Cold and Flu Season Coming

As we head into fall and winter we see an increase in the number of viral respiratory illnesses in the community. Most of these are simple self-limited infections that healthy individuals can weather after a period of a few days to a week of being uncomfortable from runny noses, sinus congestion, sore throats, coughs, aches and pains and sometimes fever. There are studies out of Scandinavia conducted in extreme cold temperature environments that show that taking an extra gram of Vitamin C per day reduces the number of these infections and the severity and duration in elite athletes and Special Forces military troops. Starting extra vitamin C once you develop symptoms does little to shorten the duration or lessen the intensity of the illness. Vigorous hand washing and avoidance of sick individuals helps as well. Flu shots prevent viral influenza and should be taken by all adults unless they have a specific contraindication to influenza. A cold is not the flu or influenza. Whooping cough or pertussis vaccination with TDap should be taken by all middle aged and senior adults as well to update their pertussis immunity. We often see pictures of individuals wearing cloth surgical masks in crowded areas to prevent being exposed to a viral illness. Those cloth surgical masks keep the wearers secretions and “germs” contained from others but do nothing to prevent infectious agents others are emitting from getting through the pores of the mask and infecting them. If you wish to wear a mask that is effective in keeping infectious agents out then you need to be using an N95 respirator mask.

Once you exhibit viral upper respiratory tract symptoms care is supportive. If you are a running a fever of 101 degrees or higher taking Tylenol or a NSAID will bring the fever down. Staying hydrated with warm fluids, soups and broths helps. Resting when tired helps. Most adults do not “catch” strep throat unless they are exposed to young children usually ages 2-7 that have strep throat. Sore throats feel better with warm fluids, throat lozenges and rest.

You need to see your doctor if you have a chronic illness such as asthma , COPD, heart failure or an immunosuppressive disease which impairs your immune system and you develop a viral illness with a fever of 100.8 or higher. If your fever is 101 or greater for more than 24 hours it is the time to contact your doctor. Breathing difficulty is a red flag for the need to contact your physician immediately.

Most of these viral illnesses will make you feel miserable but will resolve on their own with rest, common sense and plenty of fluids.

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Medicare Part D Open Enrollment For 2015

MedicareFrom October 15, 2014 through December 14, 2014 Medicare beneficiaries will have an opportunity to choose their 2015 prescription drug plan. These plans change annually. If you do nothing you will remain in your current plan in 2015 even though the price will change and the drugs covered will change.

On your computer go to http://www.medicare.gov . Choose prescription drug plans. You will be asked to put in your name, your Medicare ID number and your zip code. They will ask you to enter your favorite pharmacy and then all your medications by name, dosage and frequency of administration. You will then run the program and it will suggest the best plan for you. I suggest you choose the least expensive plan. There are elective add on features which pay your drug deductible and even cover the donut hole for a higher fee.

If you have any questions feel free to call us. If you cannot use a computer and need our help please let us know.

There is no Way to Control the Cost of Care in the Last Few Months of Life

Sun and Wispy Clouds Over Mountains“J.T.” is 92 and clearly a soul who lives to the beat of a different drummer. She has no children and her closest relative is a niece who she despises. Despite this the niece oversees her care, sending in a full time aide and her personnel assistant to run the household. J.T. will not come to the office for a visit. If I call and make an appointment to see her in her home she at times will not permit me into her home. Despite her abrasive nature she is legally competent to make decisions and remains thin and frail but with no major acute medical problems. She is cognitively impaired to a moderate degree but legally competent to make decisions.  She too has executed a living will and has a large “Do Not Resuscitate” form posted on her refrigerator door.

Several months ago the niece called me to say her aunt was failing. She claimed she was ungroomed and refusing to bathe or eat. She said her hair was unkempt and nails long and filthy. She said she wasn’t eating.  She asked me to make a home visit.  I went out to the home with my nurse.

