Tuesday, June 24, 2008

HR 676 and it’s problems

This is my critique of the current HR 676-Conyers/Kucinich bill in the House creating UHC.


(a) In General- All individuals residing in the United States (including any territory of the United States) are covered under the USNHI Program entitling them to a universal, best quality standard of care. Each such individual shall receive a card with a unique number in the mail. An individual’s social security number shall not be used for purposes of registration under this section.

I would like to see this changed to say: …All individuals LEGALLY residing in…


(a) In General- The health insurance benefits under this Act cover all medically necessary services, including at least the following:

(4) Emergency care.

(c) No Cost-Sharing- No deductibles, copayments, coinsurance, or other
cost-sharing shall be imposed with respect to covered benefits.

I would like to see a provision added that would provide for a substantial penalty, copay, fine (call it what you will), for visiting an emergency room in a non-emergency situation.


(a) Requirement To Be Public or Non-Profit-

(1) IN GENERAL- No institution may be a participating provider unless it is a public or not-for-profit institution.

Why? What is the fear from any clinic/hospital being a for profit?


(a) Establishment of Operating Budget and Capital Expenditures Budget-

(1) IN GENERAL- To carry out this Act there are established on an annual basis consistent with this title–

(C) reimbursement levels for providers consistent with subtitle B

No different than the current system of government price controls.


(c) Capital Expenditures Budget- The capital expenditures budget shall be used for funds needed for–

(1) the construction or renovation of health facilities; and

(2) for major equipment purchases.

Who would be eligible for these funds? Would it only be government owned facilities or would any facility be able to get money for these purposes? Who would decide who needed improvements and who didn’t? Lot’s of room for pork-barrel spending here.


(a) Establishing Global Budgets; Monthly Lump Sum-

(2) ESTABLISHMENT OF GLOBAL BUDGETS- The global budget of a provider shall be set through negotiations between providers and regional
directors, but are subject to the approval of the Director. The budget
shall be negotiated annually, based on past expenditures, projected
changes in levels of services, wages and input, costs, and proposed new
and innovative programs.

“Global budget of providers set through negotiations”? Does this mean the government is now going to mandate the operating budgets of private businesses? How much closer to socialism, no communism, can you get?


(b) Three Payment Options for Physicians and Certain Other Health Professionals-

(1) IN GENERAL- The Program shall pay physicians, dentists, doctors of osteopathy, psychologists, chiropractors, doctors of optometry, nurse practitioners, nurse midwives, physicians’ assistants, and other advanced practice clinicians as licensed and regulated by the States by the following payment methods:

(A) Fee for service payment under paragraph (2).

This seems to say that only individual providers, not hospitals or clinics, are eligible for the “fee for payment” option. Why can organizations such as hospitals and clinics not be paid on a fee for service basis?


(b) Three Payment Options for Physicians and Certain Other Health Professionals-


(A) IN GENERAL- The Program shall negotiate a simplified fee schedule that is fair with representatives of physicians and other clinicians, after close consultation with the National Board of Universal Quality and Access and regional and State directors. Initially, the current prevailing fees or reimbursement would be the basis for the fee negotiation for all professional services covered under this Act.

(B) CONSIDERATIONS- In establishing such schedule, the Director shall take into consideration regional differences in reimbursement, but strive for a uniform national standard.

How is this any different at all from the current Medicare/Medicaid system? You still have the government dictating to providers how much they will be paid for each of their services. How does this in anyway prevent the current situation from happening wherein the provider receives payment for services that is below what it costs to provide the service? You say I cannot compare the newly proposed system to the current Medicare/Medicaid system, yet this part of the bill tells me that comparing the two systems is comparing apples to apples, period.


(b) Three Payment Options for Physicians and Certain Other Health Professionals-


(A) IN GENERAL- In the case of an institution, such as a hospital, health center, group practice, community and migrant health center, or a home care agency that elects to be paid a monthly global budget for the delivery of health care as well as for education and prevention programs, physicians employed by such institutions shall be reimbursed through a salary included as part of such a budget.

