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Comment Re:Burnt out doc here: (Score 1) 326

The HITECH Act and Meaningful Use, err, "Advancing Care Information" does not consider an EMR to be "Certified EHR Technology" and thus compliant unless it does all of the auditing and reporting tasks that the government states it must. Doctors have no use for that stuff and would not include it as it greatly hinders the usability of an EMR, thus it would never get off the ground. Also, there are very draconian federal restrictions on physicians doing anything that could be considered a medical-related business activity outside of their employment. Add to that the current oligopoly EMR vendors lobby the government heavily to maintain their legislated captive market, and you have the reasons why this does not happen.

Comment Re:If you want to get an appreciation for this (Score 1) 326

That's not even the correct use of the "subsequent encounter." Everything in billing is episode-based as Medicare is episode-based as they deal with episodes of care for bundled payments. You get struck by a baseball and go to the ED, it's an initial encounter. You develop a hematoma that needs drained 5d afterwards by your family doctor, it's a sequela. Then you go back a couple days later to get your sutures removed, it's a subsequent encounter, since you only dealt with the initial issue (laceration) and not the complication (hematoma). Also, you will need to additional code the actual condition the baseball caused (laceration, hematoma) as struck by baseball is a mechanism code and doesn't describe a particular medical diagnosis. If you get struck a second time by a second baseball, it's "initial encounter" all over again plus whatever diagnosis code the baseball injury caused.

And if your EMR is one of the two largest ones in the U.S. you can't even put in a subsequent encounter code as the EMR won't let you put in anything but initial encounter codes. Oh, and most laterality codes also only map to "left" even if there is a separate "left," "right," and "bilateral" ICD-10 code for that condition.

Comment Re:Expected 'Outcome' (Score 1) 326

And then you get a patient complaint and a crappy Press Ganey survey as the patient wanted you to bill this as a "free wellness visit" so they didn't have a co-pay, you didn't give him Soma, Dilaudid, and Xanax, and also dared to tell him to quit smoking, take evil statin medication, get a colonoscopy, and get shots, as some porno actress 15 years ago said would cause autism. Oh, and then since the patient refused their colonoscopy and the MAC didn't get billed with charges for a colonoscopy, your "quality" metric suffers and you get paid less...because you suck as a doctor. And then you get to repeat that again 20+ more times the next day, and the next day, and the next day, and the next day...

Comment Re:Brazil wasn't far off (Score 1) 326

You must be an oncologist or rheumatologist, or at least know some. The current drug class "on the outs" is clearly the statins. Even people who have had several MIs and a stroke still think that some random Guy on the Internet stating that statins cause everything from their penis flying off (as in what gluten did in the funny South Park episode) to anal leakage is much more credible than millions of patient-years of studies which clearly prove that these medications work and just about all of them are a "couple of lottery tickets a month" generics as well.

Comment Re:Burnt out doc here: (Score 1) 326

The reason they want the data was to be able to try to write heavily confirmation biased studies to try to find some "scientific" reason to try to bolster their political goals. They want to show that things they don't like such as football, wheat, GMO-containing foods, living outside of a proper giant urban area on the coasts, driving a car, being religious, or the worst of them all, owning a firearm is associated with all sorts of terrible outcomes. Their first attempt with this was to show that healthcare in the backwards flyover country and in rural hick areas is terrible and that no healthcare dollars should be spent there, and instead it should only go towards giant urban and academic hospitals in areas with a proper Democrat majority. Those studies spectacularly backfired with the giant urban and academic hospitals performing worse on most metrics than some dinky red-state place, and that those giant urban and academic hospitals which were so-called "Medicare Centers of Excellence" fared worse than average for surgical outcomes. You will see this tried with the rest of the items on my list and many others. CMS is a political body, and of course what they do is political.

Comment Re:Burnt out doc here: (Score 1) 326

I have seen many hospitals in different states and I was around before EMRs existed. Pre-HITECH Act, EMRs *were* rare. Yes, practices often had computer programs for accounting/billing and sometimes for scheduling, but the physicians didn't input their notes and orders and such into them. (Thinking of somebody typing a note into something like IDX would be ridiculous enough to be funny.) Things were all on paper. A very small number of practices started to use some kind of EMR in the late 90s/early 2000s but these were often little more than a directory of scanned paper forms for archival. It wasn't until the early 2000s that some of the largest systems started to use what we would consider a current type EMR, and even then things were from a physician perspective read-only with dictation transcribed into it and orders were still on paper. Many hospitals didn't "go live" with computerized physician progress note and order entry until the early 2010s when they were mandated to. Been there, done that with several different institutions. MACs only need to know the patient identifying information, ICD code, and CPT code for billing, and you have to be able to provide them a note if they ask for it, which they generally only do if they want to dispute charges. Ironically this is done in many places by printing out a paper superbill and manually inputting the information into the billing software (which may or may not be sold by your EMR vendor but if it is, it may be a completely separate program that may not even communicate with the EMR) to submit to the MAC. We were much better at protecting data pre-HIPAA. It is far, far worse today. What happened was that a some office staff might get a few pieces of hot gossip from perusing through a paper chart of somebody they knew. It is NOTHING like what we see today. You didn't see the equivalent of what happens today as cracking into a buggy EMR that is mandated to be connected to the wider Internet through a software vulnerability and stealing *everything* would have required going to dozens of hospitals with a fleet of semi trucks and copying millions of pages of records. Never would have happened. I'd blame the monopoly EMR vendors that abdicate themselves from any responsibility for their crappy buggy code in their NDAed EULAs for a good chunk of the current security problems. That and if you don't want it public, don't put it on the Internet! HIPAA is intended as yet another way for the government to find yet another excuse to fine private individuals and groups and justify their own existence.

