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Posts Tagged ‘politics’


I know I said I was done with writing on my blog, but now I have to put in my 2 cents on the so-called Affordable Care Act, more commonly known as Obama Care. My own health insurance rates have double in the last 2 years so that I could cover my children (which are over 30 and have been on their own for years), and so I could get maternity care and 2 free breast pumps a year (in my 50’s), and so my deductible for the year would be lower….. my husband and I have been buying our own health insurance for years, basically a catastrophic plan which would cover expenses in case we were hit by the proverbial bus or needed surgery, with a $2000 annual deductible. We are both healthy in general, don’t smoke, don’t drink, get a reasonable amount of exercise, eat pretty healthy and try to keep our weight within reason.

I got a notice from our health insurance company that we would have to “transition” to another plan in August, when we are up for renewal. This tells me our plan meets the guidelines, but that the insurance company can get a lot more money out of us with the new plans set up for Obama care. After a little research (went on the now-infamous website) and found out that only one health insurance company is authorized in our county (so much for competitive rates) and it is the one we have now. Checked on available plans, found one equivalent to what we have now, more or less. This is the so called platinum plan, and it will cost us a whopping 4 times as much as we pay now, frankly, more than the highest mortgage we ever paid. The bronze plan would cost us twice what we pay now, plus a $6000 annual deductible and they pay only 60%????? Say, what???? A 40% co-pay??? Where is the affordable part of the health insurance here? When I went on the health insurance company website, the plan quoted to me on the government site actually costs 50% MORE than the government quoted. 

I was hoping at some point to get a knee replacement as my right knee is pretty much crunching at this point, daily Aleve and repeated steroid injections have kept it going. The average cost of a TKR in Florida is about $40,000. So first I have to pay over $6,000 (that is just my insurance, double the cost for both of us) in insurance premiums for that year, then $6000 in deductible, and 40% of $40,000: $16,000. This is not including the PT I will need afterwards. Cost of knee replacement with “insurance”: $28,000 out of pocket plus PT. Uhm, what is wrong with this picture? With my current insurance, I would pay $2400 for insurance, $2000 in deductible, and that’s it.

Bottom line is I will have to pay so much money for “affordable care” health insurance for me and my husband, that we are not going to be able to save any money at all. I would have to save up $20,000 above the cost of insurance for the surgery. We will be reduced from feeling financially stable and able to save money for a “rainy day” to living pay-check to pay-check. WTF!!!!! Did I go to school for over 8 years for this? I am working in a little town for a single doctor, I am not making a huge amount of money. I love my job, and don’t want to go somewhere else to make enough money to pay for the damn health insurance. This is all F-ing ridiculous. To be honest, I have cried over this. I can’t even begin to imagine what it is like for a family with kids and less income. 

We are already getting many patients who have lost their doctors through retirement (recently, all of a sudden) and due to the insurance companies not coming into this county anymore. 

The politicians are so glib and smug, thinking they are able to FIX all of our problems. Well, they FIXED me all right, and lots of other people.

Honestly, when they said this is all about wealth redistribution and not health care, that was the truth.

“The trick is figuring out how do we structure government systems that pool resources and hence facilitate some [wealth] redistribution — because I actually believe in redistribution, at least at a certain level to make sure that everybody’s got a shot.”

Obama, 2008

 

Well, I make my own shot through hard work, and he is taking it away from me. The shame is, NO ONE is being helped in this restructuring of the government. 

 

“This is also an income shift — it’s a shift, it’s a leveling to help lower income Americans. Too often, much of late, the last couple three years the mal-distribution of income in America is gone up way too much, the wealthy are getting way, way too wealthy, and the middle income class is left behind. Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America, because healthcare is now a right for all Americans, because healthcare is now affordable for all Americans.”

US Senator Max Baucus (D-Mont.)

Oh, really?

Sigh, I guess I will never get that knee.

old-woman-cane-18640048

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I was in the bathroom at work yesterday, and this poster is hanging on the door.

Really???? What are these idiot politicians thinking of when they dream up this stuff?
And they constantly cut the pay to the providers and then expect them to try to keep up with all of these ridiculous new regulations and rules.

Do they actually believe that all of this stuff is going to improve healthcare, decrease fraud and decrease the cost of healthcare?  Evidently they do:

Check this link: ICD-10 benefits for healthcare providers

Note that the guy writing it, if you even get half of what he is saying, is an IT guy, NOT a healthcare professional. The talk is about “data-driven” patient care. Huh? My patient care is driven by the patient’s needs, not some IT guy’s addiction to data in his little cyber-world. I don’t think that a coding set is going to alter the fact that a laceration that is bleeding all over the place needs to be sutured. Who gives a crap if the cut is caused by a paring knife versus a steak knife. Time is wasted in asking the difference and looking up the code in a set of 140,000 codes.

“The increased auto adjudication of claims due to increased granularity of ICD-10 code will help in reduced number of claims being investigated or rejected due to insufficient information. ” Right. The fact the patient is cut and bleeding is not enough information to pay for a suture job?

