Narcotics Maximus

[Boatswain2PA]

11 hours ago, EMEDPA said:

think many other nations have shown that this can be done well at a lower cost than pay for service options. Today many

Had a long a perfect reply typed up to this, then Internet crashed.  Will reply in a few days my friend.

[thinkertdm]

4 hours ago, weezianna said:

I've worked at different VAs and administrations range from pretty good to abysmal.  At this location, pharmacy hasn't batted an eye when a patient was rx'd 180 MEDD.

You get the PIV card issue.  It should be an easy fix - just take the day or two off and go and get it.  I don't know why they're dragging their heels on this.   This doc seems very fixed on making sure that there are no veteran complaints and I wonder if someone is putting pressure on him.  He is away this weekend and an NP who fills in from time to time is signing all his narcotic requests

I received an email from the medical director saying that there should be no problems signing for someone else's narcs, as it's "just like someone was on vacation". so it is indeed possible.   

A piece of the puzzle is missing and I will find out what it is.

I think you hit the nail on the head- patient advocates and "congressionals" ensure that opiate bullying become institutionalized, because public perception is that we are already mistreating veterans, and so now we get a focus on reducing pain, which becomes a focus on "don't take away my hydros or I will tell on you".  Unfortunately, we all know that what a patient wants and what is medically safe many times are two different things, but public perception has forced us to compromise.  This is present in civilian places too, but public opinion focuses more on the VA.

 

[TWR]

Weezianna,  Look in a mirror and picture prison scrubs!!  A lot of the above responses are excellent . Start your paper trail today and get the hell out of that job.  You might even want to speak to an attorney.  How long have you been practicing?

[sas5814]

7 hours ago, CAdamsPAC said:

Why are pts with "End Stage" anything being admitted to the ICU?

 

I can only speak from my personal experience in providing end of life care but in a word...families. I could tell you a lot of stories about family members prolonging their loved ones misery out of purely selfish motivations. Some are emotionally stressed and makes poor decisions. Some are just a little nuts.

I got a call from a hospitalists one time about one of my nursing home patients who, quite frankly, should have died years earlier who was sent to the hospital in her last hours at the insistence of her daughter. When the patient died the daughter stood in the hallway of the hospital and screamed "YOU KILLED MY MOTHER!" over and over at the hospitalist and the floor staff.

I suspect now that patients are customers and satisfactions surveys rule the day more and more of this is happening.

[EMEDPA]

10 hours ago, CAdamsPAC said:

Why are pts with "End Stage" anything being admitted to the ICU?

 

agree. one of my partners(for reasons I don't understand) sent a DNR/DNI pt by lifeflight recently.....

[weezianna]

TWR, I am not a neophyte, have been practicing for over 20 years and in medicine for 40.  The paper and email trails are there, and I have no plans to wear prison scrubs.  I will be out of here shortly.   Thinkertdm made some very good points about the VA though, that most people don't understand.  Like the civilian world, it is largely driven by patient satisfaction surveys, but with a political twist.  If you say no, your are mistreating the veteran and when they file a congressional management gets all upset.  When narcs are taken away, there are complaints that veterans' rights are being infringed upon.   At my last place of employment, the facility manager, who isn't even a medical person, threatened a physician and later a PA to sign for opioids for a patient who had gone up to management and complained they weren't getting what they wanted.   I have no qualms in setting up boundaries as to what I will and won't do.  The one rural office in question here has an enormous, tremendous number of people on opioids, and in some charts there is no evidence as to why they're taking them.

[sas5814]

*sigh* the evil satisfaction survey. There is some emerging data about how the satisfaction survey is causing worse outcomes for patients. I'll be dead and gone before any changes happen but they will come someday. They always do. Today's fad becomes tomorrow's "what the hell?".

I am a bit of a Pollyanna in that I think doing what is right is always what is best. Sadly it doesn't always play out that way.

[Reality Check 2]

I am very grateful that my VA has a better administrative atmosphere and support system.

I have never been bullied into doing something for a vet that I did not clinically believe in or support. My panel has its share of crazies and conspiracy theorists and tin foil and watch dogs.

