Executive Pay
I am fascinated by the ability that the defenders of massive executive salaries have in keeping a straight face while they talk about the "need" to pay these people high salaries and bonuses. This is supposed to be capitalism at work, capitalism doing its thing to ensure that the "best minds" are running these corporations. I'm blogging about this because I lump insurance company executives in this same group.
These same people believe that doctors are paid too much, as if there is less desire or need to have the "best minds" in medicine. No, let's put them in executive suites with lavish lifestyles so that they can decide the lives of others by withholding payment for care, and deny coverage for the unfortunately sick.
Even the "fee for service" concept has come under attack. But doctors didn't invent this, they did, and have carefully honed into a process that defies logic much of the time. They did it to specify that only certain things a doctor does are worthy of payment. So we define payable services, and everything else you do is gratis. I don't get paid for phone conversations with various people to come up with investigations and treatment plans, not for discussing results over the phone, not for reviewing charts and records (in a sense one might argue this is, but it's bundled into some patient contact service, not payable by itself).
What this means is that in a day in which I may be nonstop involved in some aspect of patient care except for a brief lunch, there are only some billable moments that actually earn me income. The side effect is that these billable moments look like I might be making $100 to $200 an hour based on actual literal patient contact time.
Contrast this with executives, who make money by just showing up, but of course showing up doesn't involve punching a time card. And they make more money by setting up systems that carve away at the doctors' billable moments, or deny coverage for something so that the doctor must spend more non-billable time to get the decision reversed.
As we crank our way through some kind of health care reform we are certain to hear more calls to limit doctors' pay, even though we're not the biggest cost of health care. Even though we actually do something for the patient (supply a service) as opposed to taking their money and then figuring out a way to not give them anything for it.
Saturday, October 24, 2009
Wednesday, October 14, 2009
Health Insurance Premiums
Taking a cue from the Republican Party playbook of idiotic moves, health insurance companies have now come up with a campaign to insure (sic) that even more of the American people stand up for their right to make nonsensical profits.
They also make it easy to decide what the responses should be: 1) controlling insurance company profits, 2) eliminating executive bonuses for increasing profits by denying coverage, and finally 3) absolutely showing the need for the public option.
Thank you, health insurance companies of America, for your thoughtful and helpful input.
Taking a cue from the Republican Party playbook of idiotic moves, health insurance companies have now come up with a campaign to insure (sic) that even more of the American people stand up for their right to make nonsensical profits.
They also make it easy to decide what the responses should be: 1) controlling insurance company profits, 2) eliminating executive bonuses for increasing profits by denying coverage, and finally 3) absolutely showing the need for the public option.
Thank you, health insurance companies of America, for your thoughtful and helpful input.
Thursday, October 08, 2009
A Week in the Life
It's been a bad week. A bad week that a logical person would say was my own (un)doing. My wife says at some moments that maybe I have Asperger's syndrome. Maybe she's right, I don't know. Maybe I'm Don Quixote, railing at windmills to the dismay of those around me.
Maybe I have cesspools of sarcasm and cynicism somewhere deep inside me that possess me and make me say things I have to explain later. Things that can't be explained.
The paradox is that I think I am personable and likeable, at least at times. I can tune into the psyche in the room like a rat terrier checking out a rat hole. (Part of the reason that I think the Asperger's accusation is weak.) I can anticipate where people's minds are, where they're going, and translate to whatever level they can understand.
The patients and the families appreciate this. They thank me for explaining things in a way they could understand. That I show that I have some understanding of what they're going through (part of which is to NEVER say, "I understand what you're going through.")
So I've gotten myself into an administrative hole, maybe a hot box, revolving around some excessive irritations with people wanting to shove information my way, any time of day, information I don't want, don't need, and if I did I wouldn't hesitate to ask about. So the cows in the world simply moo and chew cud and listen, but I say, "I don't need or want this information." But you can't stop it, I guess any more than you can stop spam or junk mail, or some guy stopping you on the street begging for money.
We get through our lives with mental images of the world and the people in it. I have an increasing number of those that enter my semi-transparent perception. Yes, they're there, they live and breathe and they sometimes talk to me with some sort of empty rendition of "How are you doing?" but I can choose to simply just say "Ok" in a monotone that invites no follow up conversation, and pass through or beyond them as if they don't exist in my world, because they don't.