Upon arrival the patient at first did not want to let me in. I pleaded with her and she opened the door and invited us in. She was in a clean house coat. Her hair was wet having just gotten out of the shower. She was clean. The home was spotless. I asked her if I could have a cold drink so that I could get a look at the inside of her refrigerator. It was full of fresh food and beverages and was spotless. I asked to use the bathroom which was clean and spotless. The patient remarked that she had been under the weather the week before and had cancelled her weekly appointment at her nail salon.  I took a history, reviewed her medicines in their original pill bottles in the closet to check for accuracy and performed a brief but thorough exam. I pronounced her fit. We reviewed her end of life issues and choices with her and the aide. She said that if she got ill she would prefer not to go to the hospital unless I needed to send her to relieve pain and suffering.

Last month my office received a call from a new aide saying that the patient had fainted at the dining room table and was uninjured. By the time she got over to check on her she was up and coherent. The patient had no chest pain or breathing problems. She had no neurologic deficits. She had no visible seizure activity.  The aide called 911 before calling my office and the paramedics were there and were transporting her to the ER.  The patient did not want to go but the niece, who has power of attorney insisted that she go.  Upon arrival in the ER she was fine. A CT of the brain was performed upon arrival and was non-diagnostic as were her EKG and blood chemistries and electrolytes. This was all completed before my arrival. 

Upon my arrival I met the new aide.  She was quite glib and forceful. She told me she had been the caregiver for the niece’s mother. When the mother passed on several weeks ago, the niece had fired her aunt’s longtime aide and replaced her with her mother’s former care giver.

We kept the patient in the hospital overnight for observation. She was seen by a neurologist and by her own clinical cardiologist who had not seen her in three years since she became a recluse. By the next morning the patient was fine with all tests and scans normal.  I wrote discharge orders.   Two hours later I received a phone call from the floor nurse telling me that prior to discharge her heart rate had dropped to below 40 beats per minute without her suffering any symptoms of illness. The cardiologist suggested we keep the patient and have her seen by an electro physiologist for evaluation for a pacemaker. I called the niece to explain the change in plans and she actually accused me of keeping her aunt and suggesting a pacemaker to generate a higher bill.  I suggested we ask her aunt if she would consent to a pacemaker if she needed one. She said she would. 

The EPS physician did an evaluation and determined that the patient did not in fact need a pacemaker. We then planned to send her home again.  I set up a phone conference with the niece and caregiver and suggested that we return to the original plan of only calling 911 or moving the patient to the ER or hospital if we needed to for the relief of pain and suffering as originally planned.  The niece refused to follow that plan. She told me the aide didn’t want to stay in the house with a dying individual and she instructed the aide to call 911 whenever she felt it was appropriate. “I can’t have my aide watching my aunt die at home. “

The decision of the niece clearly is contrary to the wishes of her aunt. It is one more example of the public being unwilling to provide comfort measures at home and follow the guidelines outlined by their senior relatives when they were competent and able to make their choices. It is one more example of why we cannot keep the costs of end of life care in a reasonable range.

Bankrupting the Medicare System – End of Life Issues

Medicare“R.D.” is 95 years old. She is frail, somewhat confused and remains in atrial fibrillation as her primary heart rhythm.  Atrial Fibrillation predisposes the patient to embolic strokes so the patient has been on anticoagulants or blood thinners for years to prevent these strokes.  Her unsteady gait and frail state have resulted in numerous falls. With each fall she bangs her legs and develops an accumulation of blood under the skin and in the soft tissues known as a hematoma. These are compressed, surgically drained and nursed to health with the help of wound care physicians and nurses who treat the patient at their office and at the patient’s home.  The process of healing is painful and takes weeks to months.  Just when we believe we have one wound under control the patient falls again and we start over. The patient is affluent and lives in her own large beautifully furnished apartment with the assistance of long term fulltime aides who care for her as if she was their own mother. Her children and grandchildren supervise the care and honor and respect their elder matriarch with the love and tenderness this sweet woman deserves.  We have discussed stopping the anticoagulant because the risk of severe injury from post-traumatic bleeding is now higher than the risk of a stroke if she is off the blood thinner. The family is fearful of a stroke robbing her of whatever existing independence and function she possesses and has declined that option repeatedly.

R.D. has a living will and has executed a “Do Not Resuscitate” form. Her home has been safety evaluated and adapted to limit or prevent falls.  Home oxygen has been supplied to keep her oxygen carrying capacity at a comfortable level. 