Explain to me how this does not say that I, as an RN and employee of a hospital, will have my salary mandated by the government through the budget control process pointed out above? I, as a professional, do not want any government controls placed on what I am allowed to make. How is this better for me than where I am now, where I negotiate a salary for myself? Not all nurses do this, of course. I am able to because I travel as a nurse. I work for a company that finds nursing openings in areas of the country where I want to go and in the type of units I work in. A salary is then negotiated between the hospital, my employer and myself. There is a contract involved spelling out all the details. Will this new system put this entire industry out of business? Why should I not have the FREEDOM to decide how I wish to make my career and how much I can make?


(a) Negotiated Prices- The prices to be paid each year under this Act for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Program.

(b) Prescription Drug Formulary-

(1) IN GENERAL- The Program shall establish a prescription drug formulary system, which shall encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.

(2) PROMOTION OF USE OF GENERICS- The formulary shall promote the use of generic medications but allow the use of brand-name and off-formulary medications when indicated for a specific patient or condition.

Explain to me how this is any different than the current system that both the government programs and private insurance companies use now? Read my forum topic entitled “Universal Healthcare Won’t Work” for my discussion of my personal experiences with this very point. Also, who is to make the decision as to what is medically necessary? Will it be as it is now with non-medical business people making that call for every claim? How does this make any sense? On this point, the bill is way too generalized and open to interpretation.


(c) Funding-

(1) IN GENERAL- There are appropriated to the USNHI Trust Fund amounts sufficient to carry out this Act from the following sources:

(B) Increasing personal income taxes on the top 5 percent income earners.

(C) Instituting a modest and progressive excise tax on payroll and self-employment income.

Why only the top 5%? Why not simplify the tax code as has been discussed with a flat tax and appropriating a portion of this? Also, I have concerns in subparagraph C of the use of the word progressive. When it comes to money and accounting, progressive means gradually increasing. To what point? Until the budget can be met?


(c) Funding-

(3) ADDITIONAL ANNUAL APPROPRIATIONS TO USNHI PROGRAM- Additional sums are authorized to be appropriated annually as needed to maintain maximum quality, efficiency, and access under the Program.

Where shall these additional funds be appropriated from? More additional taxes? I thought one of the lynch pins of the argument for single-payer, universal healthcare was that it could be done by spending even less than what we do now? Comparisons are always made to countries who have UHC and how they spend less than we do? So why the need throughout this entire section about the need for additional revenue to pay for the program?


(c) Regional Office Duties-

(1) IN GENERAL- Regional offices of the Program shall be responsible for–

(A) coordinating funding to health care providers and physicians; and

(B) coordinating billing and reimbursements with physicians and health care providers through a State-based reimbursement system.
Again, how is this any different from the current system wherein states are required to administer the federal program? Talk to any state legislator about how big a bite is taken out of the state’s budget to administer federally mandated federal programs. Shouldn’t a new, comprehensive reform to the healthcare system relieve the states of at least some of the fed’s unfunded mandates?


(d) State Director’s Duties- Each State Director shall be responsible for the following duties:

(2) Health planning, including oversight of the placement of new hospitals, clinics, and other health care delivery facilities.

(3) Health planning, including oversight of the purchase and placement of new health equipment to ensure timely access to care and to avoid duplication.

Why should the government (any government state, federal or local) be in control of how a hospital may wish to expand their offerings? How is the government in any better position to decide whether or not an area can support a hospital expansion? Would a hospital expand their facility if their market could not support it? Are the people running hospitals that bad when it comes to running a business? Where is your precious freedom of choice if the government is going to ration the availability of services?


(e) First Priority in Retraining and Job Placement; 2 Years of
Unemployment Benefits- The Program shall provide that clerical,
administrative, and billing personnel in insurance companies, doctors
offices, hospitals, nursing facilities, and other facilities whose jobs
are eliminated due to reduced administration–

(1) should have first priority in retraining and job placement in the new system; and

(2) shall be eligible to receive 2 years of unemployment benefits.