The codes are bordering on the ridiculous. I heard stuff I couldn’t believe. Yet, when looking them up, it turns out to be true. Example: Here in Florida, there is the occasional person who gets injured at the beach. Here are the codes for one type of incident:

2012 ICD-10-CM Diagnosis Codes > External causes of morbidity V00-Y99 > Exposure to animate mechanical forces W50-W64>

Contact with nonvenomous marine animal W56- >

Type 1 Excludes

  • contact with venomous marine animal (T63.-)
W56Contact with nonvenomous marine animal
W56.0Contact with dolphin
W56.01Bitten by dolphin
<span class="identifier">W56.01XA</span> is a billable ICD-10-CM diagnosis codeW56.01XA…… initial encounter
<span class="identifier">W56.01XD</span> is a billable ICD-10-CM diagnosis codeW56.01XD…… subsequent encounter
<span class="identifier">W56.01XS</span> is a billable ICD-10-CM diagnosis codeW56.01XS…… sequela
W56.02Struck by dolphin
<span class="identifier">W56.02XA</span> is a billable ICD-10-CM diagnosis codeW56.02XA…… initial encounter
<span class="identifier">W56.02XD</span> is a billable ICD-10-CM diagnosis codeW56.02XD…… subsequent encounter
<span class="identifier">W56.02XS</span> is a billable ICD-10-CM diagnosis codeW56.02XS…… sequela
W56.09Other contact with dolphin
<span class="identifier">W56.09XA</span> is a billable ICD-10-CM diagnosis codeW56.09XA…… initial encounter
<span class="identifier">W56.09XD</span> is a billable ICD-10-CM diagnosis codeW56.09XD…… subsequent encounter
<span class="identifier">W56.09XS</span> is a billable ICD-10-CM diagnosis codeW56.09XS…… sequela
W56.1Contact with sea lion
W56.11Bitten by sea lion
<span class="identifier">W56.11XA</span> is a billable ICD-10-CM diagnosis codeW56.11XA…… initial encounter
<span class="identifier">W56.11XD</span> is a billable ICD-10-CM diagnosis codeW56.11XD…… subsequent encounter
<span class="identifier">W56.11XS</span> is a billable ICD-10-CM diagnosis codeW56.11XS…… sequela
W56.12Struck by sea lion
<span class="identifier">W56.12XA</span> is a billable ICD-10-CM diagnosis codeW56.12XA…… initial encounter
<span class="identifier">W56.12XD</span> is a billable ICD-10-CM diagnosis codeW56.12XD…… subsequent encounter
<span class="identifier">W56.12XS</span> is a billable ICD-10-CM diagnosis codeW56.12XS…… sequela
W56.19Other contact with sea lion
<span class="identifier">W56.19XA</span> is a billable ICD-10-CM diagnosis codeW56.19XA…… initial encounter
<span class="identifier">W56.19XD</span> is a billable ICD-10-CM diagnosis codeW56.19XD…… subsequent encounter
<span class="identifier">W56.19XS</span> is a billable ICD-10-CM diagnosis codeW56.19XS…… sequela
W56.2Contact with orca
W56.21Bitten by orca
<span class="identifier">W56.21XA</span> is a billable ICD-10-CM diagnosis codeW56.21XA…… initial encounter
<span class="identifier">W56.21XD</span> is a billable ICD-10-CM diagnosis codeW56.21XD…… subsequent encounter
<span class="identifier">W56.21XS</span> is a billable ICD-10-CM diagnosis codeW56.21XS…… sequela
W56.22Struck by orca
<span class="identifier">W56.22XA</span> is a billable ICD-10-CM diagnosis codeW56.22XA…… initial encounter
<span class="identifier">W56.22XD</span> is a billable ICD-10-CM diagnosis codeW56.22XD…… subsequent encounter
<span class="identifier">W56.22XS</span> is a billable ICD-10-CM diagnosis codeW56.22XS…… sequela
W56.29Other contact with orca
<span class="identifier">W56.29XA</span> is a billable ICD-10-CM diagnosis codeW56.29XA…… initial encounter
<span class="identifier">W56.29XD</span> is a billable ICD-10-CM diagnosis codeW56.29XD…… subsequent encounter
<span class="identifier">W56.29XS</span> is a billable ICD-10-CM diagnosis codeW56.29XS…… sequela
W56.3Contact with other marine mammals
W56.31Bitten by other marine mammals
<span class="identifier">W56.31XA</span> is a billable ICD-10-CM diagnosis codeW56.31XA…… initial encounter
<span class="identifier">W56.31XD</span> is a billable ICD-10-CM diagnosis codeW56.31XD…… subsequent encounter
<span class="identifier">W56.31XS</span> is a billable ICD-10-CM diagnosis codeW56.31XS…… sequela
W56.32Struck by other marine mammals
<span class="identifier">W56.32XA</span> is a billable ICD-10-CM diagnosis codeW56.32XA…… initial encounter
<span class="identifier">W56.32XD</span> is a billable ICD-10-CM diagnosis codeW56.32XD…… subsequent encounter
<span class="identifier">W56.32XS</span> is a billable ICD-10-CM diagnosis codeW56.32XS…… sequela
W56.39Other contact with other marine mammals
<span class="identifier">W56.39XA</span> is a billable ICD-10-CM diagnosis codeW56.39XA…… initial encounter
<span class="identifier">W56.39XD</span> is a billable ICD-10-CM diagnosis codeW56.39XD…… subsequent encounter
<span class="identifier">W56.39XS</span> is a billable ICD-10-CM diagnosis codeW56.39XS…… sequela
W56.4Contact with shark
W56.41Bitten by shark
<span class="identifier">W56.41XA</span> is a billable ICD-10-CM diagnosis codeW56.41XA…… initial encounter
<span class="identifier">W56.41XD</span> is a billable ICD-10-CM diagnosis codeW56.41XD…… subsequent encounter
<span class="identifier">W56.41XS</span> is a billable ICD-10-CM diagnosis codeW56.41XS…… sequela
W56.42Struck by shark
<span class="identifier">W56.42XA</span> is a billable ICD-10-CM diagnosis codeW56.42XA…… initial encounter
<span class="identifier">W56.42XD</span> is a billable ICD-10-CM diagnosis codeW56.42XD…… subsequent encounter
<span class="identifier">W56.42XS</span> is a billable ICD-10-CM diagnosis codeW56.42XS…… sequela
W56.49Other contact with shark
<span class="identifier">W56.49XA</span> is a billable ICD-10-CM diagnosis codeW56.49XA…… initial encounter
<span class="identifier">W56.49XD</span> is a billable ICD-10-CM diagnosis codeW56.49XD…… subsequent encounter
<span class="identifier">W56.49XS</span> is a billable ICD-10-CM diagnosis codeW56.49XS…… sequela
W56.5Contact with other fish
W56.51Bitten by other fish
<span class="identifier">W56.51XA</span> is a billable ICD-10-CM diagnosis codeW56.51XA…… initial encounter
<span class="identifier">W56.51XD</span> is a billable ICD-10-CM diagnosis codeW56.51XD…… subsequent encounter
<span class="identifier">W56.51XS</span> is a billable ICD-10-CM diagnosis codeW56.51XS…… sequela
W56.52Struck by other fish
<span class="identifier">W56.52XA</span> is a billable ICD-10-CM diagnosis codeW56.52XA…… initial encounter
<span class="identifier">W56.52XD</span> is a billable ICD-10-CM diagnosis codeW56.52XD…… subsequent encounter
<span class="identifier">W56.52XS</span> is a billable ICD-10-CM diagnosis codeW56.52XS…… sequela
W56.59Other contact with other fish
<span class="identifier">W56.59XA</span> is a billable ICD-10-CM diagnosis codeW56.59XA…… initial encounter
<span class="identifier">W56.59XD</span> is a billable ICD-10-CM diagnosis codeW56.59XD…… subsequent encounter
<span class="identifier">W56.59XS</span> is a billable ICD-10-CM diagnosis codeW56.59XS…… sequela
W56.8Contact with other nonvenomous marine animals
W56.81Bitten by other nonvenomous marine animals
<span class="identifier">W56.81XA</span> is a billable ICD-10-CM diagnosis codeW56.81XA…… initial encounter
<span class="identifier">W56.81XD</span> is a billable ICD-10-CM diagnosis codeW56.81XD…… subsequent encounter
<span class="identifier">W56.81XS</span> is a billable ICD-10-CM diagnosis codeW56.81XS…… sequela
W56.82Struck by other nonvenomous marine animals
<span class="identifier">W56.82XA</span> is a billable ICD-10-CM diagnosis codeW56.82XA…… initial encounter
<span class="identifier">W56.82XD</span> is a billable ICD-10-CM diagnosis codeW56.82XD…… subsequent encounter
<span class="identifier">W56.82XS</span> is a billable ICD-10-CM diagnosis codeW56.82XS…… sequela
W56.89Other contact with other nonvenomous marine animals
<span class="identifier">W56.89XA</span> is a billable ICD-10-CM diagnosis codeW56.89XA…… initial encounter
<span class="identifier">W56.89XD</span> is a billable ICD-10-CM diagnosis codeW56.89XD…… subsequent encounter
<span class="identifier">W56.89XS</span> is a billable ICD-10-CM diagnosis codeW56.89XS…… sequela
Do you get paid more to stitch up an killer whale (orca) bite than a sea lion bite? How does this information improve patient care in the future as stated by the panting IT guy? Will there be required signage on a beach that says “Caution: orcas are 19.75% more likely to bite you than dolphins. Stay clear of orcas.”?
ICD-9 codes numbering at 17000 was bad enough, but 144000 is clearly over-the-top.
This one is also so very necessary here in Florida:  2012 ICD-10-CM Diagnosis Code V91.07XA: Burn due to water-skis on fire, initial encounter.

