As a general rule, as I understand them, hospitals will either submit charges for inpatient or observation, but generally not both by doing retrospective reviews on hospital admissions and that means, for physicians, their billing must also align with either the inpatient or outpatient charges.

In answer to your question, I do go back and change my charges to align with the charges the hospital is going to submit. That way, my CPT® charges more accurately describe the work that I provided, based on an analysis and correct interpretation of the rules, that may have been inaccurate on admission by no fault of anyones. If Medicare expects physicians to know every complicated rule required to make accurate determinations of observation or inpatient stays at the bedside, on admission, they have clearly lost touch with the realities of how medicine is practiced and the folks defining those expectations should be fired. It is simply not a workable expectations under any circumstance, unless they expect hospitals to support on call coding managers for every 3 am admission that comes through the door 365 days a year.

If I'm billing inpatient and the hospital is billing outpatient or if I'm billing outpatient and the hospital is billing inpatient, then one of us is committing fraud or medically unnecessary care, neither of which is true, but will be construed as such by the Medicare algorithms.

The other alternative is that nobody at the Medicare National Bank is paying attention and you can submit what ever you want and it will likely get paid.

Read more about my free evaluation and management coding help.

Grand Rounds Heads to USA Today

2012-01-24T11:51:00.001-06:00

Grand Rounds, a collection of the internet's best medical blog offerings is being hosted by USA Today this week. Here are the links to the four part series presentation.

You can even find my contribution in the mix as well

Hawk Sitting On Street Light and Utility Pole (Cool Pictures)

2012-01-20T15:15:00.003-06:00

I saw this hawk flying near my neighborhood today and I snapped a few pictures of it sitting on a street light bulb and utility pole. Cool stuff. So graceful.

Top 10 Ways To Survive a Hospital Stay While Maintaining Your Sanity.

2012-01-18T18:48:00.004-06:00

Hospital stays can be traumatic for patients and their family members. This Happy Hospitalist exclusive gives you the top 10 ways to survive a hospital stay while maintaining your sanity.

#10 Bring your own pillow. Trust me.

#9 Bring a laptop computer or request one from the hospital. Hospitals all have free wireless these days and many will actually provide you with a laptop if you just ask.

#8 Bring an accurate and updated medication list with you. Nothing leaves you more vulnerable to hospital errors than to have your doctor give you medication you haven't taken in months or for you to miss medications that haven't been updated by your five outpatient doctors since they bought their worthless EMR three years ago.

#7 Write down all your questions early. Your doctor will only come to your room once a day (because they only get paid by Medicare to come once in a day) and any unanswered questions will have to wait until the following day.

#6 Be patient. There is no clock in a hospital. Nobody knows when any of your tests are scheduled to be done. Not the cleaning lady. Not your nurse. Not even the doctor doing the procedure knows when you're up. You'll know when you're up when they cart you away. Believing anything otherwise will just make you frustrated.

#5 You're going to be told things that contradict each other multiple times a day. That's normal. Accept it. All your doctors and nurses carry their own perspective and experience. There is no right answer to many of the questions you will seek. In order to feel the best, simply pick the answer that makes you feel the best and run with it.

#4 Being sick is highly unpredictable. If hospital care was easy and straightforward, we would be monitoring you from home with our Skype account. But we aren't. You may be stable one hour and unconscious the next. That's not your doctor's or your nurse's fault. That's why you're in the hospital.

#3 Your doctors and nurses are not dumb or uncaring because they don't do things exactly as you wish or respond to your every need or request with immediacy. We see thousands of patients a year who all carry their own life baggage in one way or another. There is no protocol for making everyone happy. The closest we can come is to provide you with our AIDET process, which does an excellent job of preparing you for #4, 5 and 6, but it won't make you happy.

#2 Be nice. If you are mean to your doctors or nurses, they will consciously (or subconsciously) avoid interaction with you and your family. There are many safely guarded methods handed down through centuries of medical and nursing training that have prepared doctors and nurses for the difficult family. We know all the methods by heart.

#1 Request a hospitalist. We'll get you out quicker and less sicker. Less sicker does not mean healthy. You are in the hospital because you aren't healthy. The best we can offer is to make you less sick. Any doctor claiming otherwise is...well...see #5

BONUS SURVIVAL TIP!