Due to her frail nature she fell again on her way to bathroom. She didn’t call her aide to assist her to the bathroom but the aide heard the fall.  The aide’s first instinct was to call 911.  The paramedics arrived and recommended transfer to the ER.  Despite a DNR form, a request for non-heroic actions and ongoing care by a team of physicians and nurses the patient ended up in an acute care hospital ER. A CT of the brain showed no cerebral bleeding. Her wounds were cleaned and antibiotics started. After 48 hours in the hospital she was ready to go home.  A friend of the family suggested a consult with Hospice. The full time aide wondered why they needed hospice. The children wanted “no stone left unturned” in providing care.

I happened to be out of town while the request for a hospice consult was made by the family. It was made to a physician who knows the patient and was covering the practice in my absence. He questioned what role hospice would play that the current caregivers were not already providing.  By the time I became aware of the request, the back and forth discussions had unfortunately turned contentious.  He and I, in my absence, were fired as care providers and hospice took over. Sedating medication was prescribed by the hospice medical director.  The patient expired from medication related issues before my return to town within 48 hours. She was essentially legally euthanized. 

In our community there are four hospice services. They are all for-profit making businesses. They do an outstanding job of relieving pain and providing comfort for dying patients and providing respite and comfort to family members. One of the agencies is known to be more aggressive with medicine than the others and when they are called in the patient sometimes expires quickly and much sooner than expected.  Since changing from volunteer agencies with no Medicare funding to for-profit institutions with Medicare and insurance coverage the hospice services have lost much of the warm personal touch.

This patient had excellent at home care and coverage.  End of life issues had been reviewed with the patient and family in advance of her decline. Despite this, changes are routinely made to the care plan as the patient’s health declines. The cost of these changes is billed to Medicare and we all pay for it. Patients who requested to be kept at home are transported to hospitals. Patients who have a complete and competent care team have well-meaning but desperate family members change the plan. It happens regularly and the services requested are often no more compassionate or comprehensive than the original plan and services but they are billed to, and paid for, by Medicare.  As long as the patient and family are not responsible for the bill the services will be provided whether they are truly needed or not even if the services are already available and being paid for privately by non-Medicare sources.

Medicare, if you only knew…

The following guest post was written by Aimee Seidman, M.D., FACP.  Dr. Seidman is an award winning internal medicine physician in Rockville, MD, a suburb of Washington, D.C.

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If I could have a penny for every dollar I saved Medicare, I’d be rich. As a concierge physician, my patients can expect advocacy that stretches from the office to the home, hospital, rehab facility, long term care setting, and to the hospice. When I work with a patient, they can expect me to intervene between the various subspecialty physicians or hospitalists involved in their care, spread out my arms in front of them as if ready to take a bullet for them, and defiantly yell “get your paws off my patient until we hear what the plan is”.

How often are x-rays, ultrasounds, MRI’s, cardiac caths, and yada, yada, yada done in patients with a shortened life expectancy, poor quality of life, or clear living will instructions? How often is patient autonomy ignored in the rush to ‘complete work-ups’? Why do we have to work everything up? We need to stop what we’re doing (and stop the cowboys who are shooting from the hip) and think about the patient’s status and whether or not the proposed intervention is appropriate.

The last time I asked one of my 80-101 year olds how aggressively they wanted their medical treatment to be, they said “no way…leave me the hell alone! When my time comes, it comes. Just make a nice party!“  I shudder to think of the feeding tubes inserted and other interventions done in clear violation of a living will, even if that living will is right there with the patient or family members present.

I believe we scare the daylights out of people by telling them all the horrible things that will happen if they don’t consent to treatment plans. But it’s all defensive medicine. “I’ve got to be able to document that I warned them about this horrible death so I don’t get sued”. I suspect non-intervention, comfort measures, and hospice care are rarely offered to families in a way they can hear it. ER doctors and hospital physicians are just doing their jobs-they want to ‘save lives’ (or at least keep them alive until the next shift) and the primary care doctor is never consulted.

What do people think we do, order mammograms all day? Those of us in concierge medicine who have close relationships with our patients know them and their families well enough to expedite decision-making in a way that is medically and ethically appropriate. The whole point of my concierge practice is to first, do no harm (remember that?), allow my late stage Alzheimers disease patient to have a dignified death, and not spend millions of dollars on unnecessary procedures.