Yep, my patients have threatened Congressional letters and many write them. One of my patients threatened to call a friend at the Pentagon. Oh well. I have the medical to back it up. The decisions are not punitive or personal - they are medical - based on sound evidence, advice, history and clinical knowledge. If a complaint involves narcotics - immediate flag that this could be Opioid Use Disorder, addiction or diversion.

Our pharmacy is all over the MED situation and participates fully.

Not all VAs are the same. I think the OP needs to vacate this situation for safety and sanity.

 

[Boatswain2PA]

On 8/13/2018 at 1:03 PM, EMEDPA said:

So we have everyone over 65, low income folks, military members/retired military, Indian and Alaska natives. That leaves out most working people18-64 years old.

So everyone except our young healthy adults are already covered, yet we're spending more than any other nation and getting poor results....why would we want to expand this failure??

On 8/13/2018 at 1:03 PM, EMEDPA said:

I think many other nations have shown that this can be done well at a lower cost than pay for service options.

Comparing us to many other nations is like comparing apples to orangutans.  France is a fraction of our size, and better compared to the size of Texas, yet with twice the population density.  Same problems with Germany, or UK...and that doesn't even begin to discuss the differences in culture that confound such comparisons.

In other words, just cause they can do it doesn't mean we can do it.

The fundamental healthcare financing problem is there is, and forevermore will be, a need to ration care.  We can ration it through death panels, ration it by what people can personally afford to pay, or ration it through different layers of bureaucracy....but it will ALWAYS be rationed.  Once we agree on that fundamental truth, then we an have an honest discussion about HOW it should be rationed.

[Cideous]

On 8/15/2018 at 10:28 PM, Boatswain2PA said:

  We can ration it through death panels, 

That sounds exactly like what Sarah Palin use to say about what would happen if the ACA was passed, and I've yet to see a death panel except for the ones set up by our good old fashion YOUR DENIED insurance companies.....but yea.....Fear.  It's a powerful tool in the R's back pocket.  Must be why they keep going back to it...

[rev ronin]

I've never liked the term 'death panel.'  Unlike in the UK, here you're free to pay whatever you want for stupidly futile care, but you just don't have the right to force other people to pay for it.

[Boatswain2PA]

1 hour ago, Cideous said:

That sounds exactly like what Sarah Palin use to say about what would happen if the ACA was passed, and I've yet to see a death panel except for the ones set up by our good old fashion YOUR DENIED insurance companies.....but yea.....Fear.  It's a powerful tool in the R's back pocket.  Must be why they keep going back to it...

Apparently you missed the rest of my statement:  Health care will always be rationed, either through death panels (government or corporate run), finances, or bureaucracy.

You can call it "Independent Payment Advisory Board (IPAB)" if you want to be more accurate, but they were the panel (sorry..."advisory board") under Obamacare who would determine which classification of people (errrr....I mean patients) would be treated for what diseases (and therefore what classifications of people would NOT be treated for what diseases).   I'm not trying to use the term "death panel" to scare anyone...it's just an abbreviated term that is relatively accurate.

We can have IPABs ration care, or we can have corporations ration care, or we can have care rationed by who can afford what.....doesn't change the fundamental problem with healthcare finances:  It's gonna be rationed somehow.

[Boatswain2PA]

1 hour ago, rev ronin said:

I've never liked the term 'death panel.'  Unlike in the UK, here you're free to pay whatever you want for stupidly futile care, but you just don't have the right to force other people to pay for it.

What do you mean "you don't have the right to force other people to pay for it."?  Yes you do...it's called Medicaid/Medicare, and to a lesser extent (lesser because you pay premiums) private insurance.

[CAdamsPAC]

5 minutes ago, Boatswain2PA said:

Apparently you missed the rest of my statement:  Health care will always be rationed, either through death panels (government or corporate run), finances, or bureaucracy.

You can call it "Independent Payment Advisory Board (IPAB)" if you want to be more accurate, but they were the panel (sorry..."advisory board") under Obamacare who would determine which classification of people (errrr....I mean patients) would be treated for what diseases (and therefore what classifications of people would NOT be treated for what diseases).   I'm not trying to use the term "death panel" to scare anyone...it's just an abbreviated term that is relatively accurate.

