The Cost of Saving My Life is to Forfeit the Rest of My Life!

     All Americans are delivered a daily diet of "Media Medication Commercials".  Every possible "dis-ease" is frightingly illuminated, followed by a recommended  prescription medication promising resolve.  Common to all advertisments is a perfunctory warning regarding limitations and side effects. These warning always ends with the CYA admonishment to......"Call Your Doctor".  A Serious Question is implicit.  Will "Calling Your Doctor" really resolve anything? 

     Well first, we all know that we can no more call "our doctor" than we can just dial-up Barack Obama.  At best we will have a brief conversation with a minimally trained receptionist whose only latitude is to schedule an appointment or instruct urgent patients to visit their Hospital ER.  At worst, "calling your doctor" yields only a telephony message asking for a call-back number, a call which never comes.  While this "in due time" protocol may be appropriate for sore throats, migraines and toenail fungus, it is not responsive to Advanced Seniors experiencing highly unstable symptoms. In these situations everyone know that the Senior should forget about their Doctor and go straight to the Hospital ER. 

      These seniors, having no practical options, are making these trip in stagering numbers. They, and their concerned family members, should realize that these Hospital ER encounters are "life changing", often for the worse.   As such, Advanced Senior must  consider that being "admitted" to the Hospital  may not only result in significant expense, but that their very freedom may be at risk!  

     This may sound preposterous, the incitings of a social alarmist, but seriously you Baby Boomers with 80's aged parents.....it happens every day;  here's Why & How!  It's all about the money. Under Medicare Payment Policies, Hospital's who "Re-Admit" Seniors for recurring related health issues are severly financially penalized by Medicare..  Indeed Doctors treating In-Hospital patients who have been Re-Admitted will also suffer starting soon.  Not surprisingly the consequence of this disincentive is that Doctors with support from Hospital Social Workers and Discharge Planners are literally "strong-arming" Advanced Seniors" to give up their private residences in favor of residence in a Nursing Home.  The motive for this almost standard practice is that the Nursing Home's are incentivized by Medicaid/Medicare to minimize Hospital Re-Admissions in favor of less expensive pallative responses to patient condition. Nursing Homes are paid special allowances to fund their expense in "educating patient families" that often it is best that unstable Nursing Home Patients not return to the Hospital.  Actually the Hospital/Doctor mandate is often so strong that family resistance to Nursing Home relocations threatens Civil Authority intervention. 

     The practice is becoming so frequent and the strategies so cavalier that if you don't allow the Hospital to discharge your aged parent directly to the Nursing Home, well you may have to deal with the Adult Protective Services Division of the District Attorneys Office.  This is a pure violation of civil rights, but regrettably not a violation that will likely have protestors rallying in the streets.  It will however likely reduce the Medicare Cost.  Sadly, it also dooms a whole lot of Advanced Seniors to spending their remaining days withering in the most pathetic social model ever contrived by 20th Century Politicians.  

Re-Admissions......"Not In My Hospital"

                         The follow "Onion Editorial" is fictional, but the truth just SCREAMS

      I am a Hospitalist.  I attend to mostly elderly women admitted by ER docs.  Mpst often these patients present the common signs of advanced age, heart/lung/stomach complicated by a destabalizing episode such as a fall or an infection.  We say UTI and CatScan a lot. I often speak with levity about these patients and the fear origins of their instinct to scurry on down to the Hospitals ER.  Of course I'm clinically sympathetic, but.....these are problems that should be relegated to a savy Nurse at the Nursing Home down the street.  The Chinese, who fund our out of control Entitlement Programs can't afford for me to be involved in these Merry-Go-Round stories.  Without days of eliminating tests, I can't be sure that there are not more critical issues present.  Neither I nor the Hospital can run that risk.  What to do?  When the profile presents, I do everything I can to direct the likely repeat patient to a new life, albeit a more impoverished life. at the Near Midnight Nursing Home. You might not like this strategy but I'm an elitist and have no time nor patience for little things.     

Branson's MD's, DO's, NP's, PA's & SSRI's

Let’s see….why would a Medical Doctor want to live and practice in Branson?  Just a quick look at the “non-Springfield” Ozark demographics screams probably not to reach the cutting edge of their chosen profession. Medicares, Medicaids and SelfPays fill virtually all seats in their waiting rooms; not landscapes in which professional challenge and health science progress take root.   Well, how about to optimize personal life style? Perhaps this explains the “South on #65” attractor.  Branson does have 9 million visitors a year whose visits subsidize community services for we locals who enjoy instant access to a recreational playland.  And, of course, there is the attraction of the “poor county” real estate market, where Dr. Gray can have a magnificent house on the lake with boats, skis, motor-homes and a $10 handyman for less than the cost of a Johnson County/West County subdivision house.  And that’s not all folks.  All of those Medicares, Medicaids and SelfPays are non-discriminating customers prone to habit visits and easy appeasement.  In short, they will accommodate being seen by a Nurse Practitioner (NP) or a Physician Assistant (PA), and  Dr. Gray, well, he can enjoy a semi-permanent holiday in the famous Ozark Mountains.