Here is one last hospital survival tip that will shed hours off your day of uncertainty:

When you are admitted to the hospital, request the highest hospital floor for your room. Most doctors will take the elevator to the top of the hospital and do gravity rounds. That's because doctors, like most Americans shun stairs in favor of elevators. That means doctors will start at the top of the hospital and work their way down from floor to floor until they are done seeing patients. If you don't want to be last, make sure you get to the top of the ~~patient list~~ hospital.

There you have it folks. A hospitalists guide exclusively for patients on how to survive a hospital stay while maintaining a sense of sanity.

iHealth Blood Pressure Dock For iPhone, iPod and iPad. (Picture)

2012-01-18T10:13:00.004-06:00

An Apple a day keeps the blood pressure at bay. We were cruising through Best Buy the other day when I saw the iHealth Blood Pressure Dock that is used to track and monitor your blood pressure through your iPhone with the free iHealth app. Your cell phone is not just a cell phone anymore. The portability of this technology is revolutionizing the way we live and care for ourselves. I'd love to now if anyone has reviewed or used this iHealth Blood Pressure Dock to monitor their blood pressures at home and to know what they think. This sounds like an excellent way for one to keep track of thier blood pressures for their doctor to review. It sells for $99.99 at Best Buy. I found the iHealth Blood Pressure Monitoring System on Amazon for $10 cheaper. It has over 20 reviews, most of them or excellent.

Walgreens Offering Bedside Consultation and Delivery of Medications On Hospital Discharge

2012-01-17T16:44:00.001-06:00

The power of innovation is alive and well. Here's a fascinating article from the The Atlanta Journal-Constitution about private market forces coming together to improve patient satisfaction scores (it doesn't even require AIDET) while providing a valuable medication reconciliation process that doesn't cost the hospital a dime and might even overcome heart failure 30 day hospital readmission barriers.

Walgreens is coming to the patient's bedside at hospital discharge to provide education, counseling and hand delivery of their necessary medication prescriptions on discharge. The potential partnership possibilities between private pharmacies and community hospitals is huge. Why didn't we think of that? With razor thin hospital profit margins from Medicare, having outside resources provide patient education seems like a perfect WIN-WIN market solution.

Italian Greyhounds Beg For Food With The Baby (Cute Video)

2012-01-16T19:09:00.000-06:00

Marty and Cooper sit patiently waiting for their nibbles of pear too as Zachary, our almost nine month old son takes in all the action. I think it's pretty cute.

Click on their respective links here for all of Zachary's and Marty's and Cooper's blog posts, videos and slideshows.

Back Talking Baby Zachary Video (At Eight Months Old)

2012-01-16T14:17:00.001-06:00

8 1/2 month old baby Zachary is just about ready to start crawling, but it looks like he decided he couldn't do that until he learned how to talk back to this daddy first.

Check out all of Zachary's blog posts, videos and pictures.

High School Dropout Tax Proposed for 2012.

2012-01-15T09:14:00.008-06:00

(HNN) President Obama is set to announce a radical shift in his economic policy by announcing a new tax on high school dropouts. The tax will be used to reduce unemployment and help to pay for a second wave of bank bailouts. The proposal, called The Tax and Lend Act of 2012, will be unveiled during the State of the Union Address on January 24th, 2012.

Four years of artificially low interest rates have devastated savers and have failed to recapitalize banks who lost heavily leveraged bets on the housing market.

Obama notes, "We know the world is headed for another recession. We must act now to ensure that our banks have continued access to other people's cash. Those without education are making my unemployment rates look bad and I need to change that. What better way to raise money for my banks and improve my job numbers than to tax the uneducated into elimination."

Economists everywhere hailed the proposal as a radical but intriguing shift on social mood. Paul Krugman said of the proposal, "The guy is a genius. The Tax and Lend Act is perfect. Why didn't I think of that? I won the Nobel Memorial Prize for Heaven's sake. It makes perfect sense. If you tax something, anything, you get less of it. We've been cutting taxes on the poor for decades and we have more poor people than ever. Heck, half the country pays no income tax. If we want fewer poor people we are going to have to increase their taxes now."

