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Walmart Rounds Helping Train Nation's Young Doctors.

Little Rock, AK - Doctors at the University of Arkansas Medical Center celebrated the three year anniversary of Walmart Rounds on Friday, a one-of-a-kind initiative exposing student doctors to a wide variety of conditions rarely seen anywhere else in the world.

Attending physicians, residents, interns and medical students  from most specialities have donned their white coats and headed to their favorite local Walmart isle for the last three years to observe the stunning pathology of Walmartians in their natural environment.

"During Walmart rounds, we try and tell our students to be as discrete as possible whenever they discover a horse or a zebra, but sometimes their excitement overcomes them," said attending Neurologist Dr. Krzesimir Bednarczyk.

"Just last week one of my gunners in isle three started yelling back to the team 'Here comes a hemochromatosis with a lupus rash, even though it was clearly just an old lady with a bad tan.'"

When the Rheumatologists heard about a possible case of lupus heading their way,  they laughed and chuckled arrogantly.  "I teach all my fellows that nobody has lupus unless we say they do," said Dr. George Bostinza, the Rheumatologist known best for his shirt 'Why the Hell did you order a sed rate anyway?'

"We also had to put up a sign that says 'If  you're here for fibromyalgia, STOP!  Turn around and go back.  Fibromyalgia is a primary care disease.'"

But FP would have no part of it.  By punting every shopper to another service, attending physicians used Walmart rounds to educate student doctors on the financial aspects of medicine.   "We always thought our young Medicaid clinic patients rolling up in their fancy rims and newest iPhone were a bit on the entitled side, but we were shocked to learn how belligerent they became when the cashier wouldn't accept their Medicaid card as payment in full," said Dr. Alan Fenwick.

ER doctors hanging out in deli hated Walmart rounds because of the never ending stream of shoppers sent over by other teams telling them to go see ER without even a courtesy call overhead.  "Just last week some old guy showed up with Dizziness of No Possible Cause to get a stat MRI and wondered why the neurosurgeon wasn't waiting for his immediate arrival," said Dr. Brenda Dresser, an Emergency Medicine doctor who has since authored a case series in the NEJM titled  Turkey Sandwich Request as a Sign of Homeless Dilaudopenia.

"We're also thankful that I.D. chose to hang out in produce so we could them all our toxic sock syndromes."

After just one week of Walmart rounds, the Infectious Disease teams started handing out gloves and yellow gowns after seeing dozens of their C. difficile and MRSA patients man-handling the grapes.  "Less than six months after starting our infection control program in produce, we noticed a statistically significant 76% reduction in mold on Walmart strawberries," said Dr Daniel Messer, the ID doctor who routinely refuses consults for bilateral cellulitis on principle.

Walmart helping train young doctors.
Over the last three years, the Pulmonologists working cigarette checkout discovered  87% of their patients did not quit smoking last week, 92% forgot to bring their oxygen with them and 98% did in fact have $30 lying around for their copays. "They're basically just a bunch of liars," said Pulmonologist Dr. Stan Spencer, himself a two pack-per-day smoker.

While hanging out in baking, ortho  routinely spilled olive oil and waited for a fracture in unsuspecting lol's.  Appalled by the caveman like approach to medicine, many ortho students tried to escape to Dermatology hanging out in skin care, but realized they didn't usually show up until 11:00 am and were usually gone by noon for a long F.A.C.

Not so for the trauma doctors. They found Walmart to be fertile training ground for excited young surglings.  "The Walmart Scooter Club  has been a  gold mine for our young trauma doctors.   We see at least at least one high impact scooter-scooter collision every Friday.  Anything can happen when you've got two 500 pound objects colliding at break-neck speed," said trauma surgeon Dr Stan Harlow.

Even the Hospitalists used Walmart rounds as a quality improvement project after they discovered none of their patients ever showed up to their PCP follow-up appointment
within a week of discharge.  "We started scheduling follow-up at our Walmart rounds and discovered a 72% reduction in 30-day readmission rates over the last three years," said Dr John Fender, Director of Outpatient Hospitalist Medicine.

Two specialties in particular, Psychiatry and Pediatrics, have both abandoned their hospital training programs all together for a full time Walmart residency experience.  "We just couldn't replicate the level of pathology seen at Walmart in our hospital," said the hospital CEO.



Rauner's Budget is Bad Medicine for State's Health Services

The following post originally appeared on Crain's Chicago Business.

The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:



• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding

It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:

• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.

As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:

• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).

We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.

Barbara A. Otto
CEO
Health & Disability Advocates

Illinois Cooperative Brings Competition, Lower Costs for Small Businesses

Taking Advantage of Land Of Lincoln Health

Consumer Operated and Oriented Plans, or CO-OPs
for short, are a new health insurance option for small business owners. Created by the Affordable Care Act, CO-OPs are consumer-directed and required to engage members in plan oversight. Only insured members can vote for and run for a seat on the CO-OP’s Board of Directors.

What is a CO-OP?