Who can say.  The PA’s and the NP’s may well be doing their best; 50 per day visit schedules being what they are.  Thankfully, with this never ending stream of, mostly psycho-based maladies, these thinly trained semi-professionals, have found “just the right remedy”...at least for themselves!  This medicine of course would be the, now available in 19 favors, SSRI’s (Selective Serotonin Reuptake Inhibitors).  While it’s pretty clear that the SEMIDOCS are not steeped in brain chemistry and really have no idea about Mabel’s neurotransmitter profile, they do know that a “nerve pill script” will end the current visit and promote the next.

 Certainly there is much good evidence that the SSRI era, now 30+ years in the making, has not brought about a national psychosis. It is far less clear that the quality of later year lives for millions of elderly (mostly women) persons is not being severely diminished by the routine random manipulation of their neural biology. Really, does it make sense to allowing NP’s and PA’s to distribute these medications without, at least, chemistry profile testing.   Of course not!

PS:  Branson Cox used to have a “Senior Transition Unit” that accepted patients whose psychoactive medications had been royally screwed up by the SEMIDOCS.  There was some evidence that with a few weeks of clinical evaluation and med modification, these persons were able to resume their normal senior lives.  Unfortunately Cox closed the unit and now advises inquirers that Medicare Beneficiaries with psychological concerns should see their Family Practice Doctor, which is to say, their PA or NP.  The Board Certified Psychiatrist that supervised the Senior Transition Unit at Cox, is now in private practice in Branson, but does not see Medicare Patients.  If you read this you should immediately take a Paxil and a Zolof, or a couple of each!

Buffy......"The Death Expeditor"

Hi!  I'm Buffy, the Discharge Planner from the Hospital's Social Services Department.  I really never wanted to be a "death expeditor".  I wanted to be a fashion designer, but my dad said that I needed a degree with Job Security, so here I am at a small hospital in Anywhere America.  I did, after 5 years, get a degree; a BS in Social Services.  I passed a lot of Psychology Courses and listened to a lot of Sociology Lectures, but they sure didn't clue me in about what I now have to do everyday that I'm at work.  My Dad says that since it's my first job, I should just be pleasant and do what I'm told.

Well, it's been a few months now and I kinda understand why the people that run the Hospital need me to be the "death expeditor", or as I self refer; the DE.  Euthanasia is, according to almost everybody, an idea that we shouldn't even talk about, much less consider.  We are the riches nation in the history of the world and we "absolutely must" be caring and compassionate to old people and dogs.  But, as my Dad has explained, we also need to be financially prudent.  Now that I've thought about it, I realize that the Hospital Accounting Department wouldn't be able to pay me if the Hospital were to spend more money than they take in.  And then when I read an article on Facebook about how most of the money that Hospitals get comes from the Government and that Medicare is running out of money and that the Government has to borrow money from China...well, it all started to make sense.

We just can't have all of these old people running to the ER every time they notice that they are feeling, as they say, "just not myself".  Maybe once, or even twice, is okay, but beyond that, we need to put a stop to it....yes a compassionate stop, but indeed a stop.  This is where I come in.  My boss says that the President of the Hospital doesn't want Doctors or Nurses having to put a stop to excess Hospital Services. He wants young and inexperienced staffers like me to communicate the news as to what's gonna happen to the patient tomorrow.  I make it seem like its no big thing and that we are all just doing what we're supposed to do.

So, what is going to happen tomorrow?  How do I "stop it", with compassion.  Well I have two choices. Both start out by my saying "The Doctor Says".  Of course this is after the Doctor has decided to release the patient and scheduled never to see them again.  Actually the Doctor, who is what we call a "Hospitalist" never sees any patients outside of the Hospital and has maybe only seen the patient once or twice for a few minutes during their average 3 day stay.  Anyway, my "patient release presentation" starts on a good note.  I say, "The Doctor has decided to release you". You don't have to be much of a Psychologist to understand that when you tell someone that they are to be "released", it overshadows the news as to what may follow.  I then say, "The Doctor wants you to receive Nursing Home Care", or I say "The Doctors is placing you on a Hospice Service."  I only choose Nursing Home Care if I'm pretty sure that the patient or their family doesn't have any money.  I choose Hospice Service if its apparent that the family has money.

Both of these "Patient Futures" accomplish the Hospitals objective; namely not to see the patient again. This may seem callous but Medicare just will not pay the Hospital to keep treating the old people over and over.

For the poor people the Nursing Home Order is never questioned.  They are used to following orders and indeed often are relieved to no longer have decision responsibility for their advanced age senior.  The accepting Nursing Home as a matter of standard proceedure overlooks or "sedative medicates" all unstable patients.  The Nursing Home Management ignores patient family requests for ER visits. As indirect benefactors of the Medicaid system, they have no power.  In fact to help the Hospitals out our State gives Nursing Homes special payments to promote patients to choose against Hospital Re-Admissions.  End result...very few readmits; either because the Nursing Home paid Doctor will not send them back, or because the life experience is so debilitating that they loose the will to eat and fshortly thereafter the will to live.