While specific details have not yet been released, inside sources also suggested Obama will recommend that all taxes be immediately eliminated on Americans with post graduate degrees. "That outa get me two or three percent on my jobs numbers by November", says Obama.

National Democratic leaders were caught off guard by this radical shift. But they've come up with the 2012 Presidential advertising campaign slogan

"Changing Our Minds"

Now thats what I call progress(ive).

Speed Reading Baby Zachary!

2012-01-14T15:23:00.000-06:00

Before he can even walk, Zachary has picked up speed reading. Not a bad talent to have! Even Marty gets in on the action near the end of the video.

Check out all of Zachary's blog posts, videos and pictures.

Girls Scout Cookie Season Is Here. I Say Donate Some Money Instead.

2012-01-13T15:55:00.001-06:00

Girls Scout cookie season is upon us. Get out there and buy your favorites today. Thin mints and carmel delights are my favorites. Depending on where you live, the price can be $3.50 to $4.00 a box, or more. Unfortunately, I'm told the girls' local troop only gets to keep 50 cents of each box sold. That's a shame. Those greedy Girls Scout corporate offices. How could they do that to these little girls? Where is the Occupy Girls Scout movement?

On the other hand, part of me wonders whether the Girls Scout cookie season is a covert way of teaching these young girls that hard work, sweat and sacrifice will be rewarded by a government that taxes them as the enemy that must be punished into mediocrity.

Just think, donating $5 to your local troop is the equivalent of buying 10 boxes of Girls Scout cookies. And since Girls Scouts is a 501c organization, you might even be able to write it off as a charitable donation on your taxes. (This is not advice. Consult your accountant for more information). WIN-WIN.

Hospitals Buy Technology They Don't Need

2012-01-13T08:02:00.001-06:00

I came across this article on seven reasons hospitals buy technology they don't need. Not a bad collection of reasons. I think the best part about the whole article was their solution to help keep hospitals from buying technology they don't need. In the third to the last paragraph of the article they discuss the use of value analysis committees including hospital executives, supply chain officials and "whiny physicians" who want the technology to hash out the needs of the hospital as a whole.

I think I'll start things off by requesting hospitals purchase technology that stuffs patient charts with progress notes and order sheets at a 100% success rate. Now that's technology money well spent.

You can read more about expensive technology by checking out:

2012 wRVU and tRVU (Work and Total) Table For E/M Hospital Codes

2012-01-10T18:07:00.000-06:00

I've updated my wRVU and tRVU tables for 2012 values. Not a lot of major differences, except I did see some significant increases in some of the lower level codes. Although, even these increases are insignificant, in my opinion, when you compare them against the time value of performing non evaluation and management codes. Feel free to compare the 2011 and 2012 tables. But, know that you get what the RUC recommends you pay for.

MARTI Interpreter Saves Lives. But, Where In The World Is MARTI?

2012-01-10T15:30:00.020-06:00

I was recently introduced to the next step in hospital interpreter services. It's called MARTI and it stands for My Accessible Real Time Trusted Interpreter. It's not the cheapest English to Spanish translation service, but it may be the best way to communicate with patients who don't ~~communicate in the same language~~ speak English.

MARTI is an internet connected touch screen computer monitor attached to ~~an upright mobile platform~~ a cart that can be moved to any patient room in the hospital. Simply push the start button on the flat screen monitor and a live video feed of a MARTI operator will get you the just about any foreign language translator you need. Many times you can see your interpreter live on screen as well. (On a side note, I'd be curious to know how the MARTI network is secured to be HIPAA compliant and inaccessible to hackers).

I'm impressed with the MARTI folks. They're good. They seem to be able to find any translator for any dialect of any language for any country anywhere. They've even got folks that know vent speak and trachonese. I don't know how they do it. Maybe the MARTI folks make big money by playing the global labor arbitrage market. Perhaps they used the Google method and scoured the world looking for folks who speak native languages and then provided them with satellite bat phones to be called up at any hour of the day or night to provide MARTI hospital interpreter services. Perhaps they pay these MARTI translators 10 cents a phone call and turn around and charge the hospital by the minute.

