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How teamwork is essential in the emergency department

Kevin — Thu, 12 Nov 2009 12:37:06 PST

by Edwin Leap, MD

I recently cared for a patient who raised my heart-rate a bit. Of course, any emergency physician will tell you, the potentially difficult and complicated cases often come at the end of the shift, as you’re trying to clean up all of the paperwork and ‘head for the house.’ Nurse Ginger came to me and said, ‘we need a doctor in room 11.’ I snarled, snatched the paper, grumped and gruffed and marched off to see the patient who had so selfishly interrupted my planned escape. (Disclaimer: I later apologized to the very correct Ginger, who had every reason to come and get me.)

Facing me was a woman in her 60’s with a tongue the size of my nurse’s head. Well, not quite, but it was sufficient to fill her entire mouth. This, of course, can sometimes be incompatible with the passage of air into the lungs, oxygen into the bloodstream and therefore, life itself.

She was breathing well, all things considered. Of course, she couldn’t speak. The swelling had been increasing over the previous six hours. For the non-medical, she exhibited signs of a syndrome called angioedema. In her case, hoof-beats usually being horses, the symptoms were probably caused by a drug called lisinopril, belonging to a class of anti-hypertensive drugs called angiotensin converting enzyme inhibitors.

This is a condition that really gets the attention of physicians who manage airways; and especially physicians like me who have struggled with airways a few times. So, I spoke to her as calmly as possible, our nurses administered oxygen, placed an IV and put her on the heart monitor. I ordered some Decadron (a steroid), some Benadryl and some Pepcid (both different versions of antihistamines). Then I started making phone calls.

Much of emergency medicine is just that. Recognize the gravity of the situation and then sending for help. Making phone calls. Rallying the troops. Calling for reinforcements. Popping a flare. You get the picture. The thing is, she didn’t need to be intubated (have a tube placed in her airway) just yet, but she was someone who might easily take that turn and desperately need an airway placed as quickly as possible.

I called anesthesia and I called ENT. Anesthesiologists are airway experts who have very cool airway tools, like fiber-optic laryngoscopes, with which to look down the airway without stimulating it or causing more swelling. They are the kings of definitive airway management. Those of us in emergency medicine are good, too. But when a smart physician senses trouble, he lets go of his pride and calls for back-up. Or, as someone put it to me in medical school, ‘focus the glory, diffuse the blame.’

Well, my anesthesiologist friend came to see the patient, and he called our ear, nose and throat surgeon friend. You see, if worst came to worst, our nice lady might need a tracheostomy placed, and he would be the guy with the skills to do it.

Then, we called her primary care doc, who knew her very well. In the end, we all decided to leave her be, admit her to the ICU with surgical airway equipment at the bedside, and wait to see if the medicines worked. Although controversy exists about whether the medicines I ordered actually help, she started to improve a little.

When I left for home at last, she was being seen by her family doc, tucked into the ICU and was breathing nicely.

But this isn’t a lesson in angioedema. It’s about teamwork. Medicine is multi-faceted. Primary care is important and specialties are important and emergency medicine is important and nurses are critical. Anytime we discuss improving medicine, we can’t ever focus on just one aspect. Primary care physicians have unique skills and the patience of Job himself. Specialists, like anesthesiologists and surgeons, have technical abilities the rest of us lack. They also have the experience to recognize when to act; and equally important, when to pause and wait.

And emergency physicians know when to make phone calls!

So I hope that whether health-care reform happens or not, we can remember that we have excellent medicine in America because we have nurses and docs with different skills and interests, different talents and knowledge.

Without that beautiful collage of professionalism, medicine just won’t function very well.

And I won’t have anyone to call when I really need help.

Edwin Leap is an emergency physician who blogs at edwinleap.com.

