Sunday, January 05, 2014

Things That Make Me Crazy

I sometimes think I live in a tight little fantasy bubble where I want life to make sense and be fair.  I want it to be an uncomplicated place where, when resources are limited, we assess the problems and direct the dollars to things we know will efficiently fix the problems.  I'd like us to use our public health  dollars to feed hungry people, to house those without some place warm to stay, to help those in need learn strategies and get jobs so they can help themselves, and to provide health care to those who are ill.  In cases where there are big-picture items that lead to devastating consequences and enormous costs to society, I'd like us to target the causes with early interventions that are known to be effective: so measures to prevent drug/alcohol/tobacco abuse, better and more available drug treatments, and more resources dedicated to early education so that everyone gets the skills they need to earn a living and grow up to be a taxpayer.  

Instead, through some mix of politics and medicine, there are these untested (or poorly tested) ideas out there that cost billions of dollars and money gets diverted away from being used for the direct good of the people.  Maybe I'm wrong-- I'm sure there are plenty of people who disagree with me and think that these changes are important and will make the world a better place -- so by all means, feel free to comment. tell me why I'm wrong, or do add to my list.  It's a little of 'one guy unsuccessfully tried to blow up a plane with his sneakers so millions take off their shoes for screening every day.'  The cost is phenomenal, but I do have to  admit that no planes have been blown up with shoe bombs since, and if my child was on a plane that didn't explode, then the cost to society was worth it, but it's not a very "public health" way of thinking.  But you have to wonder what we're giving up when we put a lot of time, money, or resources towards low-probability events or towards paperwork for the sake of paperwork.  In no particular order:

