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Posts Tagged ‘Medicare’

Update to my Kentucky medical story and a flip side of the same coin

Monday, September 26th, 2011

Update to my Kentucky medical story and a flip side of the same coin.

I spoke too soon on my belief that the American Medical Association would be interested in my comments about a Medicare patient and a doctor in a small town in Kentucky – but a “Kentucky Medical Complaint” Google search brought up some answers.

Update in my friends Kentucky case – she, as of Saturday, 24 September 2011 had not heard from the doctor for test results.  She called the local hospital where the cardio tests (2) were performed and told the results were in and she could pick them up.

She called the doctor’s office yesterday and told the PFTs were normal and the heart tests were normal too.  What justified the cardiac tests when the PFTs were normal?

Why would the PFT procedure be so different in a small town in Kentucky than in the rest of the nation?  Is the 29 days it took to wait for the doctor results due to a state raising fast horses and s l o w doctors in general or specific to one doctor in one small Kentucky town?

Having dependence on Medicare/Medicaid and being old, poor and trusting should not be a factor in a doctor’s way of making a living off the patients through unnecessary testing and no follow up contact with the patient.

The plus side is that she now has the physical test results of her lungs and heart but not a clue what they mean.  When she called the doctor’s office this time, she was told the results of the PFT and cardiac tests were ‘normal’.

Why did the doctor order cardiac testing if the Pulmonary Function Tests were normal?

I called the doctor’s office this morning, Monday, 9/26/11 and asked several questions including why the doctor didn’t call the patient in 29 days to give her the test results and was told that it can take two or three weeks to get the results and another week for the doctor to review the results.  My friend the patient was told two weeks.  When I asked why the cardiac tests were ordered when her PFT was ‘normal’ – BEFORE he spoke to the patient - I was told to call back later to speak with the office manager.

I was told if my Kentucky friend wanted to know the meaning of the test results, she should call and make an appointment with the doctor.

Fast horses and slow doctors in a small town in Kentucky – doesn’t seem right to me.  Are other seniors on Medicare/Medicaid being ill treated by this doctor? 

Are most Kentucky doctors as seemingly indifferent to their senior patients by failing to give test results in a timely manner and ordering cardiac tests without apparent need – or just this one based on my own PFT experience?

The flip side of the coin is the unfair treatment of the medical profession by Medicare and Medicaid.

I wrote the following in answer to a Letter to the Editor, Kitsap Sun:

“Well…health care costs...not one post has mentioned WHY doctors don’t take Medicare or Medicaid. The fact is physicians and the health care industry is the only profession in this nation that PENALIZES the doctor and health care businesses!

Any other business in the country can set their price and people pay it or go elsewhere. Not so the physician. Medicare and Medicaid pay only a fraction of the set price per service of each doctor.

Why should doctors take patients that COST them money to see them…they LOSE money.

If a plumbing business could take ten calls during the business day – why would they take a call from someone that will not pay their full price for the service?

Some doctors DO TAKE MEDICARE/MEDICAID patients and I for one – am grateful mine do.

I will mention here that I saw a medical devise recently that cost Medicaid/Medicare about nine thousand dollars per patient that has one. For a patient to buy it outright it cost about twelve thousand dollars.

If that isn’t outrageous enough for you – my opinion of the value of the devise – it MIGHT be worth one thousand dollars TOPS.

In my opinion, what seems to be happening in some cases is that the health care folks have tacked outrageous prices on cheap junk to make up for the low Medicare/Medicaid set prices.

Who loses? WE DO! The taxpayer AND the patient.”

Read more: http://www.kitsapsun.com/news/2011/sep/19/letter-to-the-editor-state-shouldnt-cut-more/#ixzz1YsPjzSZ4

http://www.kitsapsun.com/news/2011/sep/19/letter-to-the-editor-state-shouldnt-cut-more/

Speaking of a medical determined momma squirrel in Silverdale…

Thanks for reading… Sharon O’Hara


Do Lung Doctors in Kitsap County Neglect Support Group Patient Education, part 2

Monday, August 15th, 2011

Obstructive Sleep Apnea is serious.  A recent Swiss study shows that even a short break in using the CPAP is harmful:

“Within 14 days, they had significant increases in heart rate and blood pressure, and deterioration in vascular function.  The results suggest that even a short break in CPAP therapy has a negative effect on the cardiovascular system … OSA patients need to continuously use CPAP….” …according to US News and World Report.  Presumably, that goes for those of us on the BIPAP machine too.

Then there is  …

  1.  Lack of treatment can lead to mental confusion, dementia and Alzheimer’s.

A physician could have answered the questions that ensued.

  1. New Medicare rules say the patient must be on the machine 4 hours a night for the entire CPAP or BIPAP rental period – no matter what – or lose the machine.

As a patient with RLS, I take meds for – Mirapex that no longer works – that is worrisome.  The fact is sometimes I cannot stay in bed where the only relief from RLS is to stand up and/or walk.

When I asked about the 4-hour Medicare rule when a person has other medical conditions, I was told I had to make the choice – the BIPAP or RLS. – Not a choice at all for me and many patients like me.

A plus here is that the last session was so bad that I spent the entire night standing up using my laptop at the kitchen counter and came to the conclusion  I think a food allergy may play a part in my RLS problem.  I will talk to my doctor about it.

Harrison has a superb respiratory department team – professional people, open and transparent.  Patients need to be educated and Harrison is stepping up with professionals educating us….but we need more physician involvement to answer the tough medical questions for pulmonary support group patients.  In Kitsap County, it is past time for physician pulmonary education now.

COPD and Sleep Apnea is a huge medical dilemma where ignorance might well be bliss for the patient…but not in the long term.  What happens when we do not get oxygen to our organs?

For starters, we lose brain cells without the oxygen to sustain them.  Our lessor organs begin to fail because the larger organs grab the available oxygen first.