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Many women report nerve-related persistent pain after breast surgery

Kevin — Thu, 12 Nov 2009 10:00:25 PST

Originally published in Insidermedicine

Nearly half of women who undergo surgery and other treatments for breast cancer report having persistent pain in and around the treatment area a year or more later, probably because of nerve damage, according to research published in the November 10 issue of the Journal of the American Medical Association.

Here is some information about neuropathic, or nerve, pain:

• It is a type of pain that occurs when a nerve is injured and begins sending incorrect messages to the brain
• It can feel like numbness, tingling, pins and needles, burning, stabbing, electric shocks, or just be very difficult to describe
• There are pain medications specifically designed to treat this type of pain

Researchers from the University of Copenhagen in Denmark sent questionnaires regarding persistent pain to nearly 4,000 women who underwent treatment, including surgery and possibly chemotherapy or radiation, for breast cancer in 2005.

Overall, 87% of the women responded to the questionnaire. Among the respondents, 47% reported having persistent pain an average of 26 months after their treatment. Nearly half had light pain only, but about 40% had moderate pain, and as many as 13% had severe pain. Overall, 20% of the women with pain had consulted a physician regarding the problem in the previous three months. Younger women, especially those who had undergone breast-conserving surgery rather than full breast removal, as well as women who underwent radiation therapy were more likely to report having pain. Younger women were also more likely to report having sensory disturbances in and around the treatment site.

Today’s research highlights the problem of persistent pain following treatment for breast cancer, which is likely due to damage that occurs to the nerves during treatment. This study demonstrates a need to more fully explore treatment techniques that protect the nerves.

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Will video cameras in the OR decrease the rate of wrong-site surgery?

Kevin — Thu, 12 Nov 2009 08:00:20 PST

by Kristina Fiore, MedPage Today Staff Writer

Rhode Island Hospital, located in Providence, will pay $150,000 and install video cameras in all of its operating rooms after performing its fifth wrong-site surgery since 2007, according to the state’s Department of Health.

The hospital will also have to open its ORs to an inspector who will observe surgical procedures and protocols for at least a year, the department said.

On Oct. 22, Rhode Island Hospital notified the Department of Health that it had performed a wrong-site procedure on a patient who was scheduled to have elective surgery on two different fingers of the right hand.

Both procedures, however, were performed on the same finger, according to a department report.

The hospital had been fined $50,000 in 2007 for errors in brain surgeries on three different patients and was reprimanded for a mistake in a cleft palate procedure last May.

In a letter to hospital CEO Timothy J. Babineau, MD, the department of health called the problem “frustrating” and said it “significantly damages the public’s perception of safety and the credibility of RI Hospital’s ability to consistently provide for safe surgical procedures.”

In a statement, Babineau said the hospital remains “committed to decreasing the frequency of medical errors including wrong-site surgery.”

Glenn Rothman, MD, chair of surgery for Banner Desert Medical Center in Mesa, Ariz., and a nationally quoted expert on the subject, said an error like the one at Rhode Island Hospital is “extremely hard to prevent” because the entire hand is dressed for surgery, and the structures are smaller and much closer together.

However, he said the overall incidence of wrong-site surgeries “appears to be unchanged, despite all measures introduced to prevent it.”

The hospital’s report of the error states that a nurse marked a straight line down the patient’s right forearm to the wrist rather than directly on the fingers because she didn’t know where, exactly, the incisions would be made and did not want to be reprimanded.

However, the surgeon did not verify the correct surgical procedures, including the site and side.

After performing both procedures on the same finger, other OR staff asked why the operation on the second finger had not been initiated. The surgeon checked with the family of the patient, and subsequently performed the surgery on the correct finger.

However, the team failed to conduct a mandatory “time out” — a protocol for confirming several surgery-related factors — between procedures, the report states.

On Oct. 26, the Department of Health issued the fine as well as the compliance order requiring every surgery at Rhode Island Hospital to be observed by a licensed clinical professional who isn’t part of the surgery team and who is trained to observe surgical site markings and time-out procedures.

That monitoring must continue for at least a year, the report states.

