Cost Share Program by Blue Cross Blue Shield.

Aspirin for headache.... 30 cents, medication for cough……. $3, antibiotics for flu…… $40. Being treated at some of the top notch hospitals.... an extra $1000. They say all good things in life are free, as long as you are not going to a hospital.

Recently Blue Cross Blue shield of Massachusetts introduced Hospital Choice Cost-Share Program. It is based on a system of High Cost hospitals and High Value hospitals. This year it was determined by CMS that all hospitals met the quality bar in Massachusetts. 

So these hospitals were than classified on the basis of cost meaning High Cost versus High Value hospitals. If you choose this program and if you decide to go to “high cost hospital”, you will end up with a higher co pay after their deductible. So far I hope this is not too confusing.

OK here goes, various hospitals charge different amount for the same services. So let’s say for a certain test one hospital charges you $1000 and another hospital charges to $600 for the same service. If you choose a Higher Cost Hospital you will pay your standard deductible + $450 co pay, for a lower cost hospital you pay only your co pay. However, if you go for the same test again within a year, for a Higher Cost Hospital you will pay $450 co pay, for a lower cost hospital you pay zero dollars. If you choose this program your premiums would not hike as much for next year.

Now if you decide to see the top 15  providers in Massachusetts, you would have to pay a higher out of pocket expense almost $1000, including hospitals like Brigham and Women’s Hospital, Harvard and University of Massachusetts Hospital (UMASS). Not so for Beth Israel Deaconess Hospital, Harvard (BIDMC) which was considered to be a low cost institute. I can relate to these issues as I saw it first hand when I was working at BIDMC and also at UMASS.

What impact this would have nationwide is still yet to be determined. I think if this becomes a trend with other insurance agencies and Medicare too, it may result in a paradigm shift in the way some hospitals do their billing. As we all know hospitals bills are not an easy thing to deal with regardless of what insurance you have. I wrote about this issue here (Bankruptcy, You Could Be Next).

Blog You Later.

About the picture: My very first day at UMASS many many many years ago.
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End Of Life Issues.

When I saw my first patient die, I was in shock. I knew that some will die but you are not really ready until you see one. You will never forget your first one, that always stays with you. When my first patient died during medical school;  a young guy around forty. He died from complications of Endocarditis. He was fine in the afternoon, talking about his family and what he does, when I came back in the morning he was gone. I was shocked beyond words. Unfortunately with time and age you get used to it. We adapt and move on but still end of life issues are difficult to deal with, even for the most experienced doctors.

I wrote about the role of hospice here earlier. But there is a transition, a process which ends up with hospice or no code status, but this process starts when a physician starts talking about end of life issues.  

During my training at UMASS, we were taught to always inquire about the code status at the completion of history and physical. This included either a Full code, DNR (do not resuscitate) or CMO (comfort measures only) status. However , most of the time this discussion is delayed until it is too late in the game. 

Some of the pitfalls I see in this matter are:

1- Physicians are a little weary about inquiring the code status. There may be a certain level of apprehension as they think that the patient may loose confidence in them if they ask this question. 

2- Patients may get angry as we all know that we will never die.

3- Often I hear physicians asking patients "do you want us to do everything". In this scenario physician assumes that the patient does not want to die.  Information is not carried to the patient properly and the patient makes a vague statement "yes", But the question is yes to what? However, code status is entered in the medical record as Full code.

I am not saying that I am an expert in this issue. Usually this is how I ask them after I am finished with history and physical that "I would like to ask what I ask all my patients, what are your wishes in case your condition deteriorate, I don't want to do any thing which is against your believes and wishes". 

You need to ask the patient how they feel or understand about their condition, otherwise it becomes a one sided discussion without giving the patient an opportunity to discuss their perspective.

If they decide to be DNR, then I go over various options which a person can choose from refusal to blood transfusions to refusal of basic CPR or intubation.

It is important to give patient time after each statement for two reasons a) It gives times for the information to sink in and b) it gives physician some time to read patients reaction and some space to to maneuver words to soften the impact.

All in all this is a very important process and physicians need to be more proactive about this process.

Blog you later.

About the picture: I woke up at 5 am to run to Na' Pali coast, Kauai when I saw this sunrise at the beach.

My Teachers.

I have been blessed with great teachers. They showed me horizons which I thought did not exist. They had an array of personalities and professions. Not all of them were strictly in the academic settings. They varied in age and things they had to offer, at different stages of my life. Like my high school teacher Ms. S, who taught me time management and brought out the best in me. My father, who showed me being a doctor, is more than billing a patient.

My little 6 year old daughter, who taught me what is more important in life, when she asked me to donate money to the hospital I work at, I asked why. She said “so that you can spend more time with me”. My teacher at Beth Israel Hospital/Harvard Dr. Ferris Hall, who taught me that you can not ask for respect, you earn it.

My “singing heart” patient who taught me that you have the power to brighten someone’s day. My supervisor at the carpet cleaner company where I worked in Chicago during my first year in America, who taught never to treat anyone the way you don’t want to be treated.

Our janitor Julie, who spent decades at University of Massachusetts, taught me never to ignore people who help you, with what you do. She said "I feel invisible, people pass by me all day long but never seem to notice my presence". Indeed, she was right when I saw her next day working, she was….invisible to everyone.

I cannot forget my senior resident Kirk MacNaught, who told me once during my intern days when I was in a hurry to make a decision about a patient, “You should never treat a patient like you would not treat your own family member”. Then he continued in his soft voice “can you please stop running around the hospital like a chicken with its head cut off and get back to work”.  

I sometimes still run like that. I never claimed that I was the best pupil, I was just lucky to have great teachers. Most of all my patients are the best teachers, who teach me things I could have never learned in any school.


About the picture: I think this does not require any explanation.

White board R’ us.

There is a white board in every patient's room. This is used to keep patient oriented and provide them with basic information. You would see some data on it, most of the time there is a date scrolled on it, name of the nurse and maybe physician’s name.

I recently read an article “getting the most out the humble white board” by Deborrah Gesenway. This is an excellent read and I would strongly recommend that you should try reading it. Dr. Niraj Sehgal, a hospitalist at the University of California conducted a survey regarding the use of white board. He inferred at the end of survey that “white board should be a patient centered tool”. This can be used to convey to the patient what the goals are for the day and what kind of test or procedures they should be expecting.

So after reading the article I decided to give it a try. I borrowed a color marker from our unit secretary and started my new quest. When I am finished talking to the patient I take out my marker and write down the plans in a bullet format. For example,

• My Name
• CT Abdomen today.
• GI consult requested.
• Transfuse 2 units of blood.

This hardly takes few seconds but provides point of reference for the patient and they feel much better when they know what their goals are for that day.

I have been doing this for the past 2 weeks, since then I feel my patients are better informed and more appreciative. What do you think?

About the picture: Umass reminds me of the old times although this is quite a big white board for some one in Tampa Bay.