I see no provision for how exactly this will be funded. Will these people then be bumping the people who are already enrolled in these programs or who become eligible in the future? If not, then there must be a new funding source for this section. Has there been any investigation done to determine what just this will cost?


(a) Establishment-

(1) IN GENERAL- There is established a National Board of Universal Quality and Access (in this section referred to as the Board’) consisting of 15 members appointed by the President, by and with the advice and consent of the Senate.

(2) QUALIFICATIONS- The appointed members of the Board shall include at least one of each of the following:

(A) Health care professionals.

I would like to see some kind of provision here that this will include those people ‘on the front lines’, not just management. Were you aware that the organization of nurses in supervisory positions (AONE, American Organization for Nurse Executives) is a subsidiary of the American Hospital Association? Therefore, the people involved in nursing leadership may not actually represent the needs of the majority of working nurses. This must be addressed.

Bottom line is this, yes I have read the bill, but I cannot support it in it’s current form. To gain my support, and others in my position, these weaknesses I have pointed out must be addressed. Secondly, without reform to Malpractice Litigation Reform as a part of this type of system, I will NEVER be able to support it. I am for COMPREHENSIVE reform of the healthcare industry, NOT band-aids and quick fixes. I see a start in the right direction here, but much more needs to be done. However, you and I both know that as an individual working class American, my voice will NEVER BE HEARD, no matter who the candidate or office-holder is. We can discuss and debate and iron out the kinks here all day, but what we discuss here will not be taken into consideration. I would welcome the opportunity to sit down and discuss these points with someone who can actually do anything about it, but alas, that will never happen. This when I currently live INSIDE the DC beltway, albeit in Virginia. I am sincerely hoping I am wrong on this point and we really are being listened to. I think any politician who could admit to not knowing everything and be open to discussing things with ‘commoners’ would be a REAL breath of fresh air.

My final point is this. I do think that nurses salaries need to be brought more in line with the job we do, however with the government (AKA Congress) setting salaries, this will never happen. How many doctors and laywers are in congress vs. nurses? You do the math.

I sincerely hope that I am coming across as discussing these points with respectful disagreement. If I come across any other way, please know this hope is my intent. I mean do disrespect or disregard for anyone else’s opinion and I sincerely hope others can view my opinion likewise.

Tuesday, February 5, 2008

Who am I?

I decided to tell you all a little more about myself. I will do this by talking about my oldest son, who comprises a large part of who I am. While I do work as a PICU RN, this is my career and not who I am as a person. My family, and especially my sons, define who I am as a person. So, without further adieu, allow me the honor of telling you about my Andy, the one on the right in the black shirt on my sidebar.

Andy is 5 years old born in May of 2002. My wife and I had tried to have a child for 7 years before Andy came along. We had visited infertility doctors and had reached the point in the spring of 2001 where they had told us that our only chance of having children would be either in-vitro or the injectable drugs that seem likely to produce multiple births. Throughout that summer, we talked about it, prayed about it and finally, in October of 2001 agreed that we could have a full life together without a child of our own. Perhaps we would look in to adopting, we even discussed. What we didn't know at the time was that we already had one of own on the way. My wife has something called polycystic ovarian syndrome, or PCOS. Not only did it make it difficult to get pregnant, but it also causes her to have very irregular cycles. Like only 3-4 a year. Therefore, Andy didn't make his presence known to us until mid-November of 2001. We, of course, were very excited but Andy wasn't finished surprising us yet.

We went through all the 'normal' experiences of being pregnant. Doctors visits, blood tests, ultrasounds, etc. Then in December, right before Christmas, we got one of those classic phone calls from the doctors office. It seems there was a positive blood test that needed further testing. Seems the MAFP level was elevated in a blood test. Of course, at the time, we had no idea what this meant. All that we were told on the phone that day was that it could mean nothing at all, could mean down syndrome, could mean ....... Basically, until we were able to get an ultrasound done, in January, we wouldn't know what, if anything, it meant. So we spent Christmas wondering if there was something wrong with the baby.