Incontinence is only one of many issues that can occur from lack of oxygen to organs…

No doubt, most of my brain cells are long gone so I have one less thing to think about.  My point here is to suggest you not to lose yours if it can be avoided.  Patient education is key to having the best quality of life possible with any medical condition and we NEED lung support group physician involvement.

http://pugetsoundblogs.com/copd-and-other-stuff/2011/08/13/do-lung-doctors-in-kitsap-county-neglect-support-group-patient-education/

The U.S. National Heart, Lung, and Blood Institute have more about sleep apnea treatments.

Copyright © 2011 HealthDay. All rights reserved.

http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html

http://health.usnews.com/health-news/family-health/sleep/articles/2011/08/12/sleep-apnea-makes-quick-return-when-treatment-stops

Better Breather’s meeting Wednesday… http://www.harrisonmedical.org/home/calendar/4897

If anyone needs a ride, let me know…the car is super clean.

Thanks for reading… Sharon O’Hara

 

 

We all cheer for the GREAT MEDICAL CARE  already in Kitsap County…and for more Pulmonary Physician support group education.


When the Power Goes Out – Is Kitsap County a Cold and Lonely Place For COPDers?

Saturday, January 15th, 2011

When the Power Goes Out – Is Kitsap County a Cold and Lonely Place For COPDers?

We had one battery charged lantern and I kept the box handy on the counter because I knew the lights would come on any minute and I could quickly put it away again. Two days later, the lights came on and I put it away.  The laptop puddled in place – a good reminder that better power days were ahead…same with the lamp.  The two drawers full of old candles were not lit…I do not want to inhale candle fumes.

The little shortwave radio was meant as a Christmas present but I’ve kept it – the so welcome sound and information was my connection to the world.

I didn’t know it when I shot this photo but less than two hours later, the tireless power wonders will have restored our power.  It was so very cold….and it felt balmy when the temperature inside finally came up to 50 degrees.

No, only for those on life giving machines such as the C-Pap and Bi-Pap machines – they have nowhere to go to plug in their life sustaining machines.   Seniors on a concentrator bleed-in usually can’t carry the heavy machines.

The plus during the last two day power outage was to discover all the people helping others in a tight fix.

My husband, the Old Guy, spent most of the two days out in the cold trying to fix the generator.

The discovery that the tube he thought would fix it, didn’t,  led to more cell calls to the generator tech folks and ultimately to another  Kitsap County Angel –Ward’s Radiator Shop in Chico.

It turned out that all we needed was an expandable plug that Wards said should work temporarily until he can solder it in this summer.  It worked and is still working!  But not until after the wonderful power workers fixed our power and we went on the emergency source heat pump. Thank you, Ward’s Radiator Shop in Chico!

Our inside temperature dropped to 40 degrees and by the second night the Old Guy fixed our old portable Honda generator and asked if I wanted it hooked to a portable heater or use it on my bi-pap and concentrator.

Well.  Having taken the Mountaineering course at Olympic College some 35 years ago and learning some survival skills,  I didn’t see the sense of blowing 41 degree air into the 98 degree body I’d carefully kept warm by layering.  And, once in bed, I stayed warm and didn’t need a heater.

Question:  Was my concern and decision against blowing 41 degree cold air into my airway wrong?

Would the cold air have been warmed enough by a warm core or would my core have begun to cool to reflect the cold air blowing in?

As it was, many of us went without the machines that keep our airway open and (for some) that keep our vital blood/oxygen numbers up.

Funny thing: With good reason, the Old Guy complains, moans, and groans whenever I ask him to get something out of the freezer and puts on heavy gloves to do it – he has Raynaud’s Disease in his fingers.

During the two day power outage, he spent hours in the below freezing weather working on the generator and never said a word…just went to work trying to fix it…and couldn’t wear the thick, warm gloves.  ‘Caregivers’ is an overdue story for another time.

Bainbridge Seniors at the Senior Center have plans to provide a place to go and I hope they coordinate with oxygen companies to assist those on machines to keep their airways open and for those on concentrators and oxygen.

http://pugetsoundblogs.com/copd-and-other-stuff/2011/01/09/cold-in-silverdale-bi-senior-center-rocks/

My bi-pap was ordered after a Sleep Apnea study in 2001and Lincare supplied my Respironics Duet on 3 August 2001, according to Mike DiMatteo of Lincare, and our insurance paid it off in February 2002.

In 2010, my secure sense of well-being went to the bottom of rattlesnake canyon in a hand basket when a home study showed my sats dropped into the basement while asleep, way below good oxygen levels.  I fell through the cracks in our system and I can’t be the only one.

We have stuff – serious stuff that needs fixing and that is another story for another time.

As I see it, oxygen companies are caught in the bind of Medicare, Medicaid and patients and one flaw has been lack of communication between patient, physician and Oxygen Company.

Patients talk to your doctor – its vital your sats stay up while awake and how much leeway do we have if they drop when we’re asleep?  We need oxygen to our organs and the brain is a vital organ.

While I had the friendly and helpful Mike DiMatteo on the phone, I asked him about offering help with the Bainbridge Senior Center seniors planning a safe haven when the power goes out.  Mike said he would be glad to offer whatever help/advice they needed.  I’m sure most of Kitsap’s oxygen companies who supply these machines will help too.

Someday the rest of Kitsap County will follow the Bainbridge Senior Center seniors lead and provide assistance for those who need help when the power goes out. For some seniors, just a viable power plug can make the difference between life and death.

A super plus is the great event next Wednesday at Harrison Silverdale speaking to this very subject of emergency assistance for those of us on oxygen, concentrators, BiPap and C-Pap – all respiratory folks.

COPDers and caregivers – Mark Wednesday, 19 January on your calendar – Full details tomorrow.

