The Medical Thread: We're experts on everything else; why not?

[busterman62]

If it?s wet, keep it dry. If it?s dry keep it wet.

and if it's red you roid it

[dxmnkd316]

Advice from the guy who couldn’t figure out what kind of kitty to get his wife!

There's another joke buried in there.

[dxmnkd316]

[leswp1]

and if it's red you roid it

this whole string of comments cracked me up.
You can't roid everything red but close.

[Swansong]

I don't have a long history in healthcare but I've been steeped in it from the IT/operational side for the last 4+ years, and I totally agree with regards to mental health. It is improving, at least here in MA, but not quickly. Most of the slowness is related to the healthcare staff itself - we have a miserable time hiring and keeping behavioral health folks (docs, therapists, social workers, etc.).

One of the requirements put on my new big company (not Partners/MGB, but the other big eastern-mass healthcare company) when we formed was a CoCM (Continuity of Care Model) program that is a big, big step in identifying patients with mental health problems and getting them the help they may need. It's been incredibly successful, even during the pandemic, but like I said the staffing has been a major, major problem.

[MissThundercat]

For my Mental Health and Health Care Policy class, I have to write a 4 page single-spaced policy brief. I was going to do Medicaid funding, but instead I'm doing mental health and how our current joke of a system led to a significant gap between the haves and have nots.

[leswp1]

I don't have a long history in healthcare but I've been steeped in it from the IT/operational side for the last 4+ years, and I totally agree with regards to mental health. It is improving, at least here in MA, but not quickly. Most of the slowness is related to the healthcare staff itself - we have a miserable time hiring and keeping behavioral health folks (docs, therapists, social workers, etc.).

One of the requirements put on my new big company (not Partners/MGB, but the other big eastern-mass healthcare company) when we formed was a CoCM (Continuity of Care Model) program that is a big, big step in identifying patients with mental health problems and getting them the help they may need. It's been incredibly successful, even during the pandemic, but like I said the staffing has been a major, major problem.

The pressure on Behavioural health Providers is ridiculous. They are underpaid, overbooked and many times work with time constraints- X visits and then not covered or unbelievable barriers trying to get reimbursement to work. Many of the larger practices treat them like sh1t- poor pay, overbooking. Can't begin to count the number of times I have seen Providers make lateral moves between practices. Unfortunately that leaves a gap in care- the pt needs to start with a new provider because most of the time insurances are not compatible b/w practices. That means they are wait listed to see a new provider and causes all sorts of disruption and trust issues.

When I was first in Practice this wasn't as bad. The whole HMO thing started the downward spiral and it has progressively gotten worse. Insurance forces people into suboptimal treatment with restricted list of Providers that rarely have openings, restricted coverage- x visits a yr with no consideration for what would be appropriate, putting rules in about meds that require inappropriate protocols. My favorite- they wanted me to prescribe a new start anti-depressant to be filled for a 90d supply because if they didn't continue for 90d we lost a boatload of $$- no chart review. If 90d wasn't billed then ding! This specifically goes against all recommendations.

[DrDemento]

Les-you knew I would read what you write. There are many dermatologic emergencies. But they really are medical emergencies that may have a dermatologic component and thus are often managed by a general medical physician or an ER doc. if they wait for a dermatologist to arrive sometimes the emergency just gets better before the consultant gets there! (which really is perhaps the most desired outcome)

[Kepler]

There are many dermatologic emergencies.

As anyone who has been to Middle School knows, jeez!

[leswp1]

Les-you knew I would read what you write. There are many dermatologic emergencies. But they really are medical emergencies that may have a dermatologic component and thus are often managed by a general medical physician or an ER doc. if they wait for a dermatologist to arrive sometimes the emergency just gets better before the consultant gets there! (which really is perhaps the most desired outcome)

I did. I couldn't recall anything that was handled that got a Derm out of bed. I was trying to think of something that only a Derm would handle - there has to be something- and was coming up blank. I was waiting for you to refresh me.

[DrDemento]

I did. I couldn't recall anything that was handled that got a Derm out of bed. I was trying to think of something that only a Derm would handle - there has to be something- and was coming up blank. I was waiting for you to refresh me.