According to the poster, every form, every procedure, every contract has to be changed to conform to the new rules. Everyone has to be retrained. I love the part where the coding clerks are required to have “a more detailed knowledge of anatomy and medical terminology”. And the nurses have to “revise or recreate every order”. Sure, they have time for that.

Here is a good one, in light of the fact that the government can’t get its shit together with current new guidelines and hasn’t paid our little clinic yet this year for any Medicare or Medicaid bills we turned in,(also note ICD-10 has been delayed due to its cumbersomeness, but when the government says GO! there can be no delay on your part!). The poster states “changes to software, training, new contracts and paperwork have to be paid for.” By whom? The individual provider, of course.  A report by a Nachimson Advisors Study shows that on average, the costs of transitioning to ICD-10 were as follows: Small practice (3-9 physicians) = $83,000, Medium practice (10-99 physicians) = $285,000, Large practice (100+ physicians) = $2.7 million.

There comes a time in each person’s mind when they are just overwhelmed and stop giving a crap.

This will do it.

And all I want to do is take care of patients. I wish the politicians and IT guys would walk a mile in our shoes.

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In light of all the political garbage recently purporting to save American healthcare, I propose that we have the power to save ourselves. Being only partially employed while I go to school, I have no employer backed health insurance, and even when I did, the insurance was still expensive and left a lot to be desired. It started me thinking.

Health insurance should be like other types of insurance, it only covers the disasters. Does your car insurance cover oil changes and windshield wiper fluid? Would you want to pay a higher premium to cover those types of expenses? I would think not. Does your homeowner’s insurance pay for cleaning supplies and new lightbulbs? Of course not. So why do we expect health insurance to cover the little dribs and drabs of regular healthcare?

I have bought insurance through one of the major companies with a $1000 copay, and coverage for hospitalization, and emergency room care that involves a procedure like splinting or admission to the hospital. It costs me about $133 dollars a month, though I am sure that is going to go up when the health care “reform” starts to take effect. I did however, have similar coverage before with another company and when they raised the rate to $180 per month, I switched. Granted, I have no major health problems, even at my age of fifty+. However, I do take care of my health, I don’t smoke, try to maintain my weight at a reasonable amount, and don’t use any chemical substances as happiness substitutes (Alcohol included. My consumption of a glass of wine at a holiday dinner constitutes my drinking).