More later… Sharon O’Hara


The National Institute on Aging and Kitsap’s Baby Boomer Resources

Wednesday, January 5th, 2011

The National Institute on Aging is a fabulous resource and according to their latest e-Update, this month is the first month the baby boomers born between 1946 and 1964 begin turning 65!

The medical influx for Medicare will no doubt cause huge sweeping changes in Medicare benefits…or sink the Medicare ship entirely but that’s another subject for another time.

The National Institute on Aging does a great job informing us – even offering seniors cost free help, education and booklets on a variety of important subjects.

The Kitsap County contacts for seniors are below.

Kitsap County Senior Resources

Area Agencies on Aging Learn More
Kitsap County Division of Aging & Long-Term Care
Address : 1026 Sidney Avenue
: Suite 105
City : Port Orchard
State : WA
Zip : 98366
County :
Website : http://www.kitsapgov.com/altc
Contact Email : sloop@co.kitsap.wa.us
Office Phone : (360) 337-7068
Information Phone : (360) 337-5700
Regional Phone : (800) 562-6418
Description : -Area Agency on Aging -Senior Information & Assistance serving Seniors 60+. -Caregiver Support Program & Respite -Medicaid In-Home Services Case Management -Long Term Care Ombudsman -Sponsor: SHIBA (Statewide Health Insurance Benefits Advisors)
Special Notes : We are in the Givens Community Center.
Hours : 9:00 AM – 4:30 PM – Pacific Time, Monday-Thursday
Directions : From Hwy 16 take the Port Orchard Tremont/Old Clifton Rd exit. From the south turn right, from the north turn left onto Tremont. Follow to Sidney Ave, turn left and go 3/4 mile. We are on the left. view on map
American Indian Tribes and Tribal Organizations Learn More
Puyallup Tribal Health Authority
Website : http://eptha.com
Office Phone : (253) 593-0232
Special Notes : Adult Day Care, Emergency Response Systems, Financial Assistance, Home Repair, Home Modification, Information and Referral/Assistance, Home Delivered Meals, Congregate Meals, Personal Care, Sr. Center Programs
Hours : 8:00-5:00 Pacific
Directions : view on map
Quinault Indian Nation-Senior Program Manager
Address : PO Box 189
: 1214 Aalis Drive
City : Taholah
State : WA
Zip : 98587
County :
Contact Email : mmills@quinault.org
Office Phone : (360) 276-8215
National Toll Free Phone : (888) 616-8211
Special Notes : Caregiver Programs, Case Management, Home Health Services, Adult Protective Services, Emergency Response System, Employment Services, Financial Assistance, Information and Referral/Assistance, Home Delivered Meals, Personal Care, Respite Care, Government Assisted Housing, Sr. Center Programs
Hours : 8:00-4:30 Pacific
Directions : view on map
State Agency on Aging Learn More
Washington Aging & Disability Services Administration
Address : 640 Woodland Square Loop S.E.
: PO Box 45600, Olympia, WA 98504
City : Lacey
State : WA
Zip : 98503
County :
Website : http://www.adsa.dshs.wa.gov
Office Phone : (360) 725-2300
Information Phone : (360) 725-2300
National Toll Free Phone : (800) 422-3263
State Phone : (800) 422-3263
Regional Phone : (800) 422-3263
Description : Administers service programs for in-home, community and residential LTC for seniors and persons w/ disabilities, including persons with developmental disabilities.
Special Notes : The Aging & Adult Services Administration (AASA) recently merged with the Developmental Disabilities Administration to become the Aging and Disabilities Services Administration (ADSA).
Hours : 8:00 AM – 5:00 PM – Pacific Time, M-F (closed holidays)
Directions : From the north take I-5 exit #109. Turn right onto Martin Wy. Turn left at first light onto College St. After 2 lights, turn right on Woodland Square Lp. ADSA HQ is a 4 story building on the right. view on map
Elder Abuse Prevention Learn More
Northwest Justice Project (CLEAR Sr.) View Coverage
Address : 401 2nd Avenue South, Suite 407
City : Seattle
State : WA
Zip :
County :
Website : http://www.nwjustice.org
Office Phone : (888) 387-7111
State Phone : (888) 387-7111
Languages : ,Spanish
Description : CLEAR*Sr is a statewide toll-free client access system for people 60 years old or older to obtain free legal assistance with civil (non-criminal) problems.
Hours : M-F 9:30AM-12:30PM, Tuesday evening 4:30PM-6:45PM
Directions : view on map
Adult Protective Services View Coverage
Address : 4710 Auto Center Blvd.
City : Bremerton
State : WA
Zip : 98312
County :
Website : http://www.aasa.dshs.wa.gov
Office Phone : (360) 473-2192
Information Phone : (360) 473-2192
State Phone : (888)833-4925
Languages : ,Ask for interpreter
Description : Adult Protective Services include investigation of alleged abuse, neglect, exploitation or abandonment of vulnerable adults, and emergency support services to those found to be in need of protection.
Hours : 8:00am – 5:00pm, M-F
Directions : view on map
Nursing Home Residents Neglect Hotline View Coverage
Address : P.O. Box 45600
City : Olympia
State : WA
Zip :
County :
Office Phone : (800) 562-6078
State Phone : (800) 562-6078
Description : Provides assistance for consumers who want to register complaints regarding licensing, incompeteince of staff, cleanliness, safety, treatment of patients, quality of care, excessive fees, unethical, improper or unprofessional conduct of staff.
Hours : Hotline is open 24 hours a day. Calls are returned M-F, 8:00am to 4:30pm.
Directions : view on map
Health Insurance Counseling Learn More
Statewide Health Insurance Benefits Advisors (SHIBA) View Coverage
Website : http://www.insurance.wa.gov
Office Phone : (360) 475-6649
Information Phone : (800) 562-6900
State Phone : (800) 562-6900
Languages : ,Chinese,Korean,Russian,Spanish,Tagalog
Description : A volunteer-based service whose mission is to give you answers. We can help you understand your health insurance, compare policies, process medical billings, pursue claims or appeals, detect and report fraud, and help you learn your rights and options.
Hours : Phone lines are open 24-hours a day. Calls are returned by volunteers M-F.
Directions : view on map
Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine View Coverage
Website : http://www.insurance.wa.gov/shiba/shiba_mission.shtml
National Toll Free Phone : 1-800-562-6900
Description : SHIBA has volunteers who can help you with your health care coverage questions. You get free health care coverage education, assistance, and advocacy.
Directions : view on map
Legal Services Learn More
Free Legal Services for Seniors View Coverage
Address : 1950 Pottery Avenue, Suite 17
City : Port Orchard
State : WA
Zip : 98366
County :
Office Phone : (360) 876-9221
Description : If you’re are over 60 you are eligible for free legal advice. We can help you if your legal needs fall under public entitlements, health care, housing, guardianship, protective services and consumer transactions. Give us a call, we can help.
Hours : 9:00am – 5:00pm, M-F
Directions : view on map