So in a week that challenged my autonomic nervous system at times, with chest pounding and the vague intimations of nausea that comes as part of the package, and I was grateful my stomach was empty at the time, I carried on, seeing patients, intent on understanding what happened, what needed to be done, and didn't shy away from sitting down with the family surrounding me in rapt attention as I related the catastrophic story about their mother, their sister, and how even though her body is still here, her mind, her brain is gone, and there is nothing that I or anyone else can do about it.
You read the faces, read them as you talk, avoiding the medical terminology as if someone's life depended on it. You listen, listen to the words, but also listen to the flushing face, the welling up tears, the bowing head, the hyperventilation, and imagine sitting in their seat, thinking their thoughts with all the turmoil and incoherency that you know is there.
And then, by some means I cannot understand, they thank me. They shake my hand for explaining the awfulness of it all, for answering questions that don't always have definite answers. So I walk out of the room, feeling like I'm imploding with every step into some sort of shriveled up raisin of myself. I cannot talk to anyone, since I have no words left inside of me now, so I leave like some hollow shell.
I go out to dinner, partly because my wife's out of town, but partly just to step into some innocuous environment where everything goes on in a simple transactional way.
As I finish my meal, a man comes up and thanks me. Thanks me for taking care of his son in the hospital, and while I remember the name, I don't remember him or remember what I did about his son. After he leaves, the server comes up and tells me that he paid for my dinner.
I don't know that this will always impress me so much, but on this particular day, in this particular week, I am deeply moved.
It's been a bad week. A bad week that a logical person would say was my own (un)doing. My wife says at some moments that maybe I have Asperger's syndrome. Maybe she's right, I don't know. Maybe I'm Don Quixote, railing at windmills to the dismay of those around me.
Maybe I have cesspools of sarcasm and cynicism somewhere deep inside me that possess me and make me say things I have to explain later. Things that can't be explained.
The paradox is that I think I am personable and likeable, at least at times. I can tune into the psyche in the room like a rat terrier checking out a rat hole. (Part of the reason that I think the Asperger's accusation is weak.) I can anticipate where people's minds are, where they're going, and translate to whatever level they can understand.
The patients and the families appreciate this. They thank me for explaining things in a way they could understand. That I show that I have some understanding of what they're going through (part of which is to NEVER say, "I understand what you're going through.")
So I've gotten myself into an administrative hole, maybe a hot box, revolving around some excessive irritations with people wanting to shove information my way, any time of day, information I don't want, don't need, and if I did I wouldn't hesitate to ask about. So the cows in the world simply moo and chew cud and listen, but I say, "I don't need or want this information." But you can't stop it, I guess any more than you can stop spam or junk mail, or some guy stopping you on the street begging for money.
We get through our lives with mental images of the world and the people in it. I have an increasing number of those that enter my semi-transparent perception. Yes, they're there, they live and breathe and they sometimes talk to me with some sort of empty rendition of "How are you doing?" but I can choose to simply just say "Ok" in a monotone that invites no follow up conversation, and pass through or beyond them as if they don't exist in my world, because they don't.
So in a week that challenged my autonomic nervous system at times, with chest pounding and the vague intimations of nausea that comes as part of the package, and I was grateful my stomach was empty at the time, I carried on, seeing patients, intent on understanding what happened, what needed to be done, and didn't shy away from sitting down with the family surrounding me in rapt attention as I related the catastrophic story about their mother, their sister, and how even though her body is still here, her mind, her brain is gone, and there is nothing that I or anyone else can do about it.
You read the faces, read them as you talk, avoiding the medical terminology as if someone's life depended on it. You listen, listen to the words, but also listen to the flushing face, the welling up tears, the bowing head, the hyperventilation, and imagine sitting in their seat, thinking their thoughts with all the turmoil and incoherency that you know is there.
And then, by some means I cannot understand, they thank me. They shake my hand for explaining the awfulness of it all, for answering questions that don't always have definite answers. So I walk out of the room, feeling like I'm imploding with every step into some sort of shriveled up raisin of myself. I cannot talk to anyone, since I have no words left inside of me now, so I leave like some hollow shell.
I go out to dinner, partly because my wife's out of town, but partly just to step into some innocuous environment where everything goes on in a simple transactional way.
As I finish my meal, a man comes up and thanks me. Thanks me for taking care of his son in the hospital, and while I remember the name, I don't remember him or remember what I did about his son. After he leaves, the server comes up and tells me that he paid for my dinner.
I don't know that this will always impress me so much, but on this particular day, in this particular week, I am deeply moved.