It also requires that every operating room at the hospital be equipped with video and audio monitoring equipment within 45 days, and that every doctor be taped performing surgery at least twice every year.

The hospital must also shut down elective surgery for one day and conduct a mandatory training and review of the uniform surgical procedures with all surgical staff.

It also has to immediately adopt and implement the state’s Uniform Surgical Safety Checklist and Standard Definition.

In the 2007 cases, neurosurgeons operated on the wrong part of the brain in three different patients.

And last May, according to a Department of Health report, a patient was scheduled for a right alveolar bone graft from the right hip to the right soft palate.

The surgeon started to operate on the left palate instead, potentially because a nurse documented the incorrect side on a written report, although the patient was marked correctly.

Rothman said the addition of cameras in the OR may do little to curb wrong-site surgeries.

“I’m not aware of any data that show that works,” he said. “Would cameras in the cockpits of planes reduce pilot error?”

Rather, a revamping of “time-out” standards from the Joint Commission on Accreditation of Healthcare Organizations’ Universal Protocol may be in order, he said.

They’ve been “diluted” to include multiple factors to assess during a time-out, while they used to focus solely on three principles — correct patient, correct site, and correct surgery, Rothman said.

“You have to simplify your checks and balances in order to make them effective,” he said. “If you’re making people pay attention to more tasks, there’s more opportunity for error.”

He noted that there is not universal acceptance that the time-out policy as it stands “prevents or reduces errors.”

The OR should also be more team-oriented, he said, with other staff feeling empowered to speak up if they notice a problem.

“Even the person who is lowest on the perceived totem pole of education and training in the room has the same responsibility to pay attention and to speak up if they have any concerns,” Rothman said. “There’s no reason a junior person can’t recognize [a mistake], but the environment may be intimidating.”

Visit MedPageToday.com for more hospitalist news.

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The decision not to test is often the more difficult choice

Kevin — Thu, 12 Nov 2009 04:00:10 PST

Ordering that head CT scan is the easy way out.

In a piece from Newsweek (via Bryan Vartabedian), Yale emergency physician Christopher Moore details a common scenario: should he order a CT scan in an asymptomatic 15-year old who was hit in the back of the head while playing soccer?

Dr. Moore encapsulates his thought process: “In a case like this, evidence shows the chance of a life-threatening injury is vanishingly small. [But] since we’re dealing with radiation, a CT scan isn’t harmless: some estimates put the long-term risk of cancer death from a single CT as high as one in 1,000—a risk that’s greater in younger patients who have longer to live.”

Cost doesn’t factor in the decision making process. There is no mention of “rationing.” The doctor is simply weighing the marginal benefit of ordering the scan versus the radiation exposure the teen will receive.

Simply ordering the scan is the path of least resistance. As Dr. Vartabedian notes, “Testing is easy. Exercising the judgment to not perform tests takes insight, experience, and confidence.”

Discussing the pros and cons with patients and their families, and coming to a shared decision – the way it should be – is difficult, and all the incentives within our health system are stacked against going down that route.

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Patients who want the H1N1 vaccine need to be triaged

Kevin — Wed, 11 Nov 2009 12:00:43 PST

by Kairol Rosenthal

I am a young adult cancer patient who waited five and a half hours for the H1N1 vaccination along with 1200 other Chicagoans in a city college hallway. I do not have the trained eye of a public health analyst, yet it was easy to spy the glaring flaws that occurred in the whimsical distribution of this short supply vaccine. One of these oversights was the absence of trained workers screening citizens to determine if they actually needed a shot.

In the midst of what the government is calling a pandemic, there was a stunning lack of triage. Anyone could wait in line and receive a shot no questions asked. The public health department merely instructed citizens to use a common sense approach: If you consider yourself high-risk, get a vaccination.