What’s Your Aging IQ?, an updated booklet from the National Institute on Aging, helps answer questions and separates fact from fiction about aging and health. Based on scientific research, this illustrated, 24-page booklet lets readers test their basic knowledge of aging. Take the quiz, based on eight brief stories—in print or online—to see how much you know about heart health, bone health, eating well, and more!

Available FREE:

* Read online, download, or order print copies, or take the online quiz: What’s Your Aging IQ?

* Call toll-free: 1-800-222-2225 or 1-800-222-4225 (TTY)

http://www.nia.nih.gov/HealthInformation/Publications/

I wholeheartedly recommend their free booklets, especially,

Exercise & Physical Activity: Your Everyday Guide from the National Institute on Aging.  Also available in Spanish.

More later… Sharon O’Hara


Political Medicare and Tricare Travesty

Saturday, November 13th, 2010

Greetings…Medicare and Tricare patients – we may soon be up that creek without a paddle if we don’t take action now.  I sent the following letter this morning to my legislators through the American Medical Association’s website to protest against  further cuts to our physicians.  They are already penalized by taking Medicare and Medicaid patients now.  If this new cut goes through,  patients like us won’t even have a canoe up that creek, much less the paddle.

***

“Dear Legislator’s…  Don’t force physicians to make the choice to of not treating Medicare or Tricare patients or go out of business for lack of income and not be able to treat anyone.

The medical profession is the only profession in this nation to be penalized by the work they do – working in health care. accepting Medicare or Medicaid patients penalize the very people working to provide health care to our citizens – our physicians.

Forcing additional physician related medical cuts will effectively take care of too much government care costs by getting rid of seniors and our retired military to make room for the baby boomers beginning to enter the system.  Is that what you want?

I fit into both categories, a senior on Medicare and Tricare.  My medical team already loses money every time they see me.

How dare the government control what should be private industry KNOWING these additional cuts will drive doctors out of business and/or be a death warrant for patients like me left stranded without medical assistance.

My husband is retired military, we’re both seniors – he is my ‘caregiver.’ I have COPD, Sarcoidosis, Bone on Bone left hip Arthritis, RLS, Lymph-edema,  Psoriasis and Other Stuff.

My parents legally immigrated to this country, the land of their dreams,  knowing they were only limited by their own imagination and willingness to work.  For shame that America could be reduced to a government willing to harm their retired military and seniors by reducing the medical care needed for their survival.

The Medicare patch Congress passed last June is only a temporary reprieve for the seniors and baby boomers who rely on the promise of Medicare. In December, the Medicare cut to doctor services will be a whopping 23 percent, increasing to nearly 25 percent in January.

It’s a tragedy that Congress has let Medicare erode into an unreliable, unstable system for both patients and their doctors.

We need a long-term solution to this annual problem, so you will no longer need to apply short-term Band-Aid fixes to stop impending cuts that get worse year after year. And don’t forget – baby boomers begin entering Medicare soon, and if this problem isn’t fixed, these new Medicare patients may not be able to find a doctor to treat them!

The vicious cycle of short-term delays that make the cuts worse and raise the cost of real reform for American taxpayers must come to an end.

This is a dangerous game of Russian roulette with seniors’ health care. Sick patients can’t wait any longer for you to do the right thing. Please stabilize this broken payment system before the damage is done and cannot be reversed.

Don’t allow a bad system to get worse.”

***

Please let your voice be heard.

http://www.ama-assn.org/

Sincerely,

Sharon O’Hara


Harrison Medical Center Works with DRG/1

Sunday, June 27th, 2010

What is YOUR Hospital DRG?

“Part 2 deals with the $11,376.32 loss to Harrison after two insurance companies paid $1,100.00 and $5,109.58.
How long can any business survive if they are compelled to absorb such losses?”

I discovered answers from Harrison’s new Patient Financial Supervisor, Christine Warner. Additionally, I learned that Harrison offers deep discounts, and has other programs in place via a “Contractual Allowance.”
Contact them and see what they can do for you.

According to Christine Warner, my DRG is 300 thus accounting for their low Medicare payment reimbursement.

The Tricare reimbursement is based on the Medicare rate of return and other insurances may pay more.

Medicare will also pay more than the hospital charges for other patients with lower numbers helping offset the high numbered patients like me.

As more baby bloomers enter Medicare, Harrison and other hospitals will be hard pressed to cut costs….and, I hope, get more into preventative issues and using patients to help each other.

Something I think would help cut future costs and that is to educate the patient by was of a genetic support group, meeting once a week. The issues are much the same for patients with multiple medical conditions and the emphasis should be on nutrition, and physical fitness. We could invite speakers from around the county…even from among the patients.

I have found a similar mindset among the best professionals I have met and been challenged by all. Patients teach each other and most medical professionals would be happy to help the cause of better health.