We can have IPABs ration care, or we can have corporations ration care, or we can have care rationed by who can afford what.....doesn't change the fundamental problem with healthcare finances:  It's gonna be rationed somehow.

Close neonatal ICUs, stop admitting dying 60-80 year olds and End Stage Anything to the ICU, stop transplanting organs into anyone over 50 no one who drinks, smokes or used drugs, no TKA or total hips for "fat people" will save money!!!

[rev ronin]

7 minutes ago, Boatswain2PA said:

What do you mean "you don't have the right to force other people to pay for it."?  Yes you do...it's called Medicaid/Medicare, and to a lesser extent (lesser because you pay premiums) private insurance.

Nope.  To the extent that any of those third party payors decide care is futile, inappropriate, unproven, etc. they don't have to pay for it.  Now, there are appeals processes, safeguards, and whatnot, but you and I both know insurance, public or private, doesn't pay for tons of things that are legitimately needed. 

BUT, none of them will ever say "No, we won't pay for it AND you can't buy it on the open market, either".  That would be a true "death panel".

[Boatswain2PA]

Ok, now I get what you mean.

Other people are forced to pay for some (or, like Emed said, most) people's healthcare, but not beyond what the rationing body (IPAB/death panel/bureaucracy panel) says.

And your bring up a second fundamental truth - capitalism will ALWAYS be there for those who can afford it.  

Why did Quebec's health minister go to Boston for his cardiac procedure?  Cause the US healthcare is better, and he could afford it.

[GetMeOuttaThisMess]

I don't know that I see a problem with a panel making a decision on whether to allow admission to ICU's/CCU's based on pre-existing health conditions and overall quality of life.  We already do this when critical care directors have to determine who gets dumped down to a lower care level to allow admission for a more critically ill patient when the unit is already full.

We (general population) do need to face reality with healthcare and acknowledge that PEOPLE DO DIE.  If we ever reach the point to where a service will not be covered based on individual case data, and you have the resources to obtain that care regardless without impacting the care of others, then good for you.  Boatswain2PA's example is a good one though I might argue that care was received here not necessarily because we do it better but maybe because it could be done sooner.  I again bring up the point that 60 Minutes brought up years ago where I think it was that the vast majority of Medicare expenses occur during the last two weeks of life.  We also need to stop providing preventive services when it provides no obvious benefit, ex.-someone on a vent in end-stage CHF needing a consultation for preventive care from another specialty field.

[Boatswain2PA]

15 minutes ago, GetMeOuttaThisMess said:

I don't know that I see a problem with a panel making a decision on whether to allow

This idea is fraught with problems.....but so is every other idea.

I don't have the perfect answer because one doesn't exist.  I just wish we (the collective, American "we") could have the discussion about rationing openly.  I detest Obamacare, mostly because it was so big and complex, and it wasn't done openly.  If they (meaning the Democrats) had openly said "We have to ration care, and we choose to START doing it through a government panel (IPAB/Death Panel)", then it would have been fine with me.

[GetMeOuttaThisMess]

1 minute ago, Boatswain2PA said:

This idea is fraught with problems.....but so is every other idea.

I don't have the perfect answer because one doesn't exist.  I just wish we (the collective, American "we") could have the discussion about rationing openly.  I detest Obamacare, mostly because it was so big and complex, and it wasn't done openly.  If they (meaning the Democrats) had openly said "We have to ration care, and we choose to START doing it through a government panel (IPAB/Death Panel)", then it would have been fine with me.

Someone like USPSTF, not a "local panel" in the majority of cases.

[ventana]

2 hours ago, Boatswain2PA said:

 

Why did Quebec's health minister go to Boston for his cardiac procedure?  Cause the US healthcare is better, and he could afford it.

 

 

Ugh

 

This is the problem with equating the best fininky high tech surgery with a health care system.......