Comment Re:Burnt out doc here: (Score 4, Interesting) 326

Surprisingly, I haven't yet seen anybody here actually say *why* we have this morass. The government forced this on physicians with the HITECH Act and subsequent Medicare dictates because it suits THEIR objectives. The government wants to amass as much information on as many people as they can- just look at what it did (as in "is still doing") with the NSA. They want to be able to pick through that information for their own political purposes, a big one being finding "reasons" to pay physicians less, since the politicians grossly over-promised on Medicare and are unwilling to face up to this. Instead, they want to shift costs to doctors, and it's easier if they are "bad." They also want to use cherry-picked data to back up other political objectives like gun control, food control, etc. EMRs are clearly designed as auditing systems around federal mandates, anybody who has put information into one knows this in spades. Analyzing this data also requires a larger federal bureaucracy which the feds always love. The cronies also love EMRs well. The EMR business grew by several orders of magnitude when they went from optional (and rare) to being mandatory. Ditto with all of the compliance firms that deal with all of the issues that having an EMR now cause. Those firms lobby and "donate" to politicians to maintain their captive markets.

Comment Re:MUMPS, ancient and rarely used (Score 1) 166

If you think EPIC might be a bad place to work, try to actually use their products. They are expensive (so expensive we are legally prohibited in the EULA from discussing how much) and difficult/slow to use (cannot say more, specific performance analyses are also prohibited by their NDA.) That $84k they are offering comes from somewhere...their largely captive market customers.

Comment Re:thanks (Score 1) 211

It's not even comparable as the entire setup here is different compared to a fully socialized system. There simply is nothing like the Medicare and Medicaid payment schedule in those countries as the government directly owns, administers, and runs the healthcare system rather than using independent contractors as in the U.S. The "cash price" that one might encounter in such a system as a foreigner is going to be a lot different than the cash price here because ironically that actually is a free market, while our "cash prices" are directly controlled by the government.

One huge reason that things cost so much more here is regulatory compliance. That is fairly minimal in directly government-run systems as the government isn't very interested in grossly running up its own costs in a fully socialized sytem. But with independent contractors, sure, make them document everything in quadruplicate and check 187 checkboxes in a very clunky inefficient mandated electronic medical record system for every patient visit and spend billions and billions of dollars in complying with arcane HIPAA, JCAHO and CMS regulations. (Note that the one fully socialized system in the U.S., the VA, is exempt from all of that.) And then fine them/reduce their reimbursements if they don't jump through all of the hoops properly. It saves the government a little money but costs the healthcare system as a whole a fortune.

The whole bit about "poorer outcomes" is mainly a combination of cherry-picked facts and factors well outside of the control of the healthcare system. For example, infant mortality in the U.S. as reported by the "socialized medicine is teh awesome" crowd is higher than most European countries. Why? We have a very different method of counting what a live birth is than Europe (they count a lot of extremely preterm births as "nonviable stillbirths," we do not), and when we use the same metrics as they do, our stats suddenly look a bunch better. Our survival rate for extremely preterm births is #1 in the world and also cancer mortality is very low as well. You don't see them touting those stats though. We do have some issues with certain populations essentially ignoring their health (such as having a higher smoking rate than most of Europe) but that is a cultural issue and has remained very resistant to even massive interventions by the healthcare field. You can't blame the healthcare field in the U.S. for that.

Comment Re: News (Score 1) 211

The reason policies cost more is that now we all are paying for everybody's everything instead of the people who were likely to run up certain costs largely being made to pay for them in higher premiums. The insurance costs pre-Obamacare for a healthy 25 year old woman compared to a healthy 25 year old male were relatively similar if the woman did not get maternity coverage. If she got that coverage, it was many times higher because a 25 year old woman is very likely to run up maternity costs. Now what's happened is the 25 year old male's rates shot up many fold because now maternity care has to be covered there is little differential pricing allowed (unless you smoke) under Obamacare.

So, while a 60 year old woman may not be running up maternity costs, others are and she is paying for it indirectly.