Sunday, October 04, 2009
Employee
A few months ago, our group, like so many across the country, made the jump to become employees of a local hospital "health care system". While we enjoyed the autonomy of making our own decisions, things were becoming progressively untenable. Each year, health insurance costs were rising, so each year we had a choice of either paying more to insure our employees or cutting back on benefits, and in the end we tended to do a bit of each.
As far as the docs' income, as things were sliding, we went to a payment system in which a significant part of our incomes were based on what was actually collected (the idea was that we needed an "incentive"). While in some mathematical sense this might seem fair and economically good for the group, it led to increasing discrepancies of income for various members, since it wasn't strictly based on how much work you did, but the economic quality of that work. As we all know, how much you might collect depends on who is paying.
A secondary side effect is that it gets harder to get people to do necessary work that is not reimbursed well, so who is available to help out with various things becomes a bit sticky at times.
After some previously spurned overtures from hospitals to become employees, we finally decided to give it a look, and had two systems competing for our affections. After some negotiations, we chose one, and so now we are employees. Now many of the headaches of staffing and overhead are gone, we have better health insurance than we had before, and more or less do the same work.
Now, however, what we get paid, aside from a base salary, has to do with RVUs -- relative value units, which means that there is a scale of value assigned to various charges, and we accumulate credit according to that. Notably, this is independent of who pays the bill or even if there is none (the misleadingly named "self-pay" patients). So in that sense I am better off than before, though it's hard to tell how much. It so happened that this all came about at about the same time that we (I) became the sole neurology consultant for the hospital next door to our office (translation: the others left), which meant that I became incredibly busy, good for any reimbursement scheme, but bad for getting home earlier than 8, 9, 10pm or later every night. Good for bonuses, bad for lifestyle (coming home at night and crashing on the couch).
We're in the process of rearranging other docs' schedules to help me out, and it's working to some extent, so now I can actually get home before dark much of the time -- it's bad when you can't get home before dark in the middle of summer's daylight savings. So far so good on this transition to being an employee.
A few months ago, our group, like so many across the country, made the jump to become employees of a local hospital "health care system". While we enjoyed the autonomy of making our own decisions, things were becoming progressively untenable. Each year, health insurance costs were rising, so each year we had a choice of either paying more to insure our employees or cutting back on benefits, and in the end we tended to do a bit of each.
As far as the docs' income, as things were sliding, we went to a payment system in which a significant part of our incomes were based on what was actually collected (the idea was that we needed an "incentive"). While in some mathematical sense this might seem fair and economically good for the group, it led to increasing discrepancies of income for various members, since it wasn't strictly based on how much work you did, but the economic quality of that work. As we all know, how much you might collect depends on who is paying.
A secondary side effect is that it gets harder to get people to do necessary work that is not reimbursed well, so who is available to help out with various things becomes a bit sticky at times.
After some previously spurned overtures from hospitals to become employees, we finally decided to give it a look, and had two systems competing for our affections. After some negotiations, we chose one, and so now we are employees. Now many of the headaches of staffing and overhead are gone, we have better health insurance than we had before, and more or less do the same work.
Now, however, what we get paid, aside from a base salary, has to do with RVUs -- relative value units, which means that there is a scale of value assigned to various charges, and we accumulate credit according to that. Notably, this is independent of who pays the bill or even if there is none (the misleadingly named "self-pay" patients). So in that sense I am better off than before, though it's hard to tell how much. It so happened that this all came about at about the same time that we (I) became the sole neurology consultant for the hospital next door to our office (translation: the others left), which meant that I became incredibly busy, good for any reimbursement scheme, but bad for getting home earlier than 8, 9, 10pm or later every night. Good for bonuses, bad for lifestyle (coming home at night and crashing on the couch).
We're in the process of rearranging other docs' schedules to help me out, and it's working to some extent, so now I can actually get home before dark much of the time -- it's bad when you can't get home before dark in the middle of summer's daylight savings. So far so good on this transition to being an employee.
Sunday, September 20, 2009
Far-sighted vs Short-sighted
We're getting a lot of play from the Libertarian camp in recent months, with their cry for smaller government, less spending, letting people do what they want to do. The Republicans and Big Business will sidle up to Libertarians on these issues, because in the end, being a Libertarian is about being selfish. Doing what you want without the government butting in. It's sounds "American", sounds like the attitude people had when they came to this country. Sounds like the freedom people had out in the romantic West.
If there ever were pockets of freedom, it was quickly realized that this really was lawlessness. And it wasn't about everyone doing what they wanted to do, it was about only certain people doing what they wanted to do. As always, to have money was to have power, so the rich guy hired the guns to enforce things as he saw fit.