To name a few: Yvonne Kerstad with Janice McFarland’s, Body ReForm, Silverdale’s Pilates and Physical Therapy Studio. Yvonne altered many of the exercises to suit my physical condition Yvonne can also address firsthand, exercising pre and post around a hip replacement.

Anna Marx, Kitsap Physical Therapy, Silverdale, is another who thinks outside the circle. She proved to me that I COULD increase the range of motion of my left hip. Additionally, Sara is a recumbent bike rider and entered in the 2010 Seattle – Portland ride

xxxxxxxxxxxxxxxxxxxxxxxxx

“Medicare Prospective Payment System

Introduction

The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1983, as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. Each patient is classified into a Diagnosis Related Group (DRG) on the basis of clinical information. Except for certain patients with exceptionally high costs (called outliers), the hospital is paid a flat rate for the DRG, regardless of the actual services provided.

Each Medicare patient is classified into a Diagnosis Related Group (DRG) according to information from the Medical Record that appears on the bill:

• Principal Diagnosis (why the patient was admitted)
• Complications and Comorbidities (CCs – other secondary diagnoses)
• Surgical Procedures
• Age
• Gender
• Discharge Disposition (routine, transferred, or expired)

How it Works

Diagnoses and procedures must be documented by the attending physician in the patient�s medical record. They are then coded by hospital personnel using ICD-9-CM nomenclature. This is a numerical coding scheme of over 13,000 diagnoses and 5,000 procedures.

The coding process is extremely important since it essentially determines what DRG will be assigned for a patient. Coding an incorrect principal diagnosis or failing to code a significant secondary diagnosis can dramatically effect reimbursement.

There are over 490 DRG categories defined by the Centers for Medicare and Medicaid Services (CMS, formerly known as HCFA). Each category is designed to be “clinically coherent.” In other words, all patients assigned to a DRG are deemed to have a similar clinical condition. The Prospective Payment System is based on paying the average cost for treating patients in the same DRG.

Each year CMS makes technical adjustments to the DRG classification system that incorporate new technologies (e.g. laparoscopic procedures) and refine its use as a payment methodology. CMS also initiates changes to the ICD-9-CM coding scheme. The DRG assignment process is computerized in a program called the grouper that is used by hospitals and fiscal intermediaries.

Each year CMS also assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average.

Top 10 DRGs
The ten highest volume Medicare DRGs represent about 30% of total Medicare patients. Each of these higher volume DRGs represent from about 2% to 6% of total Medicare volume.

DRG DRG Description % Total Rel Wt

1 127 Heart Failure & Shock 5.99 1.0234
2 089 Simple Pneumonia & Pleurisy Age>17 w/CC1 3.85 1.1447
3 014 Specific Cerebrovascular Disorders except TIA 3.18 1.2056
4 430 Psychoses 3.18 0.9153
5 088 Chronic Obstructive Pulmonary Disease 3.11 1.0067
6 209 Major Joint & Limb Reattachment Procedures, Lower Extremity 2.78 2.3491
7 140 Angina Pectoris 2.33 0.6241
8 182 Esophagitis, Gastroent & Misc Digest Disorders Age>17 w/CC1 2.09 0.7617
9 174 G.I. Hemorrhage w/CC1 2.07 0.9657
10 296 Nutritional & Misc Metabolic Disorders Age>17w/CC1 1.93 0.9313

Note: “CC” signifies a significant complication or comorbidity
Source: Health Care Financing Administration, 1994.
DRG-based Payments
The DRG payment for a Medicare patient is determined by multiplying the relative weight for the DRG by the hospital�s blended rate:…”
DRG PAYMENT = WEIGHT x RATE

Read more: http://pugetsoundblogs.com/copd-and-other-stuff/2010/06/26/harrisons-strength-is-in-her-volunteers-and-staff/#ixzz0s42zrGV0

http://www.ahd.com/pps.html

More later… Sharon O’Hara


Seniors Learn and Chat New Government Benefits TODAY

Thursday, April 8th, 2010

The Department of Health and Human Services want Seniors to know stuff.

They’ve scheduled weekly web chats and TODAY, 8 April at 1:00pm “.. top experts on health care and seniors will join Secretary Sebelius live for a discussion about some important benefits for older Americans .” Don’t miss it.

Read on for more information to benefit Seniors, including the donut hole filler.

“Now that the Affordable Care Act is law, the Department of Health and Human Services wants you to be sure you are getting the information you need about the important early benefits that will be available this year.

Each week HHS will be hosting a weekly web chat with Secretary Sebelius and other top officials at HHS. You’ll be able to hear more about what the new health insurance reform law means for you, and you can submit your questions directly to Healthreform@hhs.gov.

Last week, the Secretary and SBA Administrator Karen Mills talked about the new tax credits that are now available to help small businesses buy health insurance for their workers. You can watch that web cast on demand by clicking here.

This Thursday, April 8th, at 1:00 PM EDT, two of HHS’s top experts on health care and seniors will join Secretary Sebelius live for a discussion about some important benefits for older Americans. Kathy Greenlee, our Assistant Secretary for Aging, and Marilyn Tavenner, Principal Deputy Administrator of the Centers for Medicare and Medicaid Services, will be available live to take your questions.

Join the conversation tomorrow at 1:00 pm EDT at http://www.hhs.gov/live.

Did you know that the new law will provide a $250 rebate this year on prescription drugs for those facing the gap in Medicare coverage known as the donut hole?

Did you know that the new law protects and strengthens Medicare by eliminating waste and fraud and ending overpayment to private insurance companies?

Did you know that preventive care will be available to Medicare beneficiaries at no cost?

We will be discussing all these benefits plus new details about a new retiree reinsurance program (pdf) that will bring much needed relief to many early retirees who cannot access affordable health coverage.

Send us your questions today to Healthreform@hhs.gov.

We’ll answer as many questions as we can during the web chat and address others in the “Your Questions Answered” section of our website.