The concept is great. But, the worst part about the MARTI system is trying to find ~~her~~ ~~him~~ it. That dilemma always leads to the actionable path of least resistance, which is to choose default documentation of "ROS unobtainable at this time due to speech and words that don't make sense". That meets all the criteria necessary to meet HPI or ROS documentation requirements of a high level hospital admission (CPT® 99223) or high level hospital follow-up visit (CPT® 99233).

Nobody ever seems to know where MARTI is. The way I see it, MARTI is taking advantage of hospitals everywhere by clocking in early, taking long lunch breaks and snoozing on the job. It seems like nobody is managing MARTI. How are we supposed to know MARTI isn't just making long distance phone calls all over the world and claiming it was a part of their routine business?

What we need now is a MARTiPAD App where I, as a hospitalist, can get any language interpreter while rounding with my iPad, instead of spending all my time trying to hunt down MARTI, who is probably busy Facebooking in the supply closet.

While MARTI has its benefits, hospitals have to be aware of the dangers of an out of control MARTI as well. And Mrs Happy and I know all about out out of control Marty's.

Lovenox Drug Assistance Program Ended December, 2011. Long Live Arixtra!

2012-01-09T14:30:00.004-06:00

Years ago I used to keep patients in the hospital for days just to receive their Lovenox shots. Then most drug companies came up with their own drug assistance programs and Congress passed the unfunded Medicare Part D benefit plan that sacrificed the future standard of living for our current generation in favor of senior votes. With many expensive drugs turning generic over the last decade, I have been thrilled that many of my patients have low cost or no cost alternatives to taking their medications.

This era may go down in history as the golden age of medication availability for hospitalist discharge. Now, I have received word that Sanofi-Aventis, the maker of Lovenox, has ended their Lovenox (enoxaparin) drug assistance program in December, 2011. That means patients with no medication insurance will be required to pay cash up front to their local pharmacy if they want to treat their deep venous thrombosis, pulmonary emboli, stroke related atrial fibrillation or any other potentially life threatening medical condition that requires Lovenox bridging anticoagulation as an outpatient.

Or they can stay in the hospital for an extra week at $3,000 a day minimum to get outpatient administration of their $100 prefilled Lovenox syringes injected by a nurse who, I'm sure, has much better things to do with their time.

Getting Lovenox shots at your local pharmacy will set you back $1,000 or more for a standard course of full dose anticoagulation. Even the cost of the recent generic expansion of enoxaparin is still out of reach for most uninsured patients.

So what's the market solution here? Patients could stay in the hospital for a week or more as proposed above and let the hospitals eat the cost as a government expense of doing business. Better yet, hospitals could start their own free Lovenox program.

The best solution, I think, might be to start prescribing Arixtra (fondaparinux) for most of my insured and uninsured patients alike as a matter of default. Arixtra carries many of the same FDA indications for therapy and, as far as I know, GlaxoSmithKline has not discontinued their assistance program.

I'm not sure if ending the Lovenox assistance program had anything to do with the availability of generic enoxaparin or has anything to do with ObamaCare rules and regulations coming down the pipeline or if there is some other brilliant rationale behind this action.

All of this may not really matter anyway as it turns out that even when given free heart medications after a heart attack, only 10% of people continued to fill their scripts after a year.

Perhaps Sanofi has it right after all and Medicare D is just wasting our money.

Baby Poker Player Superstar! (Pictures of Intense Concentration)

2012-01-07T15:56:00.002-06:00

I never knew Zach was a little baby poker player in the making. That is, until I found him thinking hard about our hand of cards.

As you can see, I'm shocked and confused about what I should do with my hand. On the other hand, Zach is calm as can be.

And here I am looking to Zach for a little help. As you can see, he has the face of a killer poker player playing out his options in his mind.

It turned out, in fact, that his first experience with poker was quite the hair raising experience.

Coed Locker Rooms In The Hospital Lead to Adultery? (Picture Explanation)

2012-01-07T10:31:00.000-06:00

Since I ~~rarely~~ never enter the surgical areas of the hospital (we have our own hospitalist pad), I found this picture and post by Dr Wes about adultery in coed locker rooms in the hospital to be a bit grounding. While hilariously funny at face value, it does have truth in perspective.