Dinah's List of Aggravating Diversions from Productivity in 2013

  • CPT codes that force psychiatrists to differentiate "medical care" from psychotherapy with rate changes depending on whether the psychotherapy component takes 52 minutes or 53 minutes or the session, and creates 15 different options for coding a single psychotherapy session.
  • 68,000 ICD-10 codes for the purpose of diagnosis/billing. Really?  ClinkShrink will be thrilled, code Y92146 is for getting hurt at a prison swimming pool.  Prisons have swimming poolsAnd Y92253 is for being hurt at the opera, so Clink and Jesse can both rest assured that injuries they may incur can be coded. This helps us how?  And, no, US prisons don't have swimming pools, but why should that stop us from having codes?
  • Legislation -- complete with the cost of databanks, means for reporting to such databanks, and the cost of enforcement -- to keep the poorly-defined 'mentally ill' from owning guns when there is no such effort to keep the family members or roommates of those people from owning guns, and there is no such effort to keep guns from those who are known to be dangerous if they are not mentally ill.  The laws in Maryland also include 'habitual drunkards,' -- but there is no provision to report those who goes to detox/rehab or have a second DWI/DUI from having a gun. 
  • Continued support of the Second Amendment as interpreted rather widely, despite 40,000 gun deaths/ year, some of them innocent small children. "A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed."  I'm just not sure that the founding fathers foresaw a society of drug addiction, rampant suicide, and a country with a firearms death rate beyond any other country in the world.  There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people, or include assault weapons that did not yet exist.  The second amendment has become an impenetrable devotion -- in Maryland's it's some state legislator's main forum -- as if it were a religious belief.  And people with mental illnesses have taken the blame for all inappropriate uses of guns.  See yesterdays Bloomberg Report for our President's pronouncement, and by all means, read the comments.   
  •  Meaningful use -- a government/Medicare phenomena that creates a tremendous amount of work for physicians that does not seem to directly improve patient care (correct me if I'm wrong), and if it does, it doesn't improve patient care/outcomes in a way that warrants the time, and expense.  I don't really know what Meaningful Use is (such details never stop me from ranting), but I know the government will give me money if I'll convert to electronic records and use it in a particular way.  Otherwise, for every Medicare  patient I see, I must charge a lower fee if I don't use e-prescribing (which is not conclusively shown to improve patient outcomes) a certain percentage of the time, and that in 2013, to prevent an drop in my fees, I needed to put a PQRS code on one patient's insurance claim form.  I could not figure out what that meant, so I asked an APA assembly member who runs a hospital.  After two  separate half-hour phone conversations, one in-person meeting, and I have no idea how many hours of his time, he provided me a list of options which included things like "medications not reconciled, reason not given."  I opted to list on one patient's claim a code indicating he was not a tobacco user, and I'm told this was good enough to keep my fees from dropping 1.5% next year.  What's meaningful about this?
  • CRISP/Government portals of patient records collected without patient knowledge/permission.  These may be very helpful for emergency care in crisis situation,  and perhaps they allow for data/outcome collection that will be used for outcomes research, but they cost a lot of money and after the NSA scandal, are we all comfortable with the government keeping our health records without our expressed permission?  Are we sure our health information won't bounce back at us in unwanted ways?
  • Hospitals that spend HUNDREDS OF MILLIONS OF DOLLARS to replace existing, function, Electronic Medical Records when there are people sleeping on cardboard boxes outside their doors, and when such medical records increase the amount of time clinicians spend with computers and decrease the amount of time they spend with patients -- and don't necessarily decrease medical errors.  This feels wrong to me  on so many levels: there are shortages of physicians and we're diverting their attention to clicking through screens and checking off boxes that have nothing to do with the care of that particular patient, adding hours a day to physician workload, promoting physician burnout, and diverting funds to this project that could be used to pay for health care for human beings.
  • Government-run health insurance exchange(ACA) websites that are basically unusuable and create too much frustration for the average person --especially the average person with medical or psychiatric issues-- to work efficiently.  One of my patients was blocked from signing up because he forgot his password, and the recovery question involved his pet's name, only he's never had a pet and was locked out of the system. 
  • Hospital medical records that afford no privacy because thousands of people have access to them and patients can not opt out, other than to get care at another institution.  But if you want information about a patient from another institution, with the patient's permission, barriers are put in place to make this next to impossible.  I recently requested records from a local hospital ten minutes from my office, and two weeks later they sent me a form saying that the authorization my patient signed was not good enough, it had to be signed on their specific form.  How crazy is this?  Perhaps it's because that hospital's administrator was so busy looking up my PQRS codes that he wasn't updating their information release policies.
  • That my state is proposing to spend money on programs to increase cultural awareness and competency on number of measures when people need food/housing/healthcare/job training.  I'm all for treating people respectfully, but maybe it would be cheaper to fire those who are demeaning to others rather than to set up training programs to make them 'culturally aware.' (Please forgive my cynicism, in a world where everyone is fed, housed, has healthcare, heat, education and jobs, I'm all in favor of programs to increase sensitivity to cultural issues).
  • "That my state is proposing to add Assisted Outpatient Treatment (read: forced care) when we don't have enough information to know if this really works without other services in place.  We don't have  enough resources to care for people who want care, and this will entail forcing people to take medications that are known to have detrimental cardiovascular effects in some people,  distressing side effects in others, and may include forcing care on people when that care does not decrease their symptoms. If I thought the legislation was truly about getting care for the very sickest of people -- those 'dying in the streets with their rights on' -- I would be in favor, but I believe it's a "do something" measure to address spree shooters and has been tied to federal funding. 
Thank you for letting me rant.  That's what this was, and I appreciate it.  I feel much better now. 


Joel Hassman, MD said...

Nice. I think you are seeing the reality that being a doctor means being harassed, intruded, minimized, and downright ignored is the standard of expectation from most in positions of power, authority, and setting of standards.

But, if you stop ranting, it reflects you don't care or are just exhausted. Which is exactly what those who want to disrupt and devalue want of you, and really all of us who are still advocates and adhere to the Hippocratic Oath.

But, Nice post!

Anonymous said...

Ever consider running for a public office, or serving on boards that make these decisions? Or starting/joining a movement for smart change? Sounds like you have the right ideas...

Anonymous said...

Thank you for this post (and thanks to Dr. Hassman for his response to the other post). I needed to read it. I get panicky about the new legislation which I feel further marginalizes people with mental illness. We have so much that needs to be done that it makes no sense to focus on laws that create more fear through increased use of force and loss of privacy. We need housing. We need treatment for people who cannot afford it. We need to provide food for those who don't have any to eat. This just isn't the way. Creating more fear, just isn't the way.

I have to remember that regardless of what stupid legislation may or may not be passed, my psychiatrist won't act on it. We have a good relationship that is based on mutual respect. I cannot ever fathom, regardless of the laws, him ever going behind my back to talk to my parents. It's just not his way. Besides, he knows me too well.