I am an extremely aggressive patient with a high level of health literacy. As the author of a book on young adult cancer, I strongly advocate for patients participating in our care and knowing our bodies. However, I am not a doctor and medical practice is not common sense knowledge. Determinations of whether a patient’s underlying medical condition puts them at high-risk for complications from influenza should have been made by trained medical professionals, not by citizens making nebulous judgment calls.

Tensions ran high in the hallway of the makeshift walk-in clinic as my linemates and I vied for low cue numbers. People cut in front of each other, police mediated shouting matches, and camera crews interviewed desperate patients. My linemates and I began discussing our ailments, each defending our high-risk need for the shot. The 51-year-old man in front of me thought he was at risk due to high blood pressure that sometimes limits his use of over the counter medications. One woman in her late fifties boasted she thought she had a predisposition for bronchitis. Were these accurate self-determinations of the need for the vaccination or were my linemates pilfering from the short supply?

A look of guilt crossed their faces when I told them I am a cancer patient. “You should stand in front of me,” the gentleman said. But who should stand in front of me? Are toddlers and asthma patients at the end of the line less needy than me, a refractory thyroid cancer patient with two incurable tumors in my neck? And did the man with high blood pressure belong in line at all?

I did not have to second-guess my decision about whether to receive a vaccination; my primary care physician recommended I get vaccinated. But many Americans do not have the luxury of access to a primary care physician. This is why we need public health workers screening patients at walk-in clinics and prioritizing risks. As we scrutinize the government about the availability of H1N1 vaccination, we also need to question the lack of discretion they are using in distributing this much needed serum.

Kairol Rosenthal is the author of Everything Changes: The Insider’s Guide to Cancer in Your 20s and 30s, and blogs at Everything Changes.

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How do people with dementia die?

Kevin — Wed, 11 Nov 2009 10:00:38 PST

Originally published in HCPLive.com

by Victor G. Dostrow, MD

Dementia is a terminal illness. However, people with advanced dementias often languish in skilled nursing facilities, far from the ministrations of specialists. And, with reasonable luck, they have directives that specify that they are not to be taken to the hospital in the event of a respiratory arrest. Consequently, most of us are not privy to the mechanisms of demise in such situations.

In the interests of demystifying this, a group of geriatrics researchers sought to prospectively study the course and concomitants of advanced dementia. They followed 323 patients, in 22 nursing homes near Boston, for 18 months. Eligible patients were identified by a variety of measures commonly already obtained on such patients. The required levels of these measures for study enrollment specify, for example, paucity or absence of speech, incontinence, and inability to walk. These were severely impaired people. The medical records were reviewed for episodes of complications such as pneumonia, eating impairment, and fevers. Other data obtained were related to “sentinel events,” evidence of distress and unpleasant interventions, and various issues regarding family members (and other “health care proxies”).

The results are instructive. The mean age of the cohort was 85.3 years old, and the median interval since dementia diagnosis was 6.0 years. 177 (54.8%) of the patients died during the 18 month study period. The median survival was 478 days, and the probability of death within 6 months was 24.7%. Probabilities for medical problems during the study period were 41.1% for pneumonia, 52.6% for an episode of fever, and an impressive 85.8% for an eating problem.

Distressing symptoms were distressingly common, and the probability increased as the patient neared death. The most common such symptoms were agitation (53.6%), dyspnea (46.0%) and pain (39.1%). The nature of sentinel events is also interesting, particularly from a neurologic perspective. 42 such events occured, of which the most common was seizure (14/42; 33.3%), followed by gastrointestinal hemorrhage (11; 26.2%) and hip fracture (3; 7.1%). Stroke also occurred in 3 patients.

During the study period, 16.7% of all patients were hospitalized and 8.0% received tube feedings. The probability of such an intervention was higher as patients neared death: Within 3 months of death, 52 (29.4%) received parenteral therapies, but fewer (12.4%) were hospitalized. In the same pre-death interval, 72 patients (40.7%) received at least one such intervention. Interventions were most common in patients with pneumonia.

