The last few months have provided a new perspective of healthcare for me. Against a backdrop of healthcare reform, passage of the Affordable Care Act, release of proposed Accountable Care Organization regulations, and a proposal from Congressman Paul Ryan on behalf of the Republican majority to transform Medicare, I have had a full knee replacement and my mother was hospitalized in ICU.
The decision to have a full knee replacement came following a succession of meniscus surgeries and a slow weight gain precipitated by difficulty exercising. Once the decision was made that a full knee replacement was the only real option available, I learned that the in-network hospital and in-network orthopedic surgeons did not match. The closest match was a group located on the other side of the city that performed procedures at the hospital ten minutes from home one day per month. A complete review of the roster of “approved,” in-network orthopedic surgeons included several orthopods who did not do total knees, two neurosurgeons who did not do any orthopedics but were approved, and an assortment of hand and shoulder specialists.
The unaligned assortment of professionals and institutions looked like a recipe for a ragout rather than an integrated delivery system. For a while, I felt like a loan ingredient in the ragout.
Homework at this point entailed researching orthopedists in the city who did knee surgery – and their outcomes; identification of the plan procedures for requesting out of network services; and an understanding of all procedures and costs associated with total knee replacement. The laborious task was addressed in the same way any project was to be undertaken. Identify the objective, understand the current situation, and developed a strategy. The objective was simple – successful total knee replacement paid for as in-network services. Research required using each and every resource mastered after thirty years in healthcare. Chief among these resources was the ability to make telephone calls using a masterful voice, being direct in questions, and assuming that I had any authorization necessary to obtain the desired response.
The result was a second appointment with the desired orthopedists. I was armed with documentation, prior authorizations, MRI scans, x-rays, memoranda, telephone contact lists, and particulars about the type of implant I would like to have. The result was scheduling the procedure at the day, time, and location of request with the orthopedic team brining the best clinical outcomes in the community. The only thing that I didn’t have time to prepare was me – emotionally, psychologically, or situationally.
My mother collapsed at home and was brought to the same hospital previously referenced by ambulance. Diagnosed with pneumonia, we were all taking turns staying with her at home. Once at the ED, she began bleeding severely, oxygen levels low, and hemoglobin levels low, renal function almost non existent. One of the physicians said that instead of presenting with a problem, she showed up like a “bungee jumper.”
The GI bleed was found to be caused by two ulcers. The surgeon requested a biopsy; but we were insured that it was due to ibuprofen consumption; especially since she was over 75-years and had a heart attack three years ago. Staff kept asking where her hearing aids were; we explained that she had severe wax in her ears and was scheduled to have it removed by her internist the following week. The ED moved swiftly to ICU. A couple of days in the ICU morphed into a room on the medical unit.
Couple of important things to note. The GI bleed was not due to ibuprofen. Rather, it was an organism that needed to be treated with medication. None of the physicians, specialists, or nurses was able to clean out the wax – she would have to be discharged as an inpatient and come back for outpatient services. Note … the wax caused her not to hear caregiver’s instructions.
Physicians, pharmacists, therapists of all types, medical bills titled “Not a Bill,” and medical bills that really were bills. Pundits and legislators have been negotiating healthcare reform implementation while we were trying to navigate a disjointed, dysfunctional system of healthcare silos. Case in point:
My first visit to my internal medicine physician following surgery included the statement, “What surgery? When did you have knee surgery?” I had signed multiple forms prior and during hospitalization with the name of my internists. She is an employed physician with the same health system that I had surgery at.
The day before surgery, I called to double check prior authorizations. There was no record of the prior authorization. After several telephone calls, they were found.
My mother was asked consistently if she had any previous surgeries. We were in the same hospital that she had her heart attack and stent placement three years previously.
I wish I had the answer to the ills of the healthcare industry. Initiative like federal support of electronic health record implementation makes sense. It would have resolved several of the issues that we experienced. Until the federal government mandates one single EHR, there will not be total interconnectivity. For history buffs, remember how train tracks were all different gauge, thereby limiting transcontinental or regional transportation. The patient centric medical home model would provide for a patient ombudsman and coordinator. Unless all physicians are part of the integrated medical home’s medical staff, there will always be outliers.
Each initiative has merit. As stand alone imperatives each appears to resolve a unique problem. Integration and coordination in a free market economy has not been achieved in the past.
My knee still hurts when I do a lot of walking. My mother was moved from ICU to a room yesterday. We both are dealing with lots of bills entitled “Not a Bill.” The next time I download proposed healthcare legislation, I may see if it is titled “Not Healthcare Reform.”
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