Not only that (I’m almost done), if all primary care physicians and the health care community made a conscious effort to inquire about living wills, explain the subtleties, and respect the choices made, fewer people would use ambulances, go to the ER, stay in the hospital, etc.

The other piece to this is the education of families regarding end of life issues, preparation, ethics, and closure. As it is, families deal with guilt, sadness, confusion, and anger when called upon to make these tough decisions or to respect an established living will. Most of us have seen families reluctant to honor a living will because they can’t bear the thought of letting grandpa starve to death.

If consulted about these decisions ahead of time, much of the combat will not occur. So how much have I saved Medicare by avoiding all this unnecessary stuff? Tens of thousands of patients, times a fortune of money, equals a boatload of bucks.

So, do you want to know ways to fix health care?

1.      Tort reform so docs aren’t so paranoid and aren’t playing “cover-your-butt medicine”;

2.      Docs, shut up and listen to your patients;

3.      Stop insulting the community of doctors who want to practice medicine in a particular model labeling them elitist and focus on things that will work (and by the way, most of us have scholarship patients, indigent patients and perform community service);

4.      A national campaign to educate consumers about the importance of living wills and have discussions over details, including family members in the discussion;

5.      Make it clear to the medical community that honoring a patient’s autonomy in the form of an advance directive is their obligation under the law

6.      Do no harm.

Just listen to me and give me a penny for every dollar I save Medicare, then I’ll really be rich.

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Please note, the opinions expressed in this guest blog post are those of Dr. Aimee Seidman, founder of Rockville Concierge Doctors.

Hospital Administration: Spending Your Tax Payer Dollars / Shorting You on Benefits

Last summer my 86 year old father awoke in the middle of the evening with profuse rectal bleeding. He felt weak and dizzy and called 911. The paramedics transported him to the local emergency room at a hospital close to his home – about one hour south of my home.

I call my parents daily to check up on them and learned of the trip to the hospital during one of these calls.  Mom is 84 and wheelchair bound with multiple structural and cardiovascular issues. Dad is 86, a WWII decorated paratrooper with dementia and orthopedic issues that dwarf his other chronic problems. They have an aide for several hours a day that is the glue that holds their lives together in their own home.

No one was home when I called and of course my folks had their Jitterbug senior special cell phone turned off so they were unreachable.   I left several messages and finally about 8:00 p.m. my mom answered the phone, denied that the cell phone was turned off, denied that I had left any messages on her answering machine and told me that dad was in the ER at Memorial Hospital. Her description was quite vague as to what was going on but I did learn that their long-time physician was unavailable and the hospitalist service was caring for him.

I phoned the ER and spoke to a nurse who was nice enough to tell me that he was stable and they were holding him for observation. He had not yet required blood transfusions and they did not know the exact source of the bleeding but he was still in the emergency department and comfortable.  I drove down that evening and saw dad in the ER. The next evening, unable to find his doctor, I drove down as well and saw dad in his hospital room on the medical floor.  He was weak but in good spirits.  I left a note with his nurse to please ask his physician to call me at his convenience and left my office and cell phone numbers.

Two days later I received a phone call from his long-time physician, who had returned from visiting her family to explain what was going on. She said that his gastroenterologist had been in to see him and he was doing well. The next day after some “tests”, dad’s liquid diet was advanced to a soft diet.

At 5:00 p.m. I received a harried phone call from my mother. She told me that dad was being discharged immediately and that if they stayed longer Medicare would not pay for it and my folks would be totally responsible for the bill. Dad had been in bed for four days, had not walked the halls, had not showered or washed himself and had not yet had a bowel movement since admission.

As a board certified geriatrician I realize the importance of these benchmark pre-discharge steps being achieved BEFORE you send a patient home.  It was too late for dad who was out the door and home.   His aide was upset because she leaves at 7:00 p.m. and she felt dad was too weak to get out of bed and walk to the bathroom without falling. I hired a night nurse and put in a call to his doctor.  I demanded that he be evaluated for a stay in a rehab facility until he was able to ambulate or at least send in a physical therapist to help him regain his strength and ability to walk. A few days of bed rest completely de-conditions most senior citizens and the complications of falls, and their prevention, must be addressed to prevent a bad situation from becoming worse.