The federal CO-OP program offers low-interest loans to eligible nonprofit groups to help set up and maintain these issuers. CO-OP loans are only made to private, nonprofit entities that demonstrate a high probability of financial viability. All CO-OPs receiving loans were selected by the Centers for Medicare & Medicaid Services on a competitive basis based on external independent review by a multi-disciplinary team. As CO-OPs meet or exceed developmental milestones, funds are allowed to be incrementally drawn down.

Taking Advantage of a CO-OP'portunity

The Illinois small business community capitalized on the CO-OP option. Small businesses in Illinois had been confronting high health insurance costs that threatened their ability to offer employee coverage. Illinois was previously dominated by one major health insurance carrier, who in 2014 wrote over 90% of the public health insurance marketplace policies in state. This market dominance gave small business owners few options in terms of obtaining and providing their employees with affordable health insurance. With CO-OPs offering the promise of increasing competition and lower rates, small businesses and individuals formed a CO-OP owned by its members and operated by its advocates.

Small Business Have More Choice

CO-OPs are following through on that promise. The Illinois CO-OP has enrolled over 50,000 businesses in 2015. During the second open enrollment period, one of every four new enrollees to the 2015 public marketplace is choosing a CO-OP. This additional competition is fantastic news for small business owners and their employees.

And High-Quality Plans

The Illinois CO-OP has been able to roll out innovative and transparent plans that connect consumers with provider choices they know and trust, because of the CO-OP's close relationship with the medical community. A consumer’s commitment, as an individual or employee, to choose the provider on the front end and at the time of selecting insurance coverage motivates the provider to build a strong relationship with that consumer. As a consumer-focused company, The CO-OP's small business insurance offerings are also designed by individuals who are attuned to the unique needs of this community.

The Bottom Line

The majority of small business owners value and care about their employees. Moreover, healthy employees with access to quality medical care are happier, more motivated and productive. Stabilizing health insurance premiums for small businesses while at the same time enabling them to procure quality coverage for their employees is a true game-changer. Small businesses drive our economy. Providing them access to affordable health insurance will benefit not only the small business community, but the entire Illinois economy.


Elliot Richardson
Founder and CEO
Small Business Advocacy Council

From Getting Insurance to Actually Using It

After the 2015 Open Enrollment Period 347,300 Illinoisans purchased plans through the marketplace, and 541,000 people have enrolled in Medicaid since its expansion in 2014. While connecting individuals to coverage is good news, the newly insured are often overwhelmed by having to navigate the overly complex healthcare system and understand the related insurance and medical jargon.  This confusion and lack of experience counteracts one of the healthcare reform law’s major goals: to reduce medical costs by increasing access to primary care. Obtaining coverage will not offset a lifetime of avoiding the doctor’s office and visiting the emergency room for primary care. The newly insured must learn how to find a doctor, fill a prescription and read a prescription label. Without that, they are subject to poor health outcomes and high costs. The newly insured must gain health literacy which can only happen through the combined efforts of consumers, communities, providers and governing bodies.

What is Health Literacy? 

The Centers for Disease Control and Prevention define health literacy as the degree to which an individual can obtain, process, communicate and understand health information and services. People with low health literacy are more likely to be uninsured. Similarly, uninsured individuals show lower health literacy scores compared to those receiving employer-based coverage.

So Why Does Low Health Literacy Matter? 

It is not altogether surprising that the uninsured and those with low health literacy are less likely to seek preventative care; more likely to experience poor health outcomes; and more likely to encounter higher medical costs. According to the Kaiser Family Foundation, only 1 in 3 uninsured adults said they had a preventive visit with their physician in the previous year, and uninsured adults experienced higher mortality rates than the insured. An Institute of Medicine report found a similar pattern of healthcare use for those with low health literacy, stating this group was less likely to seek preventive care. Research also found that lower health literacy in Medicaid managed care settings is connected with higher mortality. This shows that the uninsured and people lacking health literacy interact with the healthcare system in similar ways: poorly. Using the healthcare system is something people must learn. Giving someone a computer does not mean they know how to type. In the same way, connecting a person with healthcare will not alter their level of health literacy.

Old Habits Die Hard. The newly insured will continue receiving care in ways most familiar to them, which can translate to using the emergency room for non-emergencies. According to the Oregon Health Insurance Experiment, individuals who received Medicaid coverage increased their emergency room use by 40%. Asked to comment on the results, the state director of policy and programs for the National Association of Medicaid Directors alluded to the importance of promoting health literacy in the newly insured. She said, “this is not something that is unexpected” and “the key to getting inappropriate costs down for all patients is educating people about where they should go when it’s not an emergency.”

How to Address Health Literacy

Government Efforts
State initiatives, including an Illinois Emergency Room Diversion Grant are acknowledging the importance of patient education and using outreach to reduce ER use. In Illinois, hospital staff led outreach explaining the proper use of the ER and offered a 24-hour nurse triage line as an alternative. Meanwhile, Maine is targeting ER super-utilizers through community care teams that offer intensive case management including home visits and health coaching. Recognizing state efforts like that of Illinois and Maine, CMS listed patient education as a recommended component of programs targeting ER super-utilizers.