So now we have Big Business and their bed mates the Republicans using the hired guns of various people with libertarian tendencies to do their dirty work. But it's really about the power and the money, that's all. The best part is, these "hired" guns are working for free, because they have no clue they're being duped by those who are making a lot of money while they stand out in the sun holding placards and yelling.
The power hungry and the greedy are the most dangerous, selfish people we have in this country. It doesn't matter how the country as a whole is doing, global warming, the economy, future generations, it's only the here, the now, the me.
Contrast this with places like Germany, where society, the government have decided that it is important to invest in the future, that one must always look beyond this year and next, or even beyond 5 and 10 years from now. So they are constantly investing in the infrastructure. As much as possible, public transportation runs on electricity, you see renewable energy projects wherever you go. You see people caring about the place they live. You also see that they see the health of the populace and future generations as an important investment.
So rather than set up barriers to getting anywhere, they set goals, standards for how their country, their society will behave, then they get to work at making progress toward their goals. Yes, this is expensive, but it's less expensive to do this gradually than it is to keep deferring it to future generations.
This isn't unamerican. It isn't something we're not smart enough to figure out. If we're not smart enough, then we might as well acknowledge that Americans are inferior to the Germans. There is nothing about this that contradicts anything in the Constitution or what the founders of the country had in mind. The question is, can America in the 21st century ever set its mind to do something that is really important for the country and for our future? Or are we once again going to be duped by the guys sitting on huge piles of money?
We're getting a lot of play from the Libertarian camp in recent months, with their cry for smaller government, less spending, letting people do what they want to do. The Republicans and Big Business will sidle up to Libertarians on these issues, because in the end, being a Libertarian is about being selfish. Doing what you want without the government butting in. It's sounds "American", sounds like the attitude people had when they came to this country. Sounds like the freedom people had out in the romantic West.
If there ever were pockets of freedom, it was quickly realized that this really was lawlessness. And it wasn't about everyone doing what they wanted to do, it was about only certain people doing what they wanted to do. As always, to have money was to have power, so the rich guy hired the guns to enforce things as he saw fit.
So now we have Big Business and their bed mates the Republicans using the hired guns of various people with libertarian tendencies to do their dirty work. But it's really about the power and the money, that's all. The best part is, these "hired" guns are working for free, because they have no clue they're being duped by those who are making a lot of money while they stand out in the sun holding placards and yelling.
The power hungry and the greedy are the most dangerous, selfish people we have in this country. It doesn't matter how the country as a whole is doing, global warming, the economy, future generations, it's only the here, the now, the me.
Contrast this with places like Germany, where society, the government have decided that it is important to invest in the future, that one must always look beyond this year and next, or even beyond 5 and 10 years from now. So they are constantly investing in the infrastructure. As much as possible, public transportation runs on electricity, you see renewable energy projects wherever you go. You see people caring about the place they live. You also see that they see the health of the populace and future generations as an important investment.
So rather than set up barriers to getting anywhere, they set goals, standards for how their country, their society will behave, then they get to work at making progress toward their goals. Yes, this is expensive, but it's less expensive to do this gradually than it is to keep deferring it to future generations.
This isn't unamerican. It isn't something we're not smart enough to figure out. If we're not smart enough, then we might as well acknowledge that Americans are inferior to the Germans. There is nothing about this that contradicts anything in the Constitution or what the founders of the country had in mind. The question is, can America in the 21st century ever set its mind to do something that is really important for the country and for our future? Or are we once again going to be duped by the guys sitting on huge piles of money?
Friday, September 18, 2009
Dell 2100N - VI
Ok, I've been using this for the past few months, carrying it with me wherever I go, finding out where various hotspots are outside the hospital.
Generally, it's working pretty well. The most common yet not really major problem is whether it all wakes up from suspend mode. Sometimes the hardware doesn't all wake up, most notably the wireless is not recognized, but I've figured out that the culprit seems to be a failure to reactivate the HAL daemon (HAL = hardware abstraction layer), which means that things like the wireless and sound chips might as well not even be there. So simply restarting the haldaemon is the answer.
Sometimes, maybe due to the haldaemon but hard to tell since this is kind of unsolvable by definition, the keyboard and mouse do not function. At all. The only thing to do here is a hard shutdown, holding the off button until it goes off, then restarting. The uglier way to do this is to unplug the battery pack.
A less severe version is just that somehow I get logged out and have to log in again. All of these examples keep me focused on frequently saving, and definitely before suspending, or using software that is always saved by definition, such as Postgresql, my database.