Finally, January came and we had an ultrasound done. The ultrasound showed signs of something call an 'open neural tube defect'. We had no idea what this meant. We met with a 'genetic counselor', who again gave us a wide range of possibilities. From a child that no one could tell had any problems all the way to a baby that only survived for a few hours after birth, and a whole bunch in between. As the shock of this was setting in, we were asked for immediate decisions on two things. First, would we allow them to do an amniocentesis in order to confirm the diagnosis. This one was an easy yes, even with the risks involved. We needed to know something concrete. Then, the 'counselor' kept asking us over and over again whether or not we wanted to terminate the pregnancy. No matter how many times or how many ways we told her "no, even with the possible problems, we will not abort', she kept on asking. She said later that we seemed overwhelmed and that was why she kept asking. Since when does being overwhelmed with finding out that your baby is not going to be 'perfectly' healthy translate into wanting to abort your baby?

So, then another 2 week wait for the results of the amnio. When the call came, it was confirmed our fears. It was positive for an 'open neural tube defect'. What did this mean. Again, anything from only living a few hours after birth to significant physical disability to not even being able to tell. Again, a huge range of unknowns, a theme that will follow throughout Andy's life story. They also asked if we wanted to know the sex of the baby. We originally wanted the traditional surprise at birth, but decided that since we now had this whole new host of unknowns, we wanted to know the sex so we could name him and also so that we would at least know one thing for sure. We found out he was a boy and gave him our previously decided 'boy name' of Michael Andrew, and we would call him Andy. As an aside, we used his middle name and wanted his 'legal' name to be M. Andrew. Don't make this mistake, it doesn't work well. Right now, he is Michael A. to most people, but on my insurance, they dropped the M. and he is listed just as Andrew. Explain that to the billing people at the doctors office!!

So, we drifted along not knowing his future for the next 4 months. Many more doctors visits, an ultrasound every week and more and more tests. They were able to determine that he had the form of 'open neural tube defect' commonly known as Spina Bifida, so we went to work on the internet. We learned all we could about Spina Bifida, yet still would not know where in the range he would fall. The range ran from no one would be able to tell to totally wheelchair bound with lots of issues. Again, the range of unknown.

Finally, we made it to May and had a prescheduled C-section scheduled for June 9th. Since Spina Bifida is where a part of the spine grows outside the body, they usually recommend a c-section to prevent further damage to the spinal cord during birth. At our now twice weekly (we lived an hour from the hospital) appointment and ultrasound with our new OB on May 23, 2002, we had yet another surprise. New OB because we now had to see a high-risk specialist. She finished the ultrasound and stated she wanted to do another amnio to determine lung development and see if we needed to go earlier. The amnio was done and we went home to wait. We no sooner got in the door and the phone was ringing. My wife answered it and, thinking sooner meant in a week or so, was shocked at what she heard. The doctors exact words were "He's fully cooked! Be here at 7 am tomorrow morning". TOMORROW MORNING?!?!?! We were not ready for it to be that soon! We called our parents and told them Andy's birthday had changed. They were shocked as well.

Well, the day finally came. We were at the hospital at 7 AM as scheduled and Andy was born at @ 9:00. He was immediately taken to the NICU as we had expected. The neurosurgeon we had met in the past few weeks came in to the recovery room to meet with us and have us sign the consent for Andy's first surgery. This surgery would repair the defect in his back and protect the spinal cord from further damage. I was able to go and see him in the NICU that first day, but my wife wasn't allowed to. The staff on the post-partem unit would let her leave the unit and go to the NICU. Andy was taken in to surgery the following morning at the ripe old age of 23 hrs. We waited in my wife's hospital room. After a couple hours, the neurosurgeon and the anesthesiologist came in to the room. Seems there had been a 'minor' complication. During the surgery, Andy had an 'episode' where his heart rate got dangerously low requiring a dose of epinepherine to correct. They had actually stopped the surgery on his back, turned him over and were prepared to start CPR. Luckily, the Epi worked and they were able to turn him back over and complete the surgery. They believed the episode occurred because of 'positioning'. This did concern us a bit, but we decided thats alls well that ends well.