So, people I talk to say, “Oh my goodness, how terrible, you don’t have access to regular healthcare!”.  What CRAP that is! Of course I do. It’s called patient managed healthcare, or PMH. This is how it works.

I wake up one morning and I have a pain in my right side, bad pain. It doesn’t go away for a couple of days. Okay, this needs to be taken care of. I call my family doctor’s office. Note: I did NOT go to the emergency room. Emergency rooms are for emergencies, like gushing arterial bleeding, heart attacks, strokes, knife sticking out of your back. Stuff like that. Not diarrhea, the flu, a pimple on your butt, a cut on your finger, or a headache. Getting back to the story. I call my family doctor’s office, make an appointment for later in the day.

Some people will say, I don’t have a family doctor, or my doctor would never get me in the same day. This is where the PMH comes in. Several years ago, when I first moved here, I asked around for a recommended MD in the area. I went to the one suggested, tried him for a while, didn’t like him, fired him. Next, I asked nurses where I worked for a recommended doctor. (Nurses are the best ones to ask…) A couple of names came up. I called the offices of those doctors and asked to interview the doctor before I signed on with them, one refused, the other agreed. This doctor let me come in that day over his lunch break to talk. Definitely a good sign..we talked for quite a while, negotiated our health care agreement and Bingo, I had a family doctor. The negotiations included the fact that I am a bit stubborn, like to do things a certain way (as few drugs as possible for example, and I like vitamins, etc.) and am not the type to blindly follow directions. He, bless his heart, was good with that and agreed to discuss options with me for every problem, and let me do it my way if it was within his parameters of feasible care, and we would switch to his way if mine didn’t work. I LOVE this doctor. Over the years, I have stopped arguing with him and I trust him now completely. I pay him a reasonable fee for a visit depending on the length of the visit, usually around $50-60. He also has open scheduling so that there is always an opening if I am ill and need to be seen that day. All good.

So, I go to my appointment, he listens to my presenting complaint and history of current illness. A physical exam follows. The differential diagnosis includes the possibility of a kidney stone. The normal route for a kidney stone is a urinalysis, a CBC and a CT scan. The urinalysis is done in the office. The CBC is important since it will tell us if there is an infection somewhere, so that is a must.

The CT scan is expensive, but in the negotiation, we decide the CT can wait, the CBC can’t. The urinalysis did not show blood, which decreased the chance of the kidney stone, but does not rule it out. I went to the lab across the way and got the CBC, it cost me $23.85.  I went home with a strainer and some samples of a med to help the ureters relax to help pass the stone. If the stone didn’t pass, or the pain got worse, then we would have to do the CT scan.

Luckily, the pain passed, and if the stone did, it was very small and I didn’t catch it. The total cost for this illness, including the lab, was around $125. If it had been done the usual way, it would have been thousands in ER costs, CTs, etc. Since I was in charge of it all in partnership with my own physician who knows me, the cost was minimal.

The bottom line: each individual should have a HSA where they put, say, 1-2% of their income from day one, have insurance only for catastrophies, and have a family physician or family nurse practitioner that they have a good working relationship with, and a sense of responsibility for their own health and health care. The price of medical care would drop like a stone. If labs, hospitals and imaging places knew everyone was shopping around and paying CASH, good old capitalism and market influences would do their magic. The other bonus is the large reduction in costs for the physicians, with the massive reduction in paperwork.

Oh, and get the fricken lawyers out of healthcare: TORT REFORM. Please! I know that this isn’t the total answer, but it would be a starting point. Some other people are getting the same idea though, see  http://www.faircaremd.com/about_us    http://www.patmosemergiclinic.com/     

There just has to be a better answer than the monstrosity the government is trying to foist on us. My mother just moved back to Europe, the model of socialized medicine we are supposed to emulate, and told me she could not get her colonoscopy or other screening tests there because “they don’t do those screenings for people over 70 years old. They save that kind of stuff for the younger people, because there isn’t enough money.” My mom is over 70, what happens if she gets sick? I shudder to think.

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I know I said I wouldn’t post about MDs again, but I just read about this on Clinician 1 and had to pass it on.

Florida is a huge state with many uninsured and underinsured people, and whole swaths of the inner state is populated very thinly with many migrant workers. Medical care is in short supply in these areas, and nurse practitioners would love to fill in the void.

Unemployment is astronomical right now, officially around 13%, but actually more like 18-20% if you take into account all the people who have dropped off the unemployment rolls as their time runs out. I heard recently that 250 people applied for a maintenance job in a trailer park for retirees, to give you an idea of the numbers of unemployed. A friend of mine works at a food bank, where, for the first time, they are running out of food to give out, as the numbers of families needing help has tripled.

The Florida Medical Association seems to be aware that there is a crisis of health care in the state, but their way of addressing the problem is cronyism and defensive legislation to protect their turf, and not trying to solve the problems and needs of Florida’s population.

According to their website: “Whatever the issue, we will work tirelessly to ensure that the interests of our physician members, and most importantly, the interests of our patients are fully recognized and reflected in all health care policies adopted by the State of Florida throughout the year.”

Right.  When tey talk about advocating for the physician’s interest, they are right, but patients? Not so much.

On their legislative page they crow about blocking everything related to increased scope of practice this year for anyone without MD after their name, “While every session sees an attempt by allied health professionals to expand their scope of practice, the battles were especially fierce this year. Optometrists, ARNPs and physical therapists pulled out all the stops to be able to do what physicians are trained to do, but without first going to medical school for the proper training. I am happy to announce that the FMA was able to defeat all of these proposals, and that not one scope-of-practice bill passed.”