Jenny Backus
Acting Assistant Secretary of Public Affairs
Moderator of the HHS Weekly Web Chat

More later… Sharon O’Hara


Government Controlled Health Care

Saturday, November 7th, 2009

Please excuse my mention of politics and our current health care system dilemma. I am a patient, not a political party…disease does not stop at borders but it sure plays a part in medicine…

“It is a common misconception that the free enterprise system is at fault for the current high cost of medical care in the US, a misconception that the current administration has no desire to refute…”

UNEMPLOYMENT RATE HITS 10.2 PERCENT, WORST SINCE 1983; EMPLOYERS CUT 190,000 JOBS ”

http://email.foxnews.com/t?ctl=2163:7A6A4B31296F1CB1EA28BA15CAB80E79&

Now the White House is extending the unemployment insurance – again. Nothing happens overnight, we know…but I would feel more hopeful if our government wasn’t spending money we don’t have… and keeps spending the same invisible money.

President Obama reminds me of a cookie starved kid suddenly turned loose in Ma Kettle’s Cookie Kitchen – he keeps making cookies long after the oven died and the shelves are bare.

The car bonanza helped people buy all electric golf carts at a fraction of the cost or got them free – thanks to the taxpayer and generosity of the White House. (WH)

The Acorn shame was hidden by the mainstream media – Fox opened Pandora’s Box and we began to learn how the WH is manipulating the media and attacking Fox for telling us THE NEWS. Real news, not slanted.

Last night I did my usual click through stations and found one miserable health condition show after another…gee, right when the WH is manipulating for government controlled health care.

Once during the past few months, I joined in on a AARP phone town meeting and listened to one amazing comment after another…until I had a page almost full of comments and questions to ask.
I called the number given for questions and left the message. The impetus to call was when AARP bragged that California had the best system of superb health care in the nation. The California health care system should be the model for the country…no one mentioned that California is BANKRUPT.

Later, the last cookie of remaining respect crumbled when I watched the CEO on a Fox interview state over and over again that AARP did not have a position yet on health care.

I have a special interest in health care, as do most of us … and do not want another government controlled agency doomed to fail…just as government controlled Social Security, Medicare and Medicaid are failed.

“Social Security is safe today but will run deficits in just 12 years. That’s not a very long time to fix the world’s biggest government program.”

http://www.socialsecurity.org/reformandyou/faqs.html

“…The current recession is wreaking havoc on the Social Security trust fund. But the real blame lies with irresponsible politicians. Instead of planning for the future—of which they had literally a generation in advance warning—politicians acted as if a severe recession would never come.

Now, instead of a trust fund filled with the accumulated dollars of previous generations to cover distributions to those taxpayers, the government is left with an empty bag of holes.
The trust fund’s annual surplus will all but vanish next year according to the Congressional Budget Office’s (cbo’s) most recent report.
With unemployment rising, there are 5.1 million fewer workers paying into Social Security than when the recession began in December 2007.

The end of the Social Security surplus could have enormous consequences.
For the government, it means not only will it need money to somehow pay those Social Security entitlements, but it will also need to find a new source of off-budget money to “borrow” from for other expenditures that were previously funded by stealing from Social Security. …

“Over the past 25 years, the government has gotten used to the fact that Social Security is providing free money to make the rest of the deficit look smaller,” said Andrew Biggs, a resident scholar at the American Enterprise Institute. “Instead of Social Security subsidizing the rest of the budget, the rest of the budget will have to subsidize Social Security.”

That is not good news for the 51 million retirees who depend on Social Security.

Already in massive debt, the government has limited options for financing Social Security.

The first two options—cutting benefits for retirees, and/or raising taxes on current workers—are probably politically impractical, especially since America is only in the early stages of the “Greater Recession.” …
…government with one last-ditch option: to just create more money…. may include discrediting the dollar, destroying America’s purchasing power and severe international consequences.

The Federal Reserve Bank has already announced that it has started down this path. Inflation will almost inevitably result.
America is facing some tough choices, none of them easy: reduced benefits, higher taxes, more borrowing, higher inflation, a damaged dollar. The consequences of big government and even bigger spending are about to slam home with landslide force.

The Social Security debacle is just one more should-have-been-avoidable financial crisis to add to the growing list. … •

http://www.thetrumpet.com/index.php?q=6106.4502.0.0

President Obama is NOT RESPONSIBLE for the SS crisis…he inherited the SS, Medicare and Medicaid disasters.
President Obama IS RESPONSIBLE for his outrageous borrowing and throwing more billions of invisible money into the pit of no return.

Between Fannie, Freddie, Ginnie and the FHA, an astounding near 90 percent of all loans being issued in the United States are now backed by the government. If home prices continue to fall, and defaults continue to grow, these organizations have the potential to destroy government finances. Yet instead of trying to mitigate this unfolding disaster, America is actually plunging in deeper. http://www.thetrumpet.com/index.php?q=6697.5217.0.0

The writing is on the wall–the Social Security system won’t be able to sustain itself much longer. When the Social Security trustees issue their 2010 report next May, the viability of this system will have deteriorated further—a fact trustees cannot hide any longer under the proverbial “political rug.” However, with media attention focused on healthcare and the death of Michael Jackson, most Americans are simply unaware of this coming tempest….”

http://www.americanthinker.com/2009/08/why_social_security_will_go_ba.html

“…Not only will Obama ration your health care — especially if you are a senior citizen — and have the government decide what treatment and benefits you get, the proposed plan will also build and expand the government’s surveillance and control grid.