Health Professional Efforts
Beyond education on how to use their health insurance, health professionals can improve the usability of health services by reducing medical speak in patient interactions. Healthcare systems can also create plain-language pamphlets for patients to reference after leaving the doctor’s office. By speaking with patients in a relatable manner and sharing usable information, doctors better position healthcare consumers to adhere to medical recommendations.

Northwestern University’s Division of General Medicine and Geriatrics focuses on improving engagement between providers and patients and has developed plain-language materials that communicate complex health topics. For example, researchers created written information and videos available in Spanish and English that teach patients diabetes self-management. The modules use simple language and rely on pictures to communicate aspects of diabetes care, such as how the disease can impact a person’s eyes. By using these materials when interacting with diabetes patients, health professionals communicate vital aspects of care in an accessible manner, increasing the likelihood that patients adopt the healthy behaviors.

Community Health Literacy Efforts
The Be Covered Illinois campaign is promoting health literacy by generating easy-to-read written and online materials, creating short videos explaining critical concepts and utilizing community partnerships to expand the reach of their communications.  By producing written fact sheets on finding the right doctor and developing web content on using your coverage Be Covered empowers the newly insured with the knowledge to navigate health insurance and health care systems more effectively. Be Covered’s Dr. Lopez video series, presented in both English and Spanish, addresses health insurance topics, chronic disease, prevention and more. Be Covered broadens the reach of their education efforts by partnering with 82 organizations in Illinois, including Illinois Health Matters, that share information and materials with their own constituencies.  As part of that effort, Be Covered provides regular content for social media and shares copies of consumer friendly resources free of charge to partners.

Illinois Health Matters recognizes the importance of not only getting insurance but using insurance. The website features resources such as a Medical Cost Look Up, that allows consumers to estimate out-of-pocket costs for medical services and a resource on Immunizations and the ACA, outlining the vaccines children and adults can access for free because of healthcare reform. The website also has a tip sheet titled What to Know About Provider Networks, explaining steps consumers can take to avoid high medical costs associated with out-of-network care. These are just a few examples.

Illinois Health Matters is taking on the challenge of supporting a more health literate population, but we can’t do it alone. Join us. One great way to start: subscribe to our newsletter to stay informed and share the knowledge with your clients and coworkers. The healthcare community can achieve the vision of the Affordable Care Act, but only through the joint efforts of providers, policymakers and organizations supporting health literacy.

Bryce Marable MSW
Health Policy Analyst 

New Granny Dumping Law Excites Doctors and Nurses.

Minneapolis, MN - Hospitalists and ER doctors clapped loudly Monday after Minnesota Governor Mark Dayton signed legislation SF 18342, making it illegal for families to drop elderly relatives off in the ER and then leave.  The offense is a misdemeanor with a fine of up to $2,500.

Dubbed the Granny Dumping Law, officials hope this puts an end to the practice of using expensive emergency rooms and hospitals as a holding tank for the state's at-risk elderly community while their children take family vacations to warmer climates or simply want a weekend alone without their parents or in-laws.

Doctors and nurses say they can see a granny dumping case from a mile away and are tired of being used as daycare staff by uncaring children who use the state's hospital system as their vacation kennel.

"At least once or twice a day every winter, we see families decked out in Tommy Bahamas, driving slowly through the ER parking lot in a minivan pilled high with suitcases before calmly wheeling granny up to triage to say something is wrong with nana and then driving off, " said ER triage nurse Adrian Bremer.

The legislation allows doctors and nurses to hand out fines on the spot, after being deputized by the state, when they suspect cases of granny littering in the ER.   The minimum fine is $1,000 but quickly rises to $2,500 for cases involving poocanos or toxic foot syndrome.

In today's age of entitlement, some families don't even try to hide their desire to rid grandma for the weekend. "I had a guy last Friday drop off his mother-in-law with a box of Kellogg's Raisin Bran ® saying he was having a big poker game this weekend and he'd be back Monday to pick her up," said Adrian. "When I told him that wasn't appropriate, he said 'EMTALA bitch' then asked where his satisfaction survey was."

Granny Dumping Law hopes to reduce Vacation Observation admissions.
Instead of working up these patients, ER doctors have started to call the hospitalist to directly admit them from triage for Vacation Observation (ICD-10 code 33.10.9).

"We used to call the families after everything came back normal except the gratuitous contaminated UA, but they never answered their phone and we aren't allowed to send an old person home from the ER," said emergency doctor James Johnson, who claims that's a hospital policy and he's just doing his job.

But hospitalists say the already busy winter months have become increasingly more intolerable with the rising number of vacation related admissions.

"I'm averaging three vacation observation patients a day on my list and they are the hardest to please.  I think the families are telling them we are a 5-star hospitel." said hospitalist Dr. Jenny Howell.

Even some community doctors have starting using Vacation Observation as a reason to clear their census for their own family vacation.

"It was awesome.  I had my Physician Assistant Assistant's nurse call the hospitalist last Friday evening and make up a story about how all seven of my patients needed a higher level of care so I could clear my census for vacation," said one Family Medicine doctor who wished to remain anonymous because he knew what he was doing was just plain shitty.