Communication with family members was quite poor. At the time of the last evaluation, only 18.0% reported receiving prognostic information from a physician. Also, while 81.4% thought they understood what complications to expect, less than one third (32.5%) indicated that a physician had counseled them about this.

So, this was a rigorously undertaken prospective study. The findings quantify the high mortality rate associated with advanced dementia, and bring some clarity to the associated pneumonias and eating impairments. The mortality rate of advanced dementia is comparable to that of metastatic breast cancer. Eating problems were common, and survival shortened after onset. And, despite a goal of comfort for such patients, distressing symptoms were quite common. Interventions of unclear value were common shortly prior to death.

While these are unpleasant matters to contemplate, they are of great importance. The population is aging and dementias are becoming more commonplace. We have an obligation to provide the best possible care for people at the end of life. We don’t seem to be doing particularly well at this, however.

Victor G. Dostrow is a neurologist who blogs at The Nerve Center.

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Will the abortion restriction survive the Senate health reform bill?

Kevin — Wed, 11 Nov 2009 08:00:38 PST

Originally published in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

After a controversial amendment to restrict abortion was approved as part of the House healthcare bill over the weekend, senators are grappling with the abortion language in their legislation.

Senate Majority Leader Harry Reid (D-Nev.), who personally opposes abortion, said the issue was being negotiated.

“I expect the bill that will be brought to the floor will ensure no federal funding for abortion and that conscience rights of providers and healthcare facilities, like Catholic hospitals, are protected,” he told reporters on Tuesday.

The House on Saturday passed sweeping healthcare legislation by a vote of 220 to 215 after months of negotiations.

In the end, support from some moderate Democrats hinged on the inclusion of an anti-abortion amendment by Bart Stupak (D-Mich.) that was pushed by the United States Conference of Catholic Bishops.

The amendment would bar the government from offering abortion in its public plan, and make it illegal for private insurers who participate in the exchange from providing abortion coverage, except in the case of rape, incest or when the woman’s health is in danger.

Women in the public plan, or who have a plan through the exchange, could choose to buy a separate abortion-coverage plan using their own money.

Women wouldn’t be affected by the amendment’s provisions if they paid for their own private insurance outside of the exchange.

The amendment passed by a vote of 240 to 194, with support from 64 Democrats.

A 1977 law, known as the Hyde Amendment, already prevents use of federal money to fund abortions except in the case of rape, incest, or if the woman’s life is in danger.

However, many insurance plans provide more broad abortion coverage. According to a 2003 report from the Kaiser Family Foundation, nearly half of all employees who receive insurance from their employers have a plan that covers abortion.

Stupak said his amendment simply applied the Hyde amendment to H.R. 3962, but opponents said it would go much further.

Not only would it prevent a new public plan from paying for abortions, opponents charged, but none of the private insurance plans that participate in the exchange could provide abortions, either, because government money would pay for the creation of the exchange.

“Simply put, the Stupak/Pitts amendment would restrict women’s access to abortion coverage in the private health insurance market, undermining the ability of women to purchase private health plans that cover abortion, even if they pay for most of the premiums with their own money,” said Cecile Richards, president of Planned Parenthood, a group which is outraged over the inclusion of the amendment in the reform bill.

“This amendment is an unacceptable addition to the healthcare reform bill that, if enacted, would result in women losing health benefits they have today,” said Richards in a press release.

The Senate bill — though not released formally — uses the same language that was originally included in the House bill. That language says that at least one health plan in the exchange should provide abortion services, and at least one should not. It says no health plan would be discriminated against for its decision either way.

Moderate Republican Susan Collins of Maine said she thinks the Senate bill’s abortion language is sufficient.

“I think that the Senate Finance Committee did a good job of putting up a firewall that would prevent federal funds from being used to finance abortions,” she said. “That is in keeping with the Hyde Amendment that has been law for many years.”

But that language on abortion was added by the Finance Committee when it appeared that a public insurance plan would not be included in Senate legislation.