Section 163 of the bill now in Congress allows the government real-time access to a person’s bank records, including direct access to bank accounts for electronic fund transfers. “Even-though the bill mentions privacy aspects, the fact remains that if approved, Obama’s health care plan will allow government access at any time to your personal bank records,” KFYI News reports.
“It’s pretty Orwellian, it certainly gets the government pretty darn deeply involved in private matters in our lives,” Arizona Congressman John Shadegg told the news radio station…. http://www.infowars.com/obama-health-bill-allows-government-real-time-access-to-bank-accounts/

“It is a common misconception that the free enterprise system is at fault for the current high cost of medical care in the US, a misconception that the current administration has no desire to refute. However, the government’s regulatory and control practices are really at fault. Ever increasing and more punitive government and Medicare regulations set the standards for the actions of the private insurance companies. … Government over-regulated and managed health care makes as much sense as government managed flying.
Frank S. Rosenbloom, M.D. “Government Health Care Won’t Fly””

http://www.americanthinker.com/2009/06/government_health_care_wont_fl_1.html

More later … Sharon O’Hara


QUALITY LIFE- TOO EXPENSIVE?

Wednesday, October 21st, 2009

QUALITY LIFE- TOO EXPENSIVE?
CHEAP DEATH – IS IT REALLY?
WHO DECIDES?

Since when does living a quality life for the medically or physically challenged mean too costly for taxpayers?

Living a quality life, to me, means seeing and feeling the world around us…seeing the sparkle and sharp colors of new daybreak splash slowly across the horizon and its new dawn promise, the muted and soft streaks of a sunset inch across the sky at day’s end, the happy, funny gurgle and contented baby coo, a bee’s buzz as it flits from flower to flower, the busy chirp and chat of birds, the cheery tug of anticipation at the shout of “STRIKE ONE!” when your child or grandchild is at bat, the intoxicating smell of freshly mowed grass, an unexpected hug from a friend, the excited bark of a welcome home greeting and the warm feel and tangy smell of a horse and the soft nudge of her head for a carrot treat – all blend together.

None have a price tag. One or more of these things and many more, give a quality life without a price tag.

Yes, for seniors, when major disease requiring intensive treatment costly to the body and pocketbook is diagnosed, open and honest dialog between the patient and doctor is a vital step to making the right decision for each patient.

If the patient is already under treatment for life altering medical conditions and treatment, the patient must be fully informed of the new estimated treatment, length and intensity of recovery, adding the cause and effect to the existing medications and prognosis.

Who should make the decision? The patient knows when his/her quality life is over. For me, it is when I can no long feel anything but the pain …when the world around me ceases to matter…before I can no longer take care of my personal needs and can’t recover…its time.

I know, understand and approve age and other limits on lungs and organ transplants. I don’t get mammograms, apps or colon tests simply because should any prove positive, I won’t do anything about it.

My doctor and I have already talked about quality of life and she is incredibly wise and informs, yet accepts my decisions about my own health care. My family knows exactly how I feel and it is not their decision, it is my life and my decisions.

It is not your decision either. I think the patient’s doctor and other medical professionals – NOT including the government – need to present the facts to the patient in a kind, straightforward manner and let the patient and medical team make the decision regarding treatment or no treatment.

IF the facts are presented properly and honestly in each case, very few, if any, senior patients would choose to undergo serious surgery, intensive recovery time, loss of ability to care for their own personal hygiene and waste what remains of their time on earth. Each situation is different and individual.

I was once present when an elderly patient was taken to the emergency room. He clearly had dementia, yet was given – it seemed – a test on every new and old machine in the hospital. One scene stands out in memory…the technician reading aloud the instruction booklet as she hooked the patient to the machine. None of the tests were productive. I’m sure it was an expensive visit.

Keep terminally ill folks comfortable … but all these things should be discussed with the PATIENT long before emergencies and urgency cloud the overall issue.

I doubt my grandmother had much quality of life after she entered the nursing home. Her false teeth were stolen along with other personal items. She fought to get out of bed and walk until she was drugged to keep her compliant and easy to care for. Soon she couldn’t get out of bed by herself and was eventually spoon fed and diapered.
Quality of life? She was over ninety, did not recognize anyone and had forgotten how to speak English. The grandmother I knew was gone.
Why hadn’t she been allowed to walk and maintain a quality of life? Too expensive?

Keep government out of health care and a single pay. Let the free enterprise system flourish and see the health care costs diminish and patient care increase. Let the insurance companies compete for business across the nation. Allow our system to work and use the system we already have in place to correct and make the needed changes. NOT GOVERNMENT.

Remember the $600 toilet seats government bought and regular folks only paid about $50 for the same seat? How about Social Security? How many years before its bankrupt and the people paying into it now will probably never get to use it?

How has the government run Clunkers worked out for our tax dollar and the economy? Well, a lot of folks bought, free, thanks to the Clunkers program, electric golf carts.

Medicare is government run…is it successful?
Please.
The government run Medicare and Medicaid is the reason the medical profession is the only profession I know of in this country that is penalized for being in health care and treating seniors and Medicaid patients.
Patients are cheated, physicians and health care professionals are cheated…and some cheat in return.
Keep government out of the health care business… for your kids’ sake.

No one in this country is denied health care…hospitals have shut their doors before or after the bankruptcy for treating patients without payment. No one is turned away. However, how long can any organization last without revenue?

In addition, ask yourself how long a civilization can last or should last, if their citizens are evaluated and cared for based on dollars not spent?

Frank and open honest discussion with the patient – educate them – will make a difference…not manipulation based on dollars. .

NO to government health care.

More later … Sharon O’Hara
This blog post was an answer to a post on Rob’s blog and tantalizing title: http://www.kitsapsun.com/news/2009/oct/16/rob-woutat-a-dying-person-needs-death/


Health Care Reform Gallops On

Monday, August 3rd, 2009

Rachel Pritchett interviewed several health care professionals resulting in her article on health care reform in today’s Kitsap Sun. I started to make a few comments in response, and then decided to put it here in COPD and Other Stuff.