Through my travels in hospitalist medicine, every so often I hear about cases of doctors (men and women alike) cheating on their spouses. It's disheartening to say the least. Lives are destroyed. Families are ripped apart. Kids are left without a regular parent in their lives.

When I was in medical school, I remember many surgical residency programs proudly proclaiming to have a 100% divorce rate. It seemed like a badge of honor for them. It's twisted thinking, I know. I'm not sure if these programs still carry that honor now that the new intern work hour restrictions mean surgeons in training are sent home in time to put the kids to bed.

With all that said, I have to admit I don't know if coed locker rooms in the hospital increase the risk of adultery or not. I'm pretty sure there are no rigorous studies on the matter. Any blinded study would require hidden video cameras and I'm pretty sure that would lead to a few arrests along the way.

I'm not even sure if surgeons have a higher rate of divorce than other doctors or even the general public. These pictures simply seem to suggest that some folks are certainly thinking about the possibility of buffoonery in the coed hospital locker room.

Fore more important information about surgeons, read the following:

Funny surgeon jokes
How do you hide $100 from a surgeon?
The Colorectal Surgeon Song (Video)
Like a Surgeon (Weird Al YouTube Video)

Hawaiian Hospitals Closed As Hawaii Medical Center East and West are No More.

2012-01-06T11:20:00.000-06:00

Honolulu based Hawaii Medical Center East in Liliha and Hawaii Medical Center West in Ewa on the Island of Oahu have officially closed their doors after a deal to sell their assets in bankruptcy court to California based Prime Healthcare Services fell through last month. Prime Healthcare's 25 million dollar offer was rejected. In mid December the hospitals abruptly closed their emergency rooms leading to a rapid chain reaction of overloaded emergency rooms in surrounding local hospitals.

The closing left nearly 1000 people without a job. The final patients were transferred out of the facility late Wednesday January 4th, 2012. HMC East had been the state's only transplant center. Another local hospital, Queen's Medical Center, is trying to get certification.

These hospitals have apparently lead a troubled past involving previous bankruptcy proceedings. I suppose, like any business, if it can't survive on its own two feet, it doesn't deserve to survive. I'm sure there are many details regarding their failure that remain outside the public realm. In the end, they couldn't pay their bills. And, unless you are the federal government, that means you disappear.

I would drop to my knees and cry out loud if I was a hospitalist at any of the other local hospitals in the surrounding community. Those hundreds of beds that disappeared overnight will get absorbed by higher patient census and higher ER volumes in surrounding community hospitals.

I can tolerate higher census, for a while. Hospitalist medicine census' can be unpredictable. However, to suddenly be responsible for dozens of additional daily patients on an ongoing basis would rapidly lead to increased physician burn out, increased medical errors, decreased efficiency, lower doctor satisfaction, lower nurse satisfaction and lower patient satisfaction.

It's the classic inner city hospital dynamics of too many patients and not enough resources to care for them. And because Medicare is going to start paying hospitals based on patient satisfaction scores, the losers are the hospitals that are most desperately needed by the poorest in our country. CMS is going to destroy access to care by our poor. Their mandates are unfunded. Their expectations are noble, but unreasonable realities of the Medicare and Medicaid National Banks failed economics.

It can be very difficult for surrounding hospital systems to rapidly absorb the census of a two large community hospitals. Heck, these centers were big enough to support a transplant program. We aren't talking about a small critical access hospital here. These were big time programs.

If you need more hospitalists and emergency room physicians to help out at surrounding hospitals, physician credentialing takes time. It just doesn't happen over night. It is a pretty rigorous multi-step process.

I'm glad I'm not a hospitalist in Honolulu these days. I'm glad I'm not a resident physician either because I'm either out of a job or I'm struggling to stay compliant with my new intern work hour restrictions as I got bombarded with a much higher daily census.

Ah, so many rules. So many unintended consequences of the regulations. The question I have is how many Hawaii Medical Center hospitals are lurking in the wind just waiting for the opportunity to throw in the towel. With hospital Medicare profit margins razor thin already, it won't take much for hospitals lacking alternative sources of revenue to die a rapid death.