Je Suis said...

I agree with pretty much everything you said in this post (surprise!), with one exception (of course..); that exception being this statement:

"There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people"

The fact that the second amendment didn't include slaves does not mean that it wasn't meant to include all people, rather it is a damning testament to the nature of slavery in existence at the time. Simply put, slaves were not considered 'people' but rather, property. As such, they were automatically excluded from the rights granted in the second amendment. The 'people' were the citizens of this country, and slave were not citizens; it took a war and later a civil rights movement to rectify this inequity.
Now that slavery is abolished, and equality constitutionally guaranteed - in word if not always in deed - do you really want to use slavery as an example of a system that allows a group of people to be summarily stripped of their rights, in whole or in part? One that creates tiers out of essential liberties, wherein one person is afforded a right based on their circumstances while another is not? I thought the goal was to do away with discrimination and stigmatization, but this second amendment argument you posit is a step in the wrong direction; it argues for the re-institutionalization of such behaviors.

Dinah said...

Je Suis, that was not my intention at all, but I see what you mean. 2nd amendment activists seem to feel that the amendment means free reign to weaponry of every kind, under nearly all conditions. The mentally ill, whoever they may be, get scapegoated. Start defining them as anyone who takes any psychotropic medicine and suddenly the NRA will be all over it. In Florida, it's illegal for a physician to ask a patient if they own a gun. What happened to the first amendment?
Not one single one of these measures would have prevented any of these high profile a spree shooting. Oh gosh, I could start ranting again and the chili will burn...

HIGurl said...


Thank you for ranting. And thank you for caring. Like Joel said, you only stop ranting once you cease to care and/or are just plain exhausted. I agree, it is frustrating that there's more paperwork, more coding, and more time and effort required when there should be more focus on patient care.

I think we all want to live in a bubble free of pain, of suffering, and of good. Our government has paved a super rocky path with tons of major potholes for us. Money is the root of all evil, right? Let's help this country even though we know they won't even help themselves. Let's build this because of that. Foolish spending has gotten our country into deep doodoo!

If only. If only we used the money we spent on this towards that, or this or that. Why not spend money putting people back into the workforce by training them? Why not offer incentives for those who receive assistance and give back to their community in some way? Why not this or that, right?

Here in the islands we have such a huge problem with homelessness. Want a one-way ticket to Hawaii where the weather is much warmer? Sure. Problem solved for that state but not ours.

Want Financial and SNAP assistance? No problem. Us locals joke on how to meet the requirements. Just keep popping out more children. The more children you have, the more money you get. When you have a family dressed up in designer clothes wearing tons of jewelry shopping at Costco, buying steaks and crab legs with EBT cards, then driving away in an Escalade, you know there's a problem with the system.

Yes, we are the melting pot of the Pacific, so to say. Our DHS Application for Public Benefits form has 17 languages listed. Granted, the cost of living here isn't cheap, which probably contributes to having more lower-income families. Add one-way tickets here. Then add friends and families of non-US citizens trying to get their Green Card. The bottom line is that there's not enough funds available to use towards early education, drug intervention, medical/mental facilities, and so forth. Unfortunately, it is what it is. Yes, it is frustrating. And yes, it is sad. Please don't stop ranting!

Sunny CA said...

While all the coding and electronic hassles of your profession cost money, to my mind a bigger problem is subsidizing oil companies and and farmers while we cut aid to hungry people.

By forcing electronic records on physicians, the companies that sell them prosper. Laws passed regarding education also serve private enterprise. Charter schools were devised as a way to steal money from public schools and put it in the pocket of business owners. Enforced testing of students rather than teaching students was set up with impossible to attain standards of annual increase in student test scores, thus breaking the back of public schools further, and allowing more funneling of public school money into private pockets.

The interests of people with money are protected and enhanced by new laws. There is no wise leader looking out for what is right and the poor people who need help.

pdf doc said...

And here I was thinking that this was the time and place to vent about the guy second in a line of cars travelling very slowly...not the first guy who is driving slowly but the second guy who doesn't pass him and allow all of us to move up one spot in the line! Ok so this isn't the time or place. Great post, Dinsh, on stuff that really matters.

Anonymous said...

Great post it made me feel not alone.
I always wonder who I am treating, the rules and regulations or my patient. I just want to be a psychiatrist and provide good care to my patients.