 

 

Just cause we have the best (debatable) valve replacement DOES NOT MEAN WE HAVE THE BEST SYSTEM

 

In fact look at the recent WHO rankings of the american health care system to realize we are awful!!

http://www.who.int/healthinfo/paper30.pdf

 

USA is #37

Canada is #30 

 

we have a system that is worse then 

 

 

 

 

France 0.994 0.982 - 1.000 2 1 - 5 Italy 0.991 0.978 - 1.000 3 1 - 6 San Marino 0.988 0.973 - 1.000 4 2 - 7 Andorra 0.982 0.966 - 0.997 5 3 - 7 Malta 0.978 0.965 - 0.993 6 2 - 11 Singapore 0.973 0.947 - 0.998 7 4 - 8 Spain 0.972 0.959 - 0.985 8 4 - 14 Oman 0.961 0.938 - 0.985 9 7 - 12 Austria 0.959 0.946 - 0.972 10 8 - 11 Japan 0.957 0.948 - 0.965 11 8 - 12 Norway 0.955 0.947 - 0.964 12 10 - 15 Portugal 0.945 0.931 - 0.958 13 10 - 16 Monaco 0.943 0.929 - 0.957 14 13 - 19 Greece 0.933 0.921 - 0.945 15 12 - 20 Iceland 0.932 0.917 - 0.948 16 14 - 21 Luxembourg 0.928 0.914 - 0.942 17 14 - 21 Netherlands 0.928 0.914 - 0.942 18 16 - 21 United Kingdom 0.925 0.913 - 0.937 19 14 - 22 Ireland 0.924 0.909 - 0.939 20 17 - 24 Switzerland 0.916 0.903 - 0.930 21 18 - 24 Belgium 0.915 0.903 - 0.926 22 14 - 29 Colombia 0.910 0.881 - 0.939 23 20 - 26 Sweden 0.908 0.893 - 0.921 24 16 - 30 Cyprus 0.906 0.879 - 0.932 25 22 - 27 Germany 0.902 0.890 - 0.914 26 22 - 32 Saudi Arabia 0.894 0.872 - 0.916 27 23 - 33 United Arab Emirates 0.886 0.861 - 0.911 28 26 - 32 Israel 0.884 0.870 - 0.897 29 18 - 39 Morocco 0.882 0.834 - 0.925 30 27 - 32 Canada 0.881 0.868 - 0.894 31 27 - 33 Finland 0.881 0.866 - 0.895 32 28 - 34 Australia 0.876 0.861 - 0.891 33 22 - 43 Chile 0.870 0.816 - 0.918 34 32 - 36 Denmark 0.862 0.848 - 0.874 35 31 - 41 Dominica 0.854 0.824 - 0.883 36 33 - 40 Costa Rica

 

 

 

[EMEDPA]

Yup- I took a doctoral course in Comparative international health systems. Some things we are very good at (cardiac surgery), other things we are not(primary care, infant mortality, maternal mortality, preventative medicine, etc). 

[Boatswain2PA]

Yes, looking at the stats that the WHO looks at (which therefore represents their bias), we suck.

But if your wife got breast cancer, and you have unlimited resources, where would you want to be?  That is a capitalistic bias.

Emed - Mmuch of those problems are cultural.  Neonatal mortalites are highest in the same areas where we have the highest rates of gun violence.  Other stereotypes, across racial and cultural spectrums, apply here as well (ie: the uneducated Appalachia family, etc).

[EMEDPA]

the problem with the breast CA question above is almost no one has unlimited resources. I am currently looking at an elective procedure that would be free in most of the developed world that I may not do because my copay would be too high and no one will pay me for sick/recovery days because I am 1099. 

[rev ronin]

The big, unanswerable question is "how do we fix the things we're bad at, without compromising the things we're good at". My ideas to fix that probably wouldn't be popular...

[EMEDPA]

8 minutes ago, rev ronin said:

The big, unanswerable question is "how do we fix the things we're bad at, without compromising the things we're good at". My ideas to fix that probably wouldn't be popular...

you mean start paying PCPs what they're worth and stop overvaluing subspecialists who make 10k by showing up for a minor procedure?