No matter how you try and sugar coat patient care, it is a business. And it will always be a business. Big business.

Critical Access Hospitals' Length of Stay Requirements Increase Hospitalist Admissions.

2012-01-05T17:14:00.000-06:00

I practice hospitalist medicine in the leading regional referral center in my state. We are a full service hospital that is capable of providing just about all medically necessary (and unnecessary) health care your Medicare National Bank can afford to pay for. If you are a Medicare patient and you get admitted to any major hospital system in this country, your hospital will get paid based on a diagnosis related group (DRG). Go here to learn more about how hospitals get paid by Medicare.

However, if you are a Critical Access Hospital (CAH), many of the rules placed on major regional referral hospitals don't apply. I always knew that critical access hospitals weren't paid based on the DRG rules of big hospital centers. You might be interested to know that

To gain CAH status, the hospital must be in a rural area and be at least 35 miles from another hospital or 15 miles from another hospital in a mountainous terrain or with secondary roads only.
As of March 31st, 2011, there were 1327 CAHs. Here is a map of all Critical Access Hospitals in the country.
CAHs receive cost-based payment from Medicare. (Cost + 1%). DRGs do not apply
CAH centers must have a maximum of 25 acute care inpatient beds.
CAH centers must maintain an average length of stay of 96 hours or less for their acute care patients.

It never occurred to me before, but this length of stay requirement may be why hospitalists are often asked to accept patients from critical access hospitals who are in their acute care hospital day #2 or #3. I rarely see transfer patients from CAHs who have been admitted more than 96 hours. That may have less to do with their severity of illness and more to do with the government mandated rules on Critical Access Hospital length of stay requirements.

That's OK though. Because they come to us with ~~urosepsis~~ sepsis with UTI and go home the next day. My hospital gets paid a nice one day DRG for sepsis, my length of stay and mortality quality data rocks the averages and the Critical Care Hospital gets their cost + 1%. It's WIN-WIN.

I just wonder how long The Medicare National Bank will be able to continue paying for it all and what effect the bundled payment models being tossed around these days will have on how patient care is divided between CAHs and acute care regional referral centers.

If CAH are excluded from the bundled care fixed pie model, there may be more incentive for big hospital systems to partner with CAHs as a way to defer radiology and laboratory and labor expenses in the first 96 hours of illness while providing highly specialized care in the form of TeliPad medicine. Once that golden 96th hour is achieved, the patient can safely be transferred for a truncated and more lucrative DRG who's upfront costs have been diverted to the cost +1% model of CAH care.

That makes sense to me.

Medical Resources Center on The Happy Hospitalist

2012-01-05T10:21:00.011-06:00

The Happy Hospitalist has brought together a list of resources helpful for all physicians in their daily practice needs. Whether you are

Searching for jobs,
Learning about evaluation & management coding
Need help at the beside with an E&M Refence card
Trying to finding the best EHR for your practice or
Discovering thousands of medical and business related books important to your practice,

The Happy Hospitalist is dedicated to helping you navigate the complicated process of delivering patient care. For example, if you are in the market for a new EHR product, you can find the best specialty specific EHR by clicking on your field of practice below.

EHR Research Guides

The resource bar is located just below the top header.

Marathon Circuit For Smokers In 2012: The Sweat While You Smoke Tour.

2012-01-02T10:29:00.003-06:00

(HNN) As 2012 ushers in the new year, so does a new era in marathon running. The American Cancer Society (ACS), the American Hospital Association (AHA), and PhilipMorrisUSA, a wholly owned subsidiary of tobacco giant Altria, have announced a multi-year corporate marathon sponsorship catered exclusively to smokers.

Called the Sweat While You Smoke Tour, this marathon circuit promises to revolutionize the way America views smokers.

Says one smoker, who wished to remain anonymous, "We aren't all lazy couch potatoes looking for our next Jonesing fix. Many of us lead healthy and active lives. I signed up for the first ever Sweat While You Smoke marathon event to prove to my nonsmoking friends and family that I'm just as healthy as they are. They're so snotty. I'll show them how tough I really am."