Following is the url to Rachel’s article and my comments to excerpts of her story.
http://www.kitsapsun.com/news/2009/aug/02/local-leaders-weigh-in-on-health-care-reform/unday, August 2, 2009

“Barbara Malich, CEO of Peninsula Community Health Services, said much of the reform talk is about expanding coverage, but rarely about improving access. Policies may lack dental care or mental-health coverage, causing even those who are insured to pay full freight or go without, she said.”
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Patient here: Dentistry and mental health should be part of the health care picture for patients. I know patients whose doctor will not take Medicare premiums, forcing the patient to pay out of pocket. That is fine for those who can afford it but what happens to the folks who can’t afford it? What happens to them?

How well can the body be when a tooth is infected or other dental problems?
Teeth and mouth attach to the body…why do we separate one from the other? Good dental care is vital to one’s health.
***************
‘Brian Wicks, president of The Doctors Clinic…“Right now, we’ve got everybody paid (based on units) of work performed, not compensated for coordination of care and disease prevention,” he said.…

Reform also should include incentives for providers to look at alternatives to traditional end-of-life care that often subjects patients to long stays in intensive-care units and risky and expensive surgeries. Instead, he said, providers should be encouraged to discuss options outside of surgery and the ICUs.

“Nobody compensates us for having that kind of group meeting to coordinate the care for that patient.” Wicks said.

To prevent widespread duplication of medical tests, providers should be able to access patients’ electronic records, even if those records are with a different provider, he said. Providers often end up ordering tests that have already been done because they can’t see the whole patient history, he said.’
~~~~~~~~~~~~~
Speaking as a patient:
When duplicate x-rays are taken within days of each other by different clinics (urgent care – surgeon) under the same umbrella, same town, is it currently ‘normal’ practice to order the second set only to squeeze the Medicare system? The reason given to this patient by the second doctor (surgeon) was that the first sets of x-rays were not clear enough.

If health reform passes, will the second doctor be unable to retake x-rays even though they are unsatisfactory to her/him?
*****************************************
“Huge savings can be made if reform moves toward a “value-based” payment system, according to Gary Kaplan, CEO of Virginia Mason Medical Center, which has a clinic on Bainbridge Island.

That means providers no longer would be rewarded in Medicare and other reimbursements for performing more tests than necessary, but for providing only treatment that is reasonable.”
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Patient speaking: I think you are selling doctors short. Fifteen years ago, Virginia Mason had at least one straight up doctor who did not order a battery of tests when he could have, with dad on Medicare and two follow up insurances, we would not have known the difference.

The doctor examined dad, told us what was wrong…and asked if dad wanted to go through more extensive testing that, in his opinion, would give exactly the same diagnosis. The doctor explained dad’s options, answered our questions, even answered questions we had not thought to ask. We were satisfied and dad’s inner ear imbalance unfolded as the good doctor told us it would.
******************
“Scott Bosch, chief executive officer of Harrison Medical Center, is among local provider chiefs hoping reform will help provide insurance for more of the 47 million people who now lack it.

His hospitals spend $30 million annually covering bad-debt and charity cases, with much of that loss coming from uninsured people seeking help through Harrison emergency rooms and urgent cares. If more of those people had insurance, Harrison’s losses might be less…”.”
~~~~~~~~~~~~~~~~~~~~~~~~
Patient speaking: How can health care reform be addressed until the illegal alien dilemma is solved? What percent of the 47 million people without health insurance are non-citizens of this country?

Government has not proved successful with Social Security, Medicare or Medicaid – what bright light have the for’s seen that tell them that our government can run a health care system any better?
***************************************
“Guy Stitt, president of AMI International Naval Analysts & Advisors of Bremerton, said reform should stop the practice of gender discrimination by insurance companies. It costs him twice as much to insure a 26-year-old female as a 26-year-old male on average, he said. … a woman in her 50s costs him 40 percent more than a man of the same age….”
~~~~~~~~~~~~~~~~~~~~~~~~~
Patient speaking: Why? What makes the insurance companies discriminate in such a manner? I know males pay more for car insurance…because they are in more accidents than women drivers are in at the same age.

The males higher auto insurance costs don’t reflect on his employment health care costs to his employer . Why, assuming woman have more medical costs than men, (keeping their sons, husbands and fathers healthy) force employers to favor male employees over females due to the increased health insurance cost to the business owner?
*****************
“Just about all the providers and insurers contacted by the Kitsap Sun said they were glad the topic has been moved to the top of national discussion. They also anticipate some kind of reform — maybe a lot less than hoped for — will pass in the fall…”
~~~~~~~~~~~~
Patient here: Change is needed, but not if it takes away from our free enterprise system – the same system my immigrant family came here for – to become Americans. They dreamt of a country, America, where their ideas and hard work are compensated and where the only limitation was a person’s imagination and willingness to work.

Medicare and Medicaid penalize doctors by telling them what they will pay for each procedure…never mind the doctor office overhead and skyrocketing insurance costs. . Add to it the cost of repaying their horrendous medical school debt.

My PCP is indispensable to my health. I trust her and we are in a health care partnership. The two doctors I tried after my previous doctor died did not work out. They might have been good doctors but I didn’t like them. How can anyone form a partnership with a doctor they don’t like?
Doctoring is more than a diagnosis. For the good of our health, we should have the freedom to choose our doctor.

I saw the results of a patient forced to see a doctor barely able to be civil to her. The doctor might well have a different attitude with a patient not on Medicare and able to pay his set fees.

How many patients thrive and get better or the best they can be when forced to see doctors they don’t like or trust and vice versa?

Yes, for health care reform, but do not jump on a hurried agreement that penalizes patients, doctors, hospitals, health care workers or taxpayers and our own government in the long run.

More later… Sharon O’Hara


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About This Blog

This is a patient to patient blog to exchange information and resources...from COPD (Chronic Obstructive Pulmonary Disease) to Arthritis to Cellulites to Sarcoidosis to Sleep Apnea to RLS to Psoriasis to Support Groups to Caregivers and all points in between. Written by Sharon O'Hara.

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