Hospital visitors

When I am hospitalized, I have a list of people who can visit me. They include my husband, my parents, and my siblings. Anyone else has to call and ask. I am serious about this. If people visit unannounced, they will find out how rude I can really be.

My strong feelings about this are due to the fact that once, after a significant surgery, a friend had to stop at the hospital for an early morning appointment, the day after my surgery. So she decided to stop by my room at 830am. I was not ready for guests.

I was talking to someone who was a friend and a nurse who was giving me some information. I did not want to socialize. She didn't understand the concept of good manners and to think that the morning after major surgery might be a bad time to visit someone.

When I am in the hospital:

1. I probably feel like crap.
2. I probably look like crap.
3. I am probably cranky.

Its not that I don't want visitors at all - they do help the time go by - but my goal is to get better enough so I can leave as soon as possible. If I can't get my naps in, I won't be able to get better.  I find the concept of visiting people in the hospital for hours on end to be a bit ridiculous.

I actually feel sorry for the patient's whose families come to visit and stay for hours in big groups. If you are sick enough to be in the hospital, you don't want to host a party, you probably want to take a nap.

There is a hospital in Hawaii which has started the policy of visiting hours 24/7 and let the patients set their visiting times. This was done at patient request citing a study that found that people surrounded by family and friends heal faster and cope with their hospital stay better.

At first I was pretty appalled by this. But then I started to think.

There are lots of people who work odd shifts or have child care issues or travel distances or work nights and I can go on and on that have off hour schedules normally and are used to getting a lot of sleep during the day wherever they are so why should hospital visitation be any different?

Hospitals are where they wake you up for a sleeping pill or to take your blood and vital signs at 2am. So you might as well have a friend hang out with you for it.

So are you an inpatient or an outpatient?

The hospital and Medicare get to decide. Not your doctor who is actually treating you.

I found this pretty appalling. Medicare patients can be in the hospital for DAYS and be called and an outpatient because they are only being 'observed'. They get the same care as everyone else. But then they get a big fat bill if they were an outpatient.

Their doctor can even admit them and make them an inpatient but then the hospital can change it back to outpatient. Hospitals like this because they get reimbursed more that way.

"Medicare originally intended observation care as a way to give doctors time to evaluate whether a patient should be admitted to the hospital or is stable enough to go home, usually within 24 to 48 hours. But hospitals are increasingly keeping patients in observation status longer: 8 percent of Medicare recipients had observation stays longer than 48 hours in 2011, up from 3 percent in 2006.
Apparently the government can tell by looking at a rule book to figure out how sick you are, not but diagnosing you and reading your chart. Or, God forbid, even talking to you.

That increase may partly be a response to aggressive reviews of hospital billing practices in recent years. Medicare contractors have demanded refunds from hospitals that admit patients the government believes should have been treated as observation patients or outpatients. Medicare pays hospitals less for those patients."

And also hospitals are now rated on their readmission rates. If you aren't admitted the first time, you are not readmitted later on.

"Toby Edelman, senior policy attorney at the Center for Medicare Advocacy in Washington, D.C., said she believes hospitals also could be trying to avoid readmission penalties, which are assessed if too many patients are readmitted within 30 days. Harold Engler, for example, went home after five days, grew sicker, and then returned for another five-day observation stay. If he had been an inpatient, he would have counted as a readmission within 30 days."

Hospitals claim they are working on it because they computer tells them what to do. The computer even knows more than the government:

"Dr. James Hart, who heads a Beth Israel Deaconess committee that makes sure the hospital follows Medicare rules, said he could not comment on Engler’s case. But he said the hospital uses a sophisticated computer program that tries to match patients with the correct Medicare designation based on their illness and the intensity of hospital services required. “We are very focused on getting the level of care accurate,’’ he said."

Medicare knows this is a problem and even has created a brochure on this telling patients the difference. But if you are sick in bed, do you really care about semantics? No.

"Case managers generally inform patients of their status, especially if they require skilled nursing care, he said. But that doesn’t mean patients digest the information, at a time when they have so much to focus on. “Part of the challenge from a patient perspective is there really is an information overload,’’ Hart said."


You just want to feel better and go home where you can be in your own bed eating real food instead of the crappy hospital food they serve.

I knew Medicare had its issues but I didn't think it was out to impoverish seniors. I thought it was supposed to be the other way around. Clearly some changes need to be made here.

Update: 8/30/13 - One of the former heads of Medicare wants the rule on observation to be abolished.

Why don't have I have a patient navigator?

I need a patient navigator. The idea behind a patient navigator is to help newly diagnosed people deal with the mysteries of all these new doctors, treatments, and help them through the process by being there as the go-to person. Its part of the new patient centered care which is a great idea.

An experienced person is assigned to a newly diagnosed person. The experienced person can be someone who simply is more familiar with the hospital and how it works or can be someone who has been through the same ailment (s).