John R Seffrin, CEO of the American Cancer Society agrees. "We understand that smokers are here to stay. After decades of encouraging state and federal legislation to eliminate tobacco from mainstream America, we at the American Cancer Society have discovered the enormous financial benefits of teaming up with big tobacco. We are making hundreds of millions of dollars on this tour to help fight cancer and smokers get a chance to show America they have the heart to exercise. It's WIN-WIN."

All marathon races will begin at the front doors of a participating hospital. This whirlwind tour will visit 52 cities in 52 weeks and give smokers the exhilarating opportunity to experience all the health benefits of marathon running while discovering the beauty of America's hospitals.

Tour organizers understand their smokers have many different levels of marathon running experience. They are offering graded running opportunities which include the full 26 block marathon, the 13 block half marathon, the 10 block, the 5 block and the 1 block run-walk experience.

All entrants will be required to submit proof of positive cotinine status obtained within the previous thirty days as a prerequisite for race enrollment. In addition, all marathoners will be required to smoke at least one cigarette during their race to prove their continued dedication to tobacco abuse. Oxygen stations will be provided every block free of charge, paid for with magic ObamaCare money.

Richard Umbdenstock, President and CEO of the AHA says, "We must make sure all our race participants are addicted to tobacco at race time if we are going to maintain the integrity of this exciting new marathon circuit for smokers. We know ex-smokers and nonsmokers will try and skirt the rules We are prepared for them."

The American Hospital Association has promised that all participating hospitals will have at least 50% of their acute medical beds open on race day. Mass casualty protocols will be in effect and participating hospital emergency rooms will be given reprieve from EMTALA rules on race day in order to divert all Medicaid patients to other nonparticipating hospitals. The AHA has also promised to provide extra staffing with hospitalists, pulmonologists and cardiologists, even providing locum tenens doctors, if necessary.

The tour will begin in San Fransisco and end at the White House in Washington DC on New Years Eve 2012. Obama reportedly signed an executive order to have the last event of the year at the White House, blaming Congress, again, for their inability to act. Says White House Chief of Staff Bill Dale, " President Obama will participate in the five block run to show his solidarity to all smokers. It also gives him an opportunity to see what the White House looks like up close, one last time."

All race participants will receive a free carton of non-filtered Marlboro light cigarettes, a 10% off coupon for a cardiac calcium scan and a free monthly newsletter from the American Cancer Society about the health benefits of exercise.

This article is copyright protected by the Happy News Network. If you are a smoker, please contact the ACS, the AHA, Altria or Obama for more details about the Sweating While You Smoke Tour.

Beautiful Nature Pictures (Original Slideshow)

2012-01-01T14:19:00.002-06:00

This is an original slideshow filled with beautiful pictures of nature. Enjoy.

Random pictures of life and beauty. Here's the direct link to the full size slideshow. I'm always adding new pictures here.

International Concierge Medicine Opportunity of a Lifetime

2011-12-30T14:50:00.001-06:00

I'm always getting junk mail from recruiters looking to fill their hospitalist or internal medicine job opportunities. This last once in a lifetime opportunity was a doozy. It's being advertised as an opportunity to practice International Concierge Medicine as a Chief Medical Officer Employed with Full Benefits. Here are some intriguing details pulled right from the advertisement:

This is "a challenging practice opportunity".

Any time I see the word "challenging" in a recruiting notice, red flags go off in my head.

This opportunity involves being a doctor for one private individual and their family to coordinate all the health and wellbeing protocols of the family, including daily health conditions, nutrition and exercising regimens.

I'd recommend they check with Dr Conrad Murray, but he is apparently tied up with other opportunities for the moment.

With primary offices to be based in New York, this individual must tolerate frequent international travel, most frequently to Monaco, Switzerland and the USA to develop and nurture a network of medical specialists across the Universe as well as to direct a team of nutritionists, dieticians, personal chefs, trainers, coaches (including yoga, martial arts, water sports, etc.).
Practice evidence based medicine, be proactive and service oriented with a "team player mentality"
Ability to perform effectively under pressure.
Speak fluent Russian and English.

I've talked over this opportunity with my colleagues. Russian? Challenging? Travel to Switzerland? Work under pressure?

I don't know about you, but that sounds like Russian mafia to me. What do you think? Would you take a position with the mob?