I got called for things like Stevens-Johnson syndrome, toxic epidermal necrolysis, some incredibly severe allergic reactions to all sorts of things but honestly, most of the midnight calls from the ER were for me to come see a patient and insure the doctors and nurses that what they were looking at was not contagious (that is was a allergic drug rash instead of scabies for example) as they were just afraid to catch something. Having trained as both an internist and a psychiatrist first, often times the emergency was something i had the advantage of an overall perspective. As the years went by, I spent most of my career as a skin cancer reconstructive surgeon and although most of the conditions I dealt with were serious, there really was virtually no emergent nature to any of them. A delay of a few hours certainly did not make a difference in the overall mortality or morbidity.
Honestly miss those years greatly but fully understand that the practice of medicine has now changed so much that much of the decision making would be removed from me and replaced by the insurance companies and the government.

[Swansong]

Honestly miss those years greatly but fully understand that the practice of medicine has now changed so much that much of the decision making would be removed from me and replaced by the insurance companies and the government.

I'll never make a clinical decision for anyone other than myself or perhaps someone for whom I am a proxy, but this still drives me nuts. The hoops you folks have to go through in order to get patients care they need without resulting in a zillion dollar bill are insane.

Insurance 1 requires steps A, B and C before approving the actual treatment Z.
Insurance 2 requires steps A, C and D before approving the actual treatment Z.
Insurance 3 requires step E to happen before steps A and B, but step E never happened so they'll never approve treatment Z.

And on and on. It's ridiculous. The last 15 years of EHRs have introduced clinical decision making tools to assist. The idea behind those is for underserved areas that perhaps don't have a Dermatologist on call to allow the local staff to make informed decisions. The reality is that we use them to make sure providers do the required bull**** for that patient's insurance company. One of the analysts that works for me spends 1/4 of his time making sure gaps in documentation are plugged just so we get reimbursed properly. And that's after 4+ years of being on this system. Claim denials for administrative reasons are the worst.

[DrDemento]

I'll never make a clinical decision for anyone other than myself or perhaps someone for whom I am a proxy, but this still drives me nuts. The hoops you folks have to go through in order to get patients care they need without resulting in a zillion dollar bill are insane.

Insurance 1 requires steps A, B and C before approving the actual treatment Z.
Insurance 2 requires steps A, C and D before approving the actual treatment Z.
Insurance 3 requires step E to happen before steps A and B, but step E never happened so they'll never approve treatment Z.

And on and on. It's ridiculous. The last 15 years of EHRs have introduced clinical decision making tools to assist. The idea behind those is for underserved areas that perhaps don't have a Dermatologist on call to allow the local staff to make informed decisions. The reality is that we use them to make sure providers do the required bull**** for that patient's insurance company. One of the analysts that works for me spends 1/4 of his time making sure gaps in documentation are plugged just so we get reimbursed properly. And that's after 4+ years of being on this system. Claim denials for administrative reasons are the worst.

This is why we now only do consulting work. And anything we do or anyone we see is all pro bono. i like to still diagnose and prescribe but fortunate that after 50+ years I can provide any care free. Before we did this, I would spend 4 hours a day seeing patients and 4 hours each day on the phone with the insurers or the medicare representatives. The only reason that my phone time was even this short was that Jenny (office nurse and manager) would handle the bulk of the approvals needed and arguing for patient reimbursement.
After 4 years of Medical school, a year of medical internship, 2 years of Medical residency, 3 years of Dermatology residency, a year of Psychiatry residency and a year of Plastic surgery and then 40+ years of experience in private practice - I just felt it too difficult to have to argue with some young lady on the phone who was popping gum while she spoke in order to provide proper medical care to my patients.

[Kepler]

This is why we now only do consulting work. And anything we do or anyone we see is all pro bono. i like to still diagnose and prescribe but fortunate that after 50+ years I can provide any care free.

You rock, man. You. Rock! :-)

[Swansong]

This is why we now only do consulting work. And anything we do or anyone we see is all pro bono. i like to still diagnose and prescribe but fortunate that after 50+ years I can provide any care free. Before we did this, I would spend 4 hours a day seeing patients and 4 hours each day on the phone with the insurers or the medicare representatives. The only reason that my phone time was even this short was that Jenny (office nurse and manager) would handle the bulk of the approvals needed and arguing for patient reimbursement.
After 4 years of Medical school, a year of medical internship, 2 years of Medical residency, 3 years of Dermatology residency, a year of Psychiatry residency and a year of Plastic surgery and then 40+ years of experience in private practice - I just felt it too difficult to have to argue with some young lady on the phone who was popping gum while she spoke in order to provide proper medical care to my patients.

And that's the worst part. You'll never speak to the person that made the decision. You'll never speak to the person that designed the actuarial table, or the adjuster/case manager that (allegedly) read through your Utilization Review or clinical notes. You'll get that front-end person that, however well-meaning they may be, has no idea why your procedure is being denied and can provide no real help to you or the patient.