They were thrilled to have blocked:

  • Legislation that would have prevented physicians from collecting full payment from out-of-network PPO patients;
  • Legislation that would have ended the use of binding arbitration agreements by physicians;
  • Legislation that would have ensured higher malpractice insurance premiums by repealing the wrongful death exemption;
  • Legislation that would have imposed unreasonable reporting requirements on physicians in relation to impaired drivers;
  • Legislation that would have provided an unreasonable standard for the treatment of foster children with psychotropic medications;
  • Legislation that would have allowed social workers and marriage and family therapists to diagnose autism;
  • Legislation that would have ensured that physicians were paid less in automobile injury cases.
  • They called all this “diverting disaster”. Then they talk about their priority legislation for the year: to “exempt medical malpractice insurance premiums from any emergency assessment levied by the Hurricane Catastrophe Fund for three more years. This bill will save physicians thousands of dollars in the event that the CAT fund incurs a deficit.”

    Lastly they are happy that a bill to restrict “pill mills” (places where drug seekers are able to get massive amounts of narcotics). “The FMA was able amend a provision that would have limited dispensing physicians to a 72-hour supply of controlled substances. With the cooperation of Rep. John Legg, the bill’s sponsor, we were able to restrict this 72-hour limitation to registered pain clinics, and then only to patients who pay by cash, check or credit card.”

    So, these almighty doctors (who are perfect in prescribing narcotics and other controlled substances like cough syrup and diarrhea medication, right) stop a measure to restrict illicit drug use fully  prescribed by MDs, for money.

    The pattern here is clear, I don’t have to spell it out do, I? Well, okay: MONEY. That is what they are about, where is the patient advocacy?

    “There is no such thing as a nurse practitioner who is ‘qualified’ to prescribe controlled substances,” said Erin Van Sickle, a spokeswoman for the FMA on Tuesday. “The Florida Medical Association is extremely concerned about the nurse practitioners’ continued attempts to gain prescriptive authority for these medications. The ability to prescribe controlled substances is limited to medical doctors for a reason: to protect patient safety. Physicians go to medical school to learn how to prescribe controlled substances safely and without interacting with other medications. ARNPs do not.”

    “Florida lawmakers have worked diligently to protect patients from those who would attempt to prescribe narcotics to patients without the training required by Florida law, and that is the safe, accountable, and common-sense thing to do,” continued Van Sickle. “We simply can’t understand why the nurse practitioners would make such an unconscionable attempt to throw away the protections they have put in place.”

    “The bottom line is, ARNPs do not have the training nor the qualifications necessary to prescribe these medications,” she said. “If they want to prescribe controlled substances, we would encourage them to go to medical school and receive the proper training to do so.” 

    I mean, really?!?!  This is just sad!

    Florida is one of only two states who restrict NPs like this, all the other states allow it, with no detrimental effect on the over-use of controlled substances.

    Shame on you FMA! And just so you all know, the FMA does not represent ALL physicians. I happen to know quite a few who don’t agree with some of this crap, but it seems the FMA owns the Florida legislature.

    References

    http://www.fmaonline.org/Council_on_Legislation_Newsletter_04-30-10.aspx

    http://www.sunshinestatenews.com/story/looking-write-controlled-prescriptions-nurse-practicioners-looking-engage-mike-haridopolos

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    “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”

    I suppose I must put in my two cent’s worth on this subject as it seems to be the subject of the day. Independence Day.

    Independence, what does that mean? Freedom? Yes and no. It actually means to not be dependent on someone else. We fought to get out from under Britain’s rule when they no longer considered this county’s welfare when making up the rules. We became non-dependent on them, ruling ourselves, providing our own food and products, taking resposibility for ourselves.

    Now, when we talk about liberty, indepence and freedom, it means the same thing. Responsible to take care of ourselves, provide for ourselves, ruling ourselves. Individually and as a nation. We are individuals and we are all part of this nation. We have responsibility for ourselves, our communities and our nation.

    Unfortunately, it seems recently that many people believe freedom means you can do and say anything you like, without regard to consequences, or respect for others. The responsibilities have been forgotten, the cost has been forgotten. When someone else pays for you, the item does not have the worth to you as it would when it cost your own time, sweat and blood.

    We have a nation bought and paid for by patriots almost 230 years ago, and kept by patriots and soldiers since then, at the cost of life and limb. Freedom is expensive. Freedom is not just about you.

    What does this have to do with the First Amendment? We have the right to say what we want, criticise the government and anyone in it, believe and practice any religion we want. We are allowed to gather in assemblies, and the press can print any diatribes they want to. We need to remember, however, that these freedoms came at a cost and also have responsibilities attached.

    We do not have the right to say anything we want unless we are willing to take the responsibility for the results of what we say. If you are of the opinion that only your own voice counts, and you are more than ready to villify and demonize others who don’t follow your game plan, then you will have to be ready to live in a nation, where there is no more free speech. If you call someone a nasty name (like “tea-bagger” or astro-turf)) when they are protesting something that they feel is a problem or a threat to their way of life, then don’t get mad if they lable you with a nasty name (libtard, or as people believe Lenin called liberals: useful idiots [actually he called them deaf-mutes]). 