His physician told me that “he did not meet criteria for home health assistance or rehabilitation stay” because he had been in the hospital for less than three full days.  I was astonished. He had been in the hospital for five to six days by my count.  She told me his first two days in the hospital were not as an admitted inpatient but as an outpatient observation.   By discharging him at 5:00 p.m. he had missed being an inpatient and qualifying for benefits by several hours.

Outpatient observation status is a game hospital case managers and administrators play to bill more money. When a Medicare senior citizen is admitted as an inpatient the hospital receives a bundled total payment based on the diagnosis or DRG.  If the patient is kept in observational status the hospital is no longer limited to receiving a flat rate but can unbundle the charges and bill ala carte for each service rendered.

The Center for Medicare and Medicaid Services (CMS) in its 12/03/2009 bulletin on page 3 defines outpatient observation services as “the use of a bed and possible monitoring by nursing or other ancillary staff, which are reasonable and necessary to evaluate the patient’s condition for possible inpatient admission.”   The decision as to inpatient admission status or observational status is supposed to be made by the patient’s doctor.  The problem is that is as far as it goes. No one at the CMS level has actually delineated criteria for an inpatient or traditional admission or for outpatient observation.

At the hospital level, administration now places a document on each patient chart requiring the physician to defer that decision to the hospital employed case manager who is not a physician. Over the years, hospital administration has diminished the political power of the individual physicians and medical staff to be advocates for their patients by destroying the medical staff bylaws and infiltrating medical staff governing bodies with physicians loyal to, and employed entirely by, the hospital.

The result is a tremendous conflict of interest with no one watching out for the patient.  The hospital then controls the rules and regulations and can even bully staff members into relinquishing decisions on admission status to the hospital employees rather than the patient’s physician.  One of the reasons hospitalist medicine has become so popular is that hospital administrators love the idea of controlling the physician side of care, something that acted like a “check and balance” in favor of patient advocacy when physicians were independent.

I bring this up because at my community hospital, where I care for my patient’s administration, is now attempting to influence doctors to give up the decision-making on admission and cede it to their case managers as well. A note was sent to the entire staff instructing us to not admit patients who do not meet “interqual” criteria for admission but to let their case managers assign them to observational status.

When I inquired about what interqual criteria were, and where “interqual” criteria were listed in the CMS bulletins or Federal Register, I was told they did not exist there.  Once again the fox is watching the hen house.

In these times of deficit spending and economic crisis hospitals are using our tax dollars to bill ala carte at a higher level and limiting senior citizens right to qualify for necessary post-hospital rehabilitative care by making much of their hospital stay “ observational” as opposed to traditional inpatient status.

I wrote a letter to Memorial Hospital about my dad’s stay and asked to see their criteria for inpatient admission.  Just like my local hospital could not produce criteria, neither could Memorial Hospital. I wondered how a frail 86 year old, dizzy, bleeding rectally and on anti-platelet agents to prevent clotting did not meet criteria for hospital admission?  I received a phone call from the Chief Medical Officer at Memorial Hospital months later saying he had reviewed my dad’s case and he was comfortable with their decision-making.

The issue needs to be addressed by patients, family members, legislators and concerned physicians. Hospital administrations are bullying physicians into relinquishing their advocacy and decision making so that they can charge more using the observational status rather than the inpatient admission status. By using this technique the patient does not meet the three day minimum hospital stay to provide post hospital care and treatment paid for by Medicare and the patients supplemental insurance policies. Once the patient’s personal physician relinquishes decision-making power to the hospital employees, they have created a conflict of interest which, if left unaddressed, will raise health care costs and affect quality of the patient’s care.

There Is A Malaise Among Us

In my professional life, and on this blog, I have complained bitterly about the orthopedic surgery department in my community changing from physicians to technicians to “consultants” as they now prefer to be called.  These same physicians once aggressively sought out hip replacement patients to admit to their surgical service where they would provide admission, discharge oversight and care.  Now, these “consultants” see the patient before surgery, operate and then turn their patients’ post operative care over to their nurse practitioners, physician assistants and technicians as well as hospital based and employed internists or, the patient’s own medical doctor.