As Senate Leaders have worked to meld that bill with the one reported by the Health, Education, Labor and Pensions Committee, Reid has said a public plan will be a part of the final bill.

“If Congress makes the mistake of establishing a new government-owned insurance company, you would need to extend the prohibition to that [plan] because it is using federal funds,” Collins said.

Several anti-abortion Democrats said they support adding stronger language to the Senate bill to establish more restrictions on paying for abortions.

“It’s got to be clear that taxpayer funds are not being used to pay for abortion,” said Sen. Kent Conrad (D-N.D.)

Sen. Ben Nelson (D-Neb.) said he’d vote against a final bill on the floor if it doesn’t contain explicit language preventing federal money from paying for abortions. He said he’d like to see something similar to the Stupak amendment in the Senate bill.

Senate Minority Leader Mitch McConnell (R-Ky.) hedged on Tuesday when a reporter asked if the GOP was preparing a Stupak-like amendment to be considered during floor debate on the healthcare bill, which is expected next week at the earliest.

“I don’t come out here and talk Republican strategy,” he said, adding that floor debate would likely take weeks.

Meanwhile, abortions-rights senators spoke out against the inclusion of such an amendment in the Senate bill.

“To take away the rights women have had for decades — I find that very hard to believe we’d vote for that,” said Sen. Dianne Feinstein (D-Calif.)

Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, said he doubts such an amendment could garner the 60 votes necessary to be approved in the Senate.

Sen. Ben Cardin (D-Md.), told reporters he’d like to see the Stupak amendment eliminated from the final bill.

Cardin also said that he would hate to see senators draw a line in the sand over the abortion issue.

“I think most senators agree that this bill is more important than any single issue,” Cardin said.

Visit MedPageToday.com for more health policy news.

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What would dissecting Hello Kitty look like?

Kevin — Wed, 11 Nov 2009 04:00:05 PST

There’s something strangely disturbing about the anatomical imagining of cute Hello Kitty’s insides.

(via Street Anatomy and Dr. Romanelli)

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How should doctors discuss healthcare reform with patients?

Kevin — Tue, 10 Nov 2009 14:00:43 PST

Originally published in HCPLive.com

Physicians are increasingly bringing their views on healthcare reform into the examination room. Others are distributing flyers or taping up signs in the office. Given that healthcare reform has become such a contentious subject in the United States, it is not surprising that conflicts have arisen between physicians and patients who hold different views.

The St. Petersburg Times in Florida reported last month on an incident involving Jim Heltsley, a 67-year-old patient who confronted his chiropractor about a flier in the waiting area that he felt misrepresented proposed healthcare legislation. Heltsley, an acknowledged Democrat, said he had been a patient of Dr. Michael Moss, age 44, for 5 years. In recounting the incident, the two men disagreed over the tone of the ensuing discussion, but Moss admitted that he lost his temper. The argument ended when Moss threw Heltsley out of his office. Moss later sent a formal dismissal letter to Heltsley and says he will not apologize.

In an interview with the Times, Moss said he made the flier to address queries he had received from numerous patients. “I was like a mad scientist until 2 o’clock in the morning, watching this stuff on Fox News,” he said. The information from Fox and points from an anti-reform viral e-mail he received make up the bulk of the flier, which continues to sit in Moss’s waiting room.

Physicians against proposed reforms are not the only ones talking to their patients about the debate. Dr. Ari Silver-Isenstadt, a pediatrician, told the Huffington Post he placed fact sheets in his examination and waiting rooms outlining his support for health insurance reform. He said he also shares his views with his patients’ parents. Another patient recounted how his physician had taped a sign to the door reading, “Why is healthcare for all Americans a foreign concept?”

Some patients told the Huffington Post they were uncomfortable with their physicians’ comments on healthcare reform during office visits. Jim Dorsey, a 68-year-old man seeing an oncologist for the first time about his newly diagnosed prostate cancer, recounted how the physician told him, “If you were in Sweden today, they’d say you’re too old. They’d tell you to go home and die.” Other patients said their physicians told them reform would mean the end of Medicare or result in long waits “like they have in Canada.”