    The nastiness and mean-spiritedness I have been seeing is appalling to me. I wish we could go back to the days when politicians were statesmen, and believed in America as an ideal, a place of freedom and goodness. Where respect and politeness were honored, where the American dream meant finding a common ground with people who came here from all over the world (including me) and working together. Of course there are always problems, but America actually tries to fix them, or used to. Now, in the name of “cultural diversity” and “political correctness”, we are being torn apart at the roots. Everyone is constantly offended by everyone and everything else. There are strident demands for tolerance, but very little tolerance given. The government has become a platform for greedy, power-hungry. palm-greasing politicians in the worst sense of the word. Disasters of epic proportions are used as leverage to gain more power for the government instead of being addressed by the full might of our nation’s wonderful and strong people.

    America grew mighty on the strength and vision of its individual people working independently and as a community (not “the people” of the social progressive world-view which has nothing to do with you or me as individuals, only a mass to be manipulated), overcoming huge odds to get here and set up new lives and accomplish for themselves. Now, people demand psychological help because oil is on their beach, instead of rolling up their sleeves and getting to work to stop the oil and clean up. (Something the President should have led from day ONE). What a nation of crybabies and wooses we have become (well, some of the most visible and loud groups, that is). Congress plays on computers to pass the time while doing nothing about real problems. This is a photo of the “healthcare debate”. The vice -president calls a hardworking American a “smart-ass” for requesting that taxes be lowered. I mean, really!?

    The whole thing makes me want to cry for those who fought and worked so hard to gain our freedoms and are ignored in the “new American” classrooms, for those who still fight and have to see politicians use them as pawns in a political game of power in Congress and the White House. I cry for those who are proud of what America stood for, and see Hollywood and Washington declare their hatred of the American way and American people who work hard for themselves. I cry when Congress has no constraints, spends OUR money like water and are willing to put our kids in hock for may generations to fund their little pet projects, and take away the power to rule ourselves from individuals and individual states. I cry when our borders are closed to those who would be American and wide open to those who hate it.

      I believe there is still a great mass of Americans in the heart of the nation and scattered through the cities and communities that are the old kind of American: proud, strong, hard-working, respectful and tolerant (a better term is accepting) of each other’s differences. I hope they speak out loud and clear, even though they will be excoriated by the media, Washington, teachers and unions. I hope that America comes to its senses and realizes we are about to lose what makes us special. I had a 92 year old patient who was watching the news with me one day recently. This man came from the Ukraine, lost most of his family in the war to Nazis and Russians. He had been a teacher in the old country, but worked as a metal worker here. He came to this country for freedom and opportunity, and found it. Watching the news that day, he remarked on what he saw happening in the government “I have seen this before, don’t people understand? This is how communism starts, I should know, I have been there. That’s why I came here to America, and now it has followed me.” He died shortly after that. God bless him, he is now with his family.

    It is time to exercise our rights, because we are responsible for what happens now.

    The American Republic will endure until the day Congress discovers that it can bribe the public with the public’s money.
    Alexis de Tocqueville

    Happy Independence Day! This is still a wonderful country! Embrace and celebrate the differences: race, religion, country of origin, culture. Each has something to offer and part of America’s greatness comes from its ability to absorb the best of all of them to make a wonderful whole.

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    The more I learn about the human machine, the more I am amazed at the intricacies and complexity of the system. Every cell, every molecule has a role to play in maintaining the all-important level of balance in our body. It is called homeostasis, and basically means equilibrium or “staying the same”.

    If there is a rise in blood pressure, for example, several sensors in diverse areas such as the kidneys and blood vessels sense the change and a multitude of signals go out in the form of nerve impulses and hormones and enzymes. Each message is sent to a specific area with a specific goal. Blood vessels relax and expand, the kidneys crank up the volume and get rid of extra fluid sucked out of the blood stream. Some effects are meant to be short term, such as the relaxed blood vessels, others more long-term, such as getting rid of fluid. All in the name of maintaining homeostasis: in this case, the optimal blood pressure: enough to get blood to all areas of the body, but not so much as to damage fragile capillaries and organs. 

    A hole somewhere that allows blood to leak out of a vein or artery causes a complex cascade of factors to be released, building up a blood clot and stimulating growth of new cells to repair the hole in the blood vessel wall. If only one out of the thirteen factors is missing or in short supply, the whole cascade is affected. hemophiliacs, people who are missing a factor, have dangerous bleeds from tiny incidents because the clotting cascade can’t work properly

    The amazing and delicate balance can be thrown off in so many ways: invading organisms (pathogens) that cause disease, injury, malnutrition, toxic substances: drugs, cigarette smoke and alcohol, malnutrition or poor environmental conditions such as extreme heat and cold. Even the body itself can have a system go wrong, as in cancer and autoimmune disorders like Lupus. An autoimmune disease is one where the body’s own defensive system, the immune system, doesn’t recognize itself and attacks its own tissues. 

    When  it comes to finding and fixing a problem, a physician or nurse practitioner has to be like Sherlock Holmes, looking at signs and symptoms of errors or breaks in the system. Some clues are obvious: bleeding or coughing. Or are they? Bleeding can be from a trauma, a coagulation disorder, or a broken spot somewhere inside the body like a perforated ulcer. A cough could mean a problem in the lungs, or it could point to a heart condition, or a reaction to a drug.

    Medicine is a science, but also an art. It takes keen observation, intuition, deduction and skill. And lots of experience. No health care provider will ever know it all. Learning never stops.

    Nurses are good in at looking for signs and symptoms. We are geared from day one to observe nuances in our patients. It was our job to see how the treatments the physicians order are actually working. Is there a subtle change in the patient’s level of consciousness? Is that little rash new? Is the pain any less? Is the amount, color, consistency, smell of any substance coming out of the body different? Is the patient moving around better, or not? How is the breathing? The heart rate? And what do all of these things mean? Is what we are seeing life-threatening? Should we notify the physician at 3 AM, or is this expected or normal? There is an enormous amount of responsibility and skill involved with nursing. Too bad that hospitals think a “patient care technician” (formerly known as nurse’s aid) can take tasks that nurses used to do, and think that it doesn’t affect patient care and mortality rates for that matter (a subject for another day). The time nurses used to spend bathing and assisting patients to the bathroom for example, were opportunities to gather a mother-lode of information. More on that later.