Comment Re:thanks (Score 1) 211

1. There is a lot of pressure to reduce costs even in the commercial insurance world. Obamacare forced insurers to pay out a lot more in costs (through a lot of things such as birth control required to be covered with no copay) and they can pass some but not all of the costs along to the employers and individuals who buy the insurance. The Obamacare "mandate" penalty is a lot less than what insurance actually costs and the bigger the delta, the more people who will eschew insurance. Those that eschew insurance are going to be the suckers, ahem "young healthies" who have few or no expenses and subsidize the people with multiple poorly-controlled chronic diseases who cost a bundle. Therefore the insurers can't simply keep raising costs forever.

2. Medicare and Medicaid pay for something like 75% of all medical charges in the country and they absolutely are decreasing what they pay hospitals and physicians (to the point they generally pay below the actual cost of providing services, especially Medicaid.) They are highly incentivized to reduce costs because it makes the federal and state budget deficits associated with their operation smaller.

3. Physician and hospital reimbursement is largely determined by Medicare. If you participate in Medicare (nearly all doctors and facilities do), your pricing structures are essentially set by CMS's "allowable charges" as laid out in the RVBRS. The actual reimbursements paid also don't vary much as private insurers know what Medicare pays (it's public) and stick pretty close to the Medicare rates.

The really screwy thing about healthcare it's essentially a government run market and health "insurance" is a third-party prepayment system. If we wanted to decrease the out of pocket for most people, it would be in having health insurance revert to actual catastrophic insurance instead of being a prepaid system and allowing balance billing (the patient pays the difference between the charged amount and what insurance pays.) That would currently be against several laws but the only reason it's illegal is that it makes a lot of sense, and would result in a relatively small number of people in highly politically valuable groups losing a bunch of discounts, subsidies, and freebies.

Comment Re:So there's 100 or so unimmunized? (Score 1) 387

1. The flu vaccines have very, very little egg in them to begin with. Also, there are now completely egg-free flu vaccines out there, namely the ccIIV4 vaccines. Most of the cases of iatrogenically-induced anaphylaxis are to other medications with a known propensity to do that, such as IM antibiotics, IV contrast, allergy shots, and quite a few chemotherapy drugs. That is why you have to wait in the office for 30 minutes after you get them. 2. Celiac disease IS an allergy! You are describing a solely autoimmune process, which would NOT abate with dietary elimination since the body would be solely sensitized to one of its own antigens instead of wreaking collateral damage in an allergic reaction. Nope, you stop eating gluten if you have celiac and you stop the disease process, you heal, and you have no symptoms...until you eat gluten again. The eating gluten part is absolutely critical to the disease being active. 3. No. That would be for things like inflammatory bowel disease which IS solely an autoimmune process and has somewhat of a genetic predisposition. You have to take meds to quiet that down, it doesn't go away with not eating certain foods like celiac disease. 4. The fact that there are unpredictable results on RASTs for drugs is why it isn't generally done. Ask your local immunologist or allergist about that one. 5. No, my understanding is based on quite a bit more education than that. I strongly suggest that YOU read up as you are the one making significantly erroneous statements.

Comment Re:So there's 100 or so unimmunized? (Score 1) 387

Did you actually read my post and the rest of the thread before you replied? First of all, we were talking about drug and vaccine allergies. Secondly, I specifically mentioned the different types of allergies possible INCLUDING the textbook example, celiac disease. Celiac disease absolutely IS an allergy, being a Type IV (delayed-type) hypersensitivity reaction which gives a specific set of GI symptoms in people who know they have the disorder. The familial tendency towards allergy manifsts itself as asthma/atopy/allergic rhinitis, not with allergies to specific drugs or foods. There has been a lot of research on the matter and this has been demonstrated many times over. Also you should know that the blood test (RAST) is absolutely worthless to determine if somebody is allergic to something if they have never been exposed to it before, such as for drugs. You have to have the initial antigen presentation from the allergen be able to get the antibody formation which is detected in the RAST. Basic immunology such as that should have been covered in your general college biology classes, if you took them.

Comment Re:So there's 100 or so unimmunized? (Score 5, Insightful) 387

There are at least two things you wrote which are generally medically incorrect. First of all, having only a stomach ache after ingesting a drug is very unlikely to be an allergy. True (IgE/T-cell-mediated) allergies usually cause things like hives, throat/lip/face swelling, low blood pressure, and trouble breathing. You simply describe a very well known NON-ALLERGIC adverse effect common to all opioids. True allergies are generally not heritable either, so the "my relative was allergic to X, so I can't take it" is nonsense. Your aunt and uncle simply had the same very common NON-ALLERGIC adverse effect you did. The exception to this is in people who have things like celiac disease who have a T-cell-mediated response to gluten in the medication which is an allergy. But you'd have a telltale set of symptoms involving more than just nausea if that was indeed the case for you. The only reason I mention this is because many people say they're "allergic" to vaccinations for similar nonsense reasons. A moderate fever and redness/aching at the injection site is a known adverse effect due to how vaccines work. You have symptoms of an immune response because you have to elicit an immune response for vaccines to work.

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