For families that seem better off financially, relocating to a Nursing Home is horrifying. They just  know more about the system; that it costs $140 a day, that Medicare will not cover, and that it is a bleak and dehumanizing way of life.  Actually, I have never really been in a Nursing Home.  Once when I was in school, we did a "day experience" in an Assisted Living Facility.  It was real nice but I have heard that Nursing Homes are really bad.  I hope my Dad never has to live in one.  Anyway, most better off families are ok with their aging parent coming to their home or if possible returning to their own home, but...when they focus on the  real issues, they realize that they will need a care taker.  I explain that if the family is willing to accept that mom or dad is really frail and will likely not recover his/her independence, that Hospice may be the solution.  Yes, historically Hospice Services were for dying patients, but in our more compassionate times the program is available to all frail elderly.  They are entitled to free medications, Durable Medical Equipment, Nurse Visits, Aide Support, and of course Chaplain visits. Everybodies happy, let's do it....Oh!, by the way the enabling paper work requires that the family relinquish future access to Hospital Services, In Home Therapies and Home Health.  Since the Hospice Agency is paid on a "Case Basis" the Agency is motivated to minimize the Hospice Patients "days on service".  Timely introduction of "Comfort Packs" into patient treatment protocols does wonders in this regard.  Yes, you get the gist!  The Hospital gets no more readmissions.

After a few months I am now pretty good at being the DE.  Like that guy on television that tries all kinds of jobs says, " It's a dirty job but somebodies got to do it".  That would be me!

You Get Physical Therapy, I Get Fiscal Therapy.... and Lots of It!

I cannot tell a lie!  I am getting rich servicing all of my 80 year old women clients!  Of course not, you moron...  I am  a Licensed Physical Therapist  providing Contract Services to Medicare Providers.  My marks are SNF's, ICF's ALF's, ARH's, and indeed any Health Services Organization with a Medicare Billing Number and access to a CMS (Center for Mecicare Services) Intermediary Database. 

Seriously, folks Health Care Pros couldn't care less about Obamacare. It's just a political side show. The "Real Money Show" is in treating the 30 million obesse, sugar sucking, grease gobbling, inflamation constricted, 65+ widowed women, all of whom are insanely afraid of dying and yet are doing everything possible to hasten their own funerals.  And that, my friend, is where I come in. You see, I put the "old broads" in play.  I certify them to be "patients" entitled to Medicare paid "Health Services", for, believe it or not,....not being able to walk as well as when they were young.  As goddamn hard as it might be to understand, CMS, and therefore it follows, HHS and Barack Obama want every American over 65 to get help from me, if they are in the least bit fearful that their ability to walk just "ain't what it used to be". 

For $200 an hour, I will watch you walk around in your kitchen, or through the halls at your apartment, often while texting framily to easy the boredom.  After  about 120 days, when the Home Health Agencies HHRG Codes tank, I'll play the "no progress card" and recommend that you relocate to a $4k a month ALF, where I get "referral benefits" and the option to resume watching you walk at $200 twice as often.  As your institutionalized depression kicks in, and your mobility crashes, along with your savings,  I will raise concerns to ALF Management about "independent evacuation". ALF Management will  have a "regulatory moment", and we will all concur that you need SNF Care.  We won't send you directly to the SNF.  We will send you to the Hospital ER, probably for some never fully identified infection.  After 3 days and $40K Medicare Billing by the  Hospital, they will send you to the SNF where you will now live in a shabby  room with a welfare roommate, a pull curtain and an unkept teenage aide mindlessly pouring water; all for a modest $1000 per day in Medicare Payments. Yes, I will receive "referral benefits" and I will now see you daily when the CNA pushes you down to my "therapy suite", where I will help you practice transfering from your wheel chair to a mock toilet. 

After about 100 days of this "worst of all possible worlds", SNF experience, Medicare will "drop you like a hot potato" and your kids will start getting bills at about $250 per day.  This will be your "no therapy time". The kids won't be able to afford me.  They will be home thinking about moving you into their garage. I'll be in the Bahamas on vacation. You'll be in a Hospital bed with the rails up.  (I know this sounds horrible, and I will wish it wasn't true....although I do like the big bucks.)  There will be some hope.  SNF management will try to get you readmitted to the Hospital so they can get you Medicare "new episode covered".  If  the SNF is successful, Ill rush back and we will all push replay.  If not, and more likely, since ObamaCare severly penalizes Hospital's for readmits, it will probably be time to sign you up for Hospice.  The garage will actually be a welcome change from the SNF, and Medicare will pay the Hospice Agency around $4000 per month to stop in once a week for 30 minutes to take your temp/pulse and say a little prayer.  I will be praying that the Hospice Agency remembers my "referral benefits".  

No, I'm not particularly proud of my career.  I have a BS from Mizzou and a Masters from Vanderbilt.  Twenty years ago, I just wanted to help people.  I still do, but there's no way to buck the system.  When I look in the mirror I see a man preying on "old flesh", but then I remember that I'm rich and I laugh like a jackel!