Dr. MJ Galceron, a physician with The Southwest Internal Medicine Specialists in Orlando, Florida, said his group avoids discussing the issue during office visits but did write to 6,000 of their patients to warn that the legislation “will harm American taxpayers and directly interfere with your healthcare.” The group also dropped its American Medical Association membership after the organization came out in support of many of President Obama’s proposed reforms.

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Doctors and patients need to learn to live with health insurance companies

Kevin — Tue, 10 Nov 2009 12:00:55 PST

by Marie Cooper

Consider two patients with the same managed care plan.

One has multiple sclerosis and receives an infusion of Tysabri every month. It needs pre-certification. The requirements are black and white. The patient qualifies if they have relapsing/remitting MS and have failed other therapies. The drug costs $2,000, the infusion center is another $1,000. The infusion center is a contracted provider that has two of their staff people dedicated to keeping track of needs for referrals and pre-authorization’s for their patients.

To the patient, this is a seamless process. She shows up every month and receives her treatment. She has no co-pay. Patient A loves her insurance plan.

The second patient had a fall and broke her right humeral head a year ago. Following an open reduction internal fixation, she has physical therapy three times a week. PT has been effective, but recovery is slow. Things are fine until the tenth week, when PT is denied, as the patient has a PT benefit of 30 visits per injury per year. The patient and the physician are incensed. This is medically necessary. The doctor has ordered it. The patient needs it. But the contract says only 30 visits will be covered. Two levels of grievances uphold the decision, it is a contractual exclusion. The patient is welcome to continue attending physical therapy. But the insurance company will not pay for it. Patient B hates her insurance plan.

Patient A and Patient B are the same person.

I use these examples to show the best of managed care and what makes people unhappiest about managed care. Managed care is designed to save money and increase profits while paying for needed care. Americans, in a culture that traditionally wants to have its cake and eat it too, has a love/hate relationship with their insurance carriers because they don’t necessarily get everything they want when they want it.

Insurance is a business and, for now, it is here. It what we have. The old days are gone and are not coming back. So I suggest the best way to cope is to deal with it.

I don’t mean that to be obnoxious. I mean deal with it in a way that is productive and emotionally healthy for doctors and patients until something better comes along.

Doctors
* Have one person (or more) in your office dedicated to dealing with managed care. Or, for practitioners with small offices, hire a part time consultant. It will pay for itself in better organized claims and increased revenue.
* Know the rules; understand that these are contracts and if something is contractually excluded, that is it, it is just not covered. It is not a malicious plot, it is a business model intended to save money, employer money and employee money. Almost all of the time, it is the employer who chooses limits in a plan, not the insurance company. And the limits are chosen to save money.
* Document everything the patient says about their condition, even if it seems innocuous or offhand. That way down the road, if something needed 6 months of conservative treatment, you have it documented. Too many progress notes simply say “no complaints” or “better”, which practically begs a denial.
* Know the criteria for your most common procedures so you can have the documentation to back up your request.

Patients
* Read your Evidence of Coverage – the book you get when you enroll. Know your benefits and their limits.
* If you don’t understand something in the EOC, go talk to your benefits rep in the Human Resources deptartment.

Remember that insurance is a business. It is not personal. If something is denied, look at your part in the process. Did you follow the guidelines? Is it a contractual exclusion?

It is not a perfect system. There is greed, carelessness and errors. It can seem complicated and capricious and unfair. But it can work.

However, if providers and insurance companies don’t work together, everyone suffers. Doctors do not receive their well-earned compensation. The insurance companies cannot sustain themselves financially because they will lose members. But most of all, it is the patient who loses the most if providers and insurers continue their hate fest.

Marie Cooper is a freelance writer and management consultant at Achievement Strategies.

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