My health is complicated and I have lots of doctors so why don't I get a patient navigator? I think the real answer is that no one else has the same set of ailments as me. I know a couple people who have had both breast and thyroid cancer. I know other people with RA. I am not sure I know anyone else with fibromyalgia, yet - I am sure that will change.

The odds of getting breast cancer in a woman's life time is 12.4%
I couldn't find the odds of getting thyroid cancer but if there are 60,000 cases diagnosed in the US this year and which is about 1/4 the rate of getting breast cancer so we'll say its about 3.1%.
Fibromyalgia affects 2-4% of the population
Rheumatoid is diagnosed in an average of 41 of each 100,000 people.

If we do all that math the answer is three people. 0.124*0.031*0.04*41*3139.14=19.15 (see below for update)

What I did is 12.4% chance of getting breast cancer times 3.1% chance of getting thyroid cancer times 4% chance for getting fibromyalgia times those 41 RA patients in each 100,000 times 3139.14 for the 313,914,040 residents of the US.

So somewhere there are 18 other people who might be like me.

The other reason I don't have a patient navigator is I know the hospital I go to better than a lot of employees. I  have been a patient there since 1981. It opened in its suburban location in the late 1970s. I run into people there who say I have been here since the 1990s. But then I tell them about the hospital before the first renovations when we all checked in at the front desk in a big line. Anyone who worked there when I started going there has since retired.

This is why I don't have a patient navigator.

I guess I have to suck it up and figure it out on my own. I'm not very good at the sucking up part.

*Update on 4/11 I found that the lifetime risk of thyroid cancer is 1.03%  so that changes my little formula to 41*0.124*0.0103*0.04*3139.14 or 6.575268. So somewhere else in the US there might be 5 and 1/2 other people like me.

Secrets of medical costs

Someone referred me to this article which I read with great interest. First I started with this video:

Then I read the article called the "Bitter Pill: Why Medical Costs are Killing Us"

FInally I watched the second video where the writer answers questions on reactions to this story:

So where does all this education leave me? I am not as smart as I thought I was.

All along I was blaming high medical costs on pharmaceutical manufacturers who were passing on the research costs long after they were paid to the patients through high drug payments. I was blaming insurance companies for high insurance premiums, denial of claims for stupid reasons, and general ignorance.

I did not know that hospitals are a big part of the problem with their secret lists, huge mark ups, and high profits - even if they are non profit. They hide behind the HIPAA laws on patient privacy to hide their 'chargemaster' list of billing amounts.

There is also the issue of the standard CYA tests ordered by doctors out of fear of lawsuits instead of best treatment for the patient. But that is another blog post.

My take away from these videos and article is that our health care system is more messed up than I previously thought. People are getting rich at the costs of the poorest people or the ones forced into bankruptcy due to medical bills. More action needs to be take in this area.

While the Healthcare Reform Act focuses on getting insurance and medical care for more American's, it does not go far enough in addressing the financial side of patient billing and who pockets the money at the end.

The unsung heroes of modern medicine

We need to take a minute to remember a few things about our medical care. We see our doctors and nurses but what about everyone else?

• If you go to the doctor for a routine appointment, there is a receptionist and nurse and a doctor at the minimum.
• If you are sent for blood work, there is also the lab tech who draws your blood but also the people in the lab who test your blood.
• If you get an x-ray, there is the person who takes the x-ray plus the radiologist who reads them. Plus there are the people who maintain the machines.
• If you go for chemo, there is a receptionist, a nurse to take your vitals and draw blood, a medical oncologist to review your blood counts and recommend chemo doses, the nurse who gives you the infusion, the pharmacist who got all your meds ready.
• If you go for radiation, there is a receptionist, a radiation tech who gives you the radiation, a radiologist who reads your latest CT scan, a nurse who checks in on your and your radiation oncologist who supervises your care.
• If you have an operation there is an anesthesiologist, several nurses, assistant surgeon, etc.
• If you come to the hospital in an ambulance, there will be some EMTs, trauma nurses, a social worker, maybe a respiratory therapist, and more.
• What about residents in training, hospitalists who manage your care why you are an in patient?
• Never mind everyone else at the hospital or medical center who make the food, clean the rooms, coordinate care, schedule procedures, (wake you up to take your vitals in the middle of the night), and more.

Modern medicine is no longer about you and your doctor and the nurse. There are many other people who work to make sure everything is running correctly and patients get the care they need.

We often forget those in the background. This article made me remember them all. We shoudl take a moment to thank them all.

Best hospital - what does that mean?

US News and World Report just announced the 2012 listings of the best hospitals. There is a big hoohah going on about this year's listings as Mass General has replaced Johns Hopkins as the best hospital in the country for the first time. The listings starting in 1990 and JH led the list for 21 years. Well, yip-dee-doo-dah! What does this really mean?