I'm a little disappointed that BasKet has not found its rightful niche in my work day. Forgetting to use it seems to be the basic problem. I have trimmed its task down to keeping notes about things I need to do but have to defer, such as when I am in the office, but need to look up something on a patient the next time I'm in the hospital. It's surprisingly hard to keep this in your head. I usually remember the next time I'm back in the office, one of these "Doh!" moments. Eventually I think I'll get the BasKet thing down though, it's just that it's a bit foreign to everything else I'm using.
I don't know how I could do without this netbook now.
Ok, I've been using this for the past few months, carrying it with me wherever I go, finding out where various hotspots are outside the hospital.
Generally, it's working pretty well. The most common yet not really major problem is whether it all wakes up from suspend mode. Sometimes the hardware doesn't all wake up, most notably the wireless is not recognized, but I've figured out that the culprit seems to be a failure to reactivate the HAL daemon (HAL = hardware abstraction layer), which means that things like the wireless and sound chips might as well not even be there. So simply restarting the haldaemon is the answer.
Sometimes, maybe due to the haldaemon but hard to tell since this is kind of unsolvable by definition, the keyboard and mouse do not function. At all. The only thing to do here is a hard shutdown, holding the off button until it goes off, then restarting. The uglier way to do this is to unplug the battery pack.
A less severe version is just that somehow I get logged out and have to log in again. All of these examples keep me focused on frequently saving, and definitely before suspending, or using software that is always saved by definition, such as Postgresql, my database.
I'm a little disappointed that BasKet has not found its rightful niche in my work day. Forgetting to use it seems to be the basic problem. I have trimmed its task down to keeping notes about things I need to do but have to defer, such as when I am in the office, but need to look up something on a patient the next time I'm in the hospital. It's surprisingly hard to keep this in your head. I usually remember the next time I'm back in the office, one of these "Doh!" moments. Eventually I think I'll get the BasKet thing down though, it's just that it's a bit foreign to everything else I'm using.
I don't know how I could do without this netbook now.
Sunday, September 13, 2009
WWJD and Other Thoughts
Remember WWJD and all those wrist bands and other labelled paraphernalia? You don't see them now, even though maybe now is the time that we might need them.
What Would Jesus Do with this health care debate? Which side would he be on? Would he be on any side at all? Would he be there in the crowd of rabble rousers shouting down the President or some other speaker, or a CNN reporter? Would he be standing at the border with a loaded gun aimed at illegal immigrants? Would he be marching to Washington to complain about the money we're spending to help people out of unemployment, to keep businesses afloat, to try to allow them to keep their homes from foreclosure?
Some believe and espouse the idea that we live in a Christian nation, but it's getting harder to see signs of that recently. Oh yes, people still go to church, pray and sing fervently to their God for forgiveness for their sins of not being kind to others, wanting ill-will on others, not being generous enough, maybe even hating someone, but after Sunday, it's back to the reality that doesn't include Christian ideals, unless it's modified to the point that it can't be recognized as such anymore.
If there are real Christians out there, maybe they need to expose and cast off the pretenders, the Pharisees and others that are into Christianity for some personal selfish reason, who really worship the almighty dollar that sits in their own bank account. Seems like I remember a story about Jesus that revolves around that issue.
Remember WWJD and all those wrist bands and other labelled paraphernalia? You don't see them now, even though maybe now is the time that we might need them.
What Would Jesus Do with this health care debate? Which side would he be on? Would he be on any side at all? Would he be there in the crowd of rabble rousers shouting down the President or some other speaker, or a CNN reporter? Would he be standing at the border with a loaded gun aimed at illegal immigrants? Would he be marching to Washington to complain about the money we're spending to help people out of unemployment, to keep businesses afloat, to try to allow them to keep their homes from foreclosure?
Some believe and espouse the idea that we live in a Christian nation, but it's getting harder to see signs of that recently. Oh yes, people still go to church, pray and sing fervently to their God for forgiveness for their sins of not being kind to others, wanting ill-will on others, not being generous enough, maybe even hating someone, but after Sunday, it's back to the reality that doesn't include Christian ideals, unless it's modified to the point that it can't be recognized as such anymore.
If there are real Christians out there, maybe they need to expose and cast off the pretenders, the Pharisees and others that are into Christianity for some personal selfish reason, who really worship the almighty dollar that sits in their own bank account. Seems like I remember a story about Jesus that revolves around that issue.
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