    Now, as a future nurse practitioner, I get to augment and utilise those nursing skills at a higher level. Now I will look at the patient to diagnose the problem, instead of assessing response to treatment. I am looking forward to this chance to solve the riddles. The education I am receiving now is fine-tuning the assessment skills and adding the treatment modalities to the skills mix. It sure is easier to look at a script or treatment ordered by someone else and criticise it, than it is to make a decision and order something yourself! It is a definite step up in responsibility, and a real opportunity to help people.

    Now a bit about evidence based practice (EBP). I have taken more than one course utilizing the concept of EBP. At first glance, it is a wonderful thing. You read research and base your treatment on things proven to work by research.

    What could be wrong with that? (Check back to my post: A new study shows…)

    I’ll tell you. Statistics and research results can be biased, inaccurate and are only as good as the data you put in, and the method used to obtain the data. Kinda like computers: garbage in, garbage out. You can read ten studies, and depending on research methods, you can get ten different results.

    Reading a research study is not a fun/easy thing. There is a language you have to learn first: P values, blinding, correlations, standard deviations, etc. etc. etc. Once you get that, it is necessary to know what type of studies they are conducting and the relative values: is it double blinded, is the cohort large enough to reach statistical significance, is there a control group, etc. Then look at who is paying for the study, this will make a huge difference. The people paying for a study have a bias and will set up a trial to get the results they want, yes, I know that sounds cynical, but let’s be real here.

    I’ll give you an example. A study showed that St. John’s Wort is not useful to treat major depression. You have also read that in Germany, St. John’s Wort is the most prescribed medication for depression. Huh, how can that be. Look again, but more closely, MAJOR depression. The study was funded by a pharmaceutical company who manufactures antidepressants. They want people to use their product, so it is first necessary to debunk the use of a product that they can’t make a profit from. If you look further, you will find that St. John’s Wort is shown to reduce minor or moderate depression in some cases. As a matter of fact, if you take it with an antidepressant drug, you are in danger of serotonin syndrome, a form of overdose for antidepressants. So, the study result was biased and designed to give a false impression that the herb does not help in depression, but it is not helpful only for MAJOR depression.

    Keep reading we are almost to the EBP part…

    What you need is a meta-analysis, You read ALL the studies you can find on a particular subject, Then weed out the ones that are designed poorly, or which don’t cover exactly what you are looking for. I recently did a meta-analysis on whether cranberry is useful for urinary infections. After wading through I don’t remember how many studies, I ended up with about 12 that were applicable. The result was that cranberry is useful to PREVENT urinary tract infections (UTI) in WOMEN who had a history of recurrent UTI. Notice, it does not apply to men, and it is only useful to prevent, not treat UTI. (It so happens that cranberry prevents those nasty little bacteria from sticking to the inside of the bladder and growing there, and has nothing to do with acidifying the urine as I previously believed). Oh, and cranberry capsules are the cheapest and easiest to use for this. So, the EBP thing to do: recommend a woman who has had multiple episodes of UTI, to take cranberry capsules daily to prevent getting so many infections. UTIs are no fun, I have had them.

    Okay, so, EBP is great, and all clinicians should participate in the plan and prescribe only things proven to work, right? Not so fast. Remember what I said about bias and inaccuracy? Back i the 70’s, when I had my children, we were lectured by the medical establishment that our infants needed to sleep on their stomach or side to prevent SIDS (sudden infant death syndrome). Studies showed that the little darlings choked on saliva or spit-up if they slept on their back. Guess what EBP says now? “Back to sleep”. Evidently new research showed that the rates of SIDS went UP when infants slept on their stomachs, and now we are to have them sleep on their back.

    So, here is the bottom line. EBP is great, but professional experience and individualised treatment plans should also be in the mix. Sometimes research lies, or it forgets something important. The recent guidelines put out by the government about breast cancer screening is an example of what I am worried about. The government guidelines state women under 50 ( actually the 40-50 year range) do not need screening for breast cancer, that breast self exam is not useful and not to be recommended. This was based on a statistic. Supposedly, if you take a whole population (women in this case) and extrapolate how much lifespan you save over the entire population with a screening test (mammograms for under 50 years of age), if the result is less than one month, the test is not financially worthwhile. The 40-50 year olds evidently did not meet this goal. So, new guideline.

    My worry is that the government and insurance companies will make these types of guidelines mandatory practice. Ask any oncologist how many forty something breast cancer patients they have treated. Each one of those women are not considered statistically important, but their families sure consider them important.

    EBP is a great tool, but each finding is not carved in stone, new research may change it at any time. Health care providers need to use the tool, but it should not be a bludgeon used by the government or health insurance companies to control cost.

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    Dr. Keith Ablow, a psychiatrist on Fox news, has posted on his blog the worst diatribe I have read in a long time. Read it here: http://health.blogs.foxnews.com/2010/04/15/nurses-masquerading-as-doctors/

    Okay, here is my response. I will do my best to keep it civil. Paragraph by paragraph.

    First of all, we will see what is in the future regarding the health care reform, but there is, and has been, a shortage of primary care physicians, especially in poor or rural areas. Patients all over America and many other countries have long received primary care from Nurse Practitioners (NPs) who worked independently, or in collaboration with a physician, depending on the state in which the NP has her license and where they choose to work. This is nothing new. Many studies on the effectiveness, safety and patient satisfaction with NP care point to equal or better outcomes than physician care (I have the references if anyone wants them) in the specialities that the NPs practice in: pediatrics, family practice, adult, and geriatric, to name a few. NPs can and do provide excellent primary and specialized care.