Seriously? If a book is the top seller they can quantify this by looking at the numbers of copies sold. But how do you do this for hospitals? Obviously you can look at death rates, ratios of nurses to patients, readmission rates, etc.

US News states:

"Best Hospitals' central mission remains unchanged: to help those who need an unusual degree of skilled inpatient care decide where to get it, especially when there's time to make a choice. Other ratings and rankings typically examine how well hospitals perform fairly routine procedures, such as hernia repair and uncomplicated heart bypass surgery, and how successfully they manage relatively unthreatening conditions such as mild heart failure. That's fine for most hospital patients—in any given year, hardly anyone who visits a hospital spends a single night there. (There are about 20 outpatient visits for every hospital admission.) But for patients whose surgery or other care poses a technical challenge, or whose age, physical condition, or infirmities multiply the risk, good may not be good enough."

They then go on to talk about number of procedures, teaching hospitals, and more. I am not sure that I would switch hospitals based on a magazine article. Where I am treated is #7 in the state. There are six better hospitals in Boston but that involves traffic, expensive parking, breaking in new doctors, finding my way to different departments with out a road map, and all sorts of other complications.

Maybe if another icky cancer showed up, I might stop by the top rated cancer hospital and see if they have anything life saving to tell me that my #7 hospital is too far in the suburbs to know.

Hospital advertising

I have wondered why hospitals seem to spend more and more on advertising. Radio, tv, bill boards - they seem to be increasing more and more. I haven't figured this out until light dawned on me - some marketing person or advertising executive convinced them they needed to advertise.

Let's take a poll here - who chooses their medical care based on a billboard or tv ad? One vote here for no. I put a little bit more research into it than that. I might ask my doctor, ask friends and family, consider how long the drive would be (because of my inherent laziness), and maybe even go look at their websites.

This morning while watching the news, an ad came on for some hospital explaining breast tomography and how good it was at detecting tumors. So therefore you should go there for breast tomography. But they forgot the important point of why tomography - is it instead of mammograms? Or if you have a 'bad' mammogram? It didn't entice me to go there at all.

The news was just interrupted by a commercial advertising another hospital's cancer center. Every hospital seems to be advertising their cancer center more and more. Why, do they expect us all to be diagnosed and come running to them for treatment because we saw them on TV or on a billboard? Cancer center's seem to be the latest fad in hospital advertising. Everyone is getting one.  So it becomes an unending game of one-upmanship.

I am  a marketing person so I understand there can be many purposes to advertising - image enhancement or promotion for a sale or event. If they are focusing on enhancing their image, I'm not sure that tv ads are a good way to spend the money. TV ads are expensive to start - you need a budget that is a upper five figures to start. Maybe they could spend some of that money on patient care instead of advertising.

Hospital parking

Yesterday I went to another hospital - not as a patient. I was there to staff a table at a community wellness day. It was full of all sorts of free screenings - PSA, skin, thyroid, cholesterol, diabetes, blood pressure, cardiac monitoring, balance testing (I passed that one) and many more. It was a nice event and I thought it was productive - meaning it created more follow up work for me. (Even though they had a continuous loop going from a camera from a colonoscopy - thank GOD I was not right across from that!)

One of the big patient peeves where I am treated are the parking fees for the garage. They are $2 for the first hour, $5 for up to 3 hours, and then $8 for 3-24 hours. The goal is always get in and out in less than an hour. Everyone complains about the parking fees because it used to be free before there was a garage and only a giant lot where you had to walk for miles to get back to the main entrance.

But at this other hospital, where half their parking is in a lot along side of the highway out in the suburbs (read 'giant snow filled parking lot in the winter where you have to figure out which bump is your car and then dig it out before driving home'), has higher parking fees. The list started at 0–½ hour - free, ½–1 hour: $4, 1–2 hours: $6, 2–3 hours: $7, and 3–24 hours: $8

Your basic doctor appointment is going to last an hour-ish by the time that you get in and out and sit around the waiting room, so unless you are lucky enough to get in and out in 30 minutes (doubtful), you are probably going to pay $6 for the privilege of parking. If you want to go to a fancy hospital in Boston, parking is more. $8 for the first hour - ow! 

I for one don't mind the parking fees. Its expected these days to have to pay to park anywhere close to where you want to be. I still live in a town without parking meters up and down the main road but I am sure this will change. We have stupid parking lots with those little machines we love to hate - put in quarters only for a little slip of paper you need to walk back to your car to put on the dash board. Half the time they are broken so you have to leave a little not for the parking ticket man so he doesn't leave you a ticket.

Really I am just not a huge fan of hospital parking. I spend entirely too much time in the parking garage at the hospital anyway. I am down to only  a couple of appointments each month right now but still its too many.