The “consultants” will no longer admit the patient to their surgical service, insisting that the patient be placed on the medical service and, they have taken steps to relinquish their skills in post operative and post surgical wound and general care. They see the patient before surgery, in the OR and several weeks later in the office to check on bone and appliance alignment and to remove the surgical sutures.   I am told the impetus for this change in the orthopedic role is cost and liability and based on specialty specific recommendations of consultants.

Over time, I have seen the post surgical stay reduced from 10 days down to less than four days. Patients no longer go directly home from the hospital.  In most cases, they are sent to skilled nursing homes for rehabilitation and strengthening. I have written about how these overregulated and inspected homes are spending so much money on personnel to keep them in compliance that they can’t afford to staff the facilities to provide skill, nursing and care.

With nighttime patient-to-nursing ratios of 40 residents to one nurse; how can anything get done each shift?   I have written about the conveyor belt / revolving door between recently discharged post hospital patients and the hospital Emergency Department using the 911 system and diverting emergency EMTs from true emergent issues to being a transportation corp.

An article in the Journal of the American Medical Association finally added some credence to my observations. Researchers looked at the subject of Medicare age patients receiving primary hip replacements and hip replacement revisions between 1991 and 2008.  They looked at over 1.4 million primary hip replacements and 348,000 hip replacement revisions. When looking at first time hip replacements they found that mean length of stay dropped from 9.1 days in 1991 and 1992 to 3.7 days in 2008.  This resulted in 20% fewer patients going directly home from the hospital and a 17% increase in patients going to skilled or intermediate care nursing facilities by 2007 and 2008.

The good news is that the overall death rate at 30 days declined from 0.7% in 1991 to 0.4% in 2008.  The bad news is that the rate of readmissions rate for complications of the surgery within the first 30 days rose to 8.5% in 2007 and 2008.

When we look at look at hip replacement revisions, the length of stay declined from an average of 12.3 days to 6 days. In hospital mortality declined from 1.8% to 1.2% but 30 day mortality increased from 2% to2.4% and 90 day mortality from 4% to 5.2%.  Fewer patients were discharged to home in 2008 than 1991 with a resulting increase in transfer to skilled and intermediate nursing facilities by about 17% at the end of the study dates.  When hospital readmission rate was looked at for revision of hips the readmission rate increased by 2007 and 2008 significantly

This data is about real human beings. It means we have not figured out the correct length of hospital stay for this procedure. It may mean that we have reduced the expense for the hospital stay while increasing the expense to the system, patients and family in other areas of health care accounting.

With regard to revisions of hips, more people are dying and more people are coming back to the hospital for readmission than in the past.  Maybe the orthopedic surgeons need to spend more post operative time attending to their patients directly for a longer hospital stay before transferring them to the care of others at a nursing home?

The topic is intensely personal to me especially as we approach Mothers’ Day. During the time of the study my Medicare age mother dislocated her hip repair repeatedly. Each time she was brought back to the operating room, given a whiff of anesthesia and the artificial ball joint was forcibly pushed back into the socket. She would awaken, be given a day or so of rehabilitation and oversight by the surgical assistants and mid level providers and then sent back to the skilled nursing facility for strengthening and rehabilitation before returning home. After each episode her orthopedist would tell me how much force and pressure and strength were required to push that hip back into the socket.

On one of those admissions the hospital physical therapist became alarmed by the fact that the involved leg appeared to be two inches shorter and externally rotated on the last day of therapy. She was having difficulty walking and bearing weight.  She called the surgeon who sent one of his staff to see her in her room prior to transfer. That staff member had never met her. He told her that our hospital physical therapy department was “notoriously inaccurate in measuring limbs.”  He didn’t examine the limb or order an x-ray but transferred her to the nursing facility immediately.

Upon arrival she could not stand up and bear weight. The receiving facility physical therapist requested a hip x-ray. The x-ray showed that she had been discharged from the hospital with the hip still dislocated. The ball could not stay in the socket because the pelvic bone had been fractured during one of the attempts to push the ball back in place.

My mom refused to go back to the same hospital or surgical group and was transferred to another center of excellence for extensive reconstructive surgery.  She has never ever walked independently again.