    The education includes pharmacotherapeutics, and have completed the requisite hours in order to be able to prescribe safely, and have the same CEU requirements as physicians. Each state has their own laws regarding  NP prescriptive privileges, but NPs write prescriptions in all states. Only 2 states do not allow NPs to prescribe controlled drugs such as cough medication, certain anti-diarrheals and pain medication. I, unfortunately live in one of them, Florida. Sixteen times a bill has been introduced and sixteen times shot down through the machinations of Florida Medical Association lobbyists, in spite of documented proof that NPs prescribe safely.  

    As to the right to be called “Doctor”. Doctor is an honorific for someone who has reached a doctorate level of education in any field, Dr. Ablow confuses this with the role of physician. But to answer his objection, NPs don’t generally want to be called doctor, even if they have the Doctor of Nursing Practice degree (DNP). When I get it, I will still introduce myself by my name and title of Nurse Practitioner. In 2015, DNP will be the entry-level degree for nurse practitioner certification, and physicians will have to stop being so touchy about it, we are all there for the patients. It isn’t about ego trips, or shouldn’t be.  The minimum degree now is Master in Science of Nursing (MSN).

    Obama care is an unknown entity so far, so calling it two-tiered care is just silly. I see no requirements that “poor” people can only see NPs and “rich” people get a “real” doctor. NPs are a resource for good primary care in a time of shortage of primary care MDs, and a great adjunct in the health care team as a whole. Many patients prefer the NP so money is not the issue. NPs are not trying to replace MDs.

    Yes, medical school is rigorous and academically challenging, but so is nursing school. Getting into nursing school is tough, many schools have waiting lists of over two years. The average NP has had many years of education to get to where they are. I myself started as an EMT, then got a Nursing Diploma (3 years with many, many clinical hours), then  got a BSN, (3 years with more clinical), now I am enrolled in a MSN-FNP program (3 more years and 700 hours of clinical time). All in all, I will  have spent 10 years in school, and have 20 years of hands-on experience in nursing. I have worked in hospitals, home health, hospice and case management. I was top of my class every time I went to school, and have a 4.0 right now (and it was not easy!) I suspect most nurses who go the extra time and effort to be NPs are intelligent, hard-working, and driven to help patients. As to physicians having more “raw intellect” than the average nurse – aren’t we a tad arrogant, Dr. Ablow? I’ll match my IQ to yours any day and blow you out of the water.

    What you are saying isn’t unpopular, it is untruthful in its insinuations. Suggesting nurse anesthetists (and advanced practice nurses in genreral) are second-rate is out-and-out ridiculous. Many rural hospitals don’t have anesthesiologists available, and would not be able to provide surgical and anesthesia services without CRNAs. Besides, anyone who works in the ER wears a mask and gown “just like the surgeon”, they aren’t hiding or masquerading, just doing their job, you moron. (Oops, sorry, not civil. Will be good…) You pay for anesthesia that is safe, and you get it. It is not relevant whether the one doing it is a nurse anesthetist or an anesthesiologist, they are both credentialed, licensed, and able to do the job equally well.

    Also, please differentiate between nurses. I wouldn’t want a psychiatrist to decide if I had pneumonia or the flu, but I sure as hell would place myself in the capable hands of an NP. LPNs and RNs can’t do what you describe, but NPs can and do, and do it well.

    • “How come no one in Congress would be able to tell you a story about that incredible nurse who diagnosed the rare condition in his or her child?” Because the idiots in Congress only listen to the lobbyists who give them lots of money, i.e. the AMA (which only represents 25% of physicians, by the way).
    • ” How come nurses either failed to be admitted to medical school or didn’t try? ” Because they wanted to be nurses. Nurses are closer to patients (in general, there are always exceptions to the rule,  my own MD is a good example), see them as whole people and not just a disease . I was working in the ER and was given D/C instructions for a patient after being seen by the medical person for hematemesis (bloody vomiting). The instructions consisted of a script for a PPI and a referral to a gastroenterologist. When I went in to discharge the patient, I saw he had fresh surgical scars on his wrists. I asked him about them and he explained he had carpal tunnel surgery three months ago. On questioning, it turns out he had been taking Motrin four times a day ever since. “The doctor didn’t tell me not to.” Further questioning of this 20 year-old determined he binge drank every weekend. The medical person never asked.  This situation wasn’t even rare or unusual and he didn’t catch it. In this case we needed to know the cause to be able to treat the problem and prevent reoccurrence, this is where NPs shine because of being a nurse.
    • “You think it’s because they thought nursing school would train them better to take care of patients? C’mon. It’s because nursing school is easier–as in, 10 times easier.” Since you never went to nursing school, you wouldn’t know, would  you? Don’t make assumptions about things you know nothing about. Nursing school is difficult, maybe not as crazy as medical school, but that does not make it less valuable. We go to nursing school because we like the nursing model of health care. We are advanced practice nurses, not mini-doctors.

    Nurses don’t impersonate doctors (oops, physicians), they are their own entity; complimentary to physicians, not replacements.

    Now a word to Dr. Ablow: Do you feel  threatened by NPs? What makes you so hostile? You are supposed to be a healer of the mind and emotional difficulties, yet you seem  beset by your own insecurities to lash out so. Perhaps you need a consultation with a psychiatric nurse practitioner, they are well-known for their good listening skills, understanding and compassion. 

    Okay, I was fairly civil, for a Viking…Sigh, I hate it when I get mad, it never feels good afterwards.

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