Andy recovered from the surgery and we went home after 6 days in the hospital. We had no idea what the future would bring except that we would be seeing many different doctors and specialists. All we knew for sure is that we would handle whatever we had to. What else would you do for your child. Tomorrow, I will post about what Andy has had to deal with since coming home from the hospital. A little hint, he has been back a total of 15 times since birth.

Saturday, January 19, 2008

New memo from Admin

Ran across this at a website on medical/nursing humor. It is quite extreme, but is it really anymore extreme than some of the real ones that are seen everyday?


To: All Hospital Employees

From: Administration

Effective immediately, this hospital will no longer provide security. Each Charge Nurse will be issued with a .38 caliber revolver and 12 rounds of ammunition. An additional 12 rounds will be stored in the pharmacy. In addition to routine nursing duties, Charge Nurses will patrol the hospital grounds 3 times each shift. In light of the similarity of monitoring equipment, the Critical Care Units will now assume security surveillance duties. The unit secretary will be responsible for watching cardiac and security monitors, as well as continuing previous secretarial duties.

Food service will be discontinued. Patients wishing to be fed will need to let their families know to bring them something, or make arrangements with Subway, Dominos, Wendy's, or another outside food preparation facility, prior to mealtime. Coin-operated telephones will be available in the patient rooms for this purpose, as well as for calls the patient may wish to make.

Housekeeping and Physical Therapy are being combined. Mops will be issued to those patients who are ambulatory, thus providing range of motion exercise, as well as a clean environment. Families and ambulatory patients may also register to clean the room of non-ambulatory patients for discounts on their bill. Time cards will be provided to those registered.

Nursing Administration is assuming the grounds keeping duties. If a Nursing Supervisor cannot be reached by phone or beeper, it is suggested to listen for the sound of the lawn mower, weed eater, or leaf blower.

Engineering will also be eliminated. The Hospital has subscribed to the Time-Life series of "How to..." maintenance books. These books may be checked out from Administration. Also, a toolbox of standard equipment will be issued to all Nursing Units. We will be receiving the volumes at a rate of one per month, and have received the volume on basic wiring. If a non-electrical problem occurs, please try to repair it as best as possible until that particular volume arrives.

Cutbacks in Phlebotomy staff will be accommodated by only performing blood-related laboratory studies on patients already bleeding.

Physicians will be informed that they may order no more than two (2) X-rays per patient per stay. This is due to the turn-around time required by the local Photomat. Two prints will be provided for the price of one and physicians are encouraged to clip coupons from the Sunday paper if more prints are desired. Photomat will also honor competitors coupons for one-hour processing in an emergency. If employees come across any coupons, they are encouraged to clip them and send them to the Emergency Room.

In light of the extremely hot summer temperatures, the local Electric Company has been asked to install individual meters in each patient room so that electrical consumption can be monitored and appropriately billed. Fans may be rented or purchased in the Gift Shop.

In addition to the current recycling programs, a bin for the collection of unused fruit and bread will soon be provided on each floor. Families, patients and the few remaining staff are encouraged to contribute discarded produce. The resulting moldy compost will be utilized by the pharmacy for nosocomial production of antibiotics. These antibiotics will be available for purchase though the hospital pharmacy, and will, coincidentally, soon be the only antibiotics listed in the hospital's formulary.

Although these cutbacks and changes may appear drastic on the surface, the Administration feels that over time we will all benefit from this latest cost cutting measures.

Maybe I shouldn't post this. It may give some admin-types too many ideas.

Original Source

Wednesday, January 16, 2008

Moving Day

I had previously hosted my blog on Wordpress. Today, I have decided to move it here as blogger has more of the features I am looking for. It seems to be much more open to my own personal touches, so here I am. I will move all of my old posts here as well. That will take a bit of time, then I will be on to new posts. I promise to post more regularly, as least every few days.