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Doctors Accepting Medicaid? Facebook Says There Are None (Picture).

Citizens who claim Obamacare is a major victory for patients are going to be greatly disappointed to learn that Obamacare promises to provide health care insurance without health care access. Obamacare promises to massively expand Medicaid. Medicaid is broke. The only places accepting Medicaid these days are hospitals and emergency rooms.   I have been a practicing hospitalist now for ten years. I have seen Medicaid failures first hand. In my community of Lincoln, NE, finding a new doctor to accept Medicaid is nearly impossible. In fact, I have witnessed first hand how difficult it is to get a hospitalized patient of mine with Medicaid to find a primary care physician post hospital stay to establish new patient care. It took over 35 phone calls to over 35 clinics to find one physician's office willing to accept a new Medicaid patients. In fact, one office even required five years worth of records and an interview appointment before they would consider accepting a new Medicaid patient.

That's thirty five calls to physicians before one would accept a new Medicaid patient. ObamaCare promises to massively expand Medicaid and promises to cover some of the expansion with unstable federal money that will surely be held hostage by party politics. Physicians aren't biting. Most physicians can easily fill their schedules with follow up appointments of their other chronic disease patients.   For many doctors' offices, accepting new Medicaid patients are not in their budget or long term business plan. It's not just internists and family medicine physicians that are not accepting new Medicaid patients. It's also our colleagues in the pediatric world. I was recently shown a Facebook screen shot of a woman who was looking for a pediatrician for their eight month old child with United Healthcare Share Advantage Medicaid insurance.

This is the same company I have have problems as a hospitalist getting inpatient status approved on patients who have spent less than 24 hours in the hospital (due to our excellent care), but meet inpatient criteria by all objective standards. What I saw was sad, but not shocking. Why should physicians be expected to accept insurance that costs them money every time an appointment is made. I recently wrote a Facebook comment about a physician in my community who said they make $1 for every Medicaid appointment. If they saw four Medicaid patients in an hour, they would only make $4 an hour. They said they don't work for $4 an hour. I am sad for this woman and her child. Their hearts must be broken just trying to find a physician to be her child's doctor. They must think all these great doctors are greedy for not accepting Medicaid. Many people have no idea just how badly Medicaid pays.

It's not the doctor's fault Medicaid pays so poorly that they have to turn away innocent eight month old children in favor of other commercial payers with more reasonable rates.    It's no wonder why so many other citizens are opposed to Obamacare. The idea of universal access to insurance does not equate to universal access to doctors. I think emergency rooms had better get prepared for a rapid rise in new patients with Medicaid insurance but no outpatient doctor willing to see them. Why don't doctors accept Medicaid? Running a doctor's office is a business. Doctors can't treat anyone if they can't pay their bills.    Hugs and thank yous don't pay the office electric bills. The future of Obamacare is here and now, but it's going to get a lot worse by making bad policy worse. Click on the Facebook screen shot below for a good look at the pain.

No-Doctors-Accepting-Facebook-Screen-Shot

Facebook universe commentary:

One thing that frustrates health care professionals is bending over backward to provide service above beyond the call of duty, often uncompensated, and then have patients flip them the bird while walking out the door waving their Medicaid card in contempt. We all end up paying for this chronic nonsense because personal responsibility is not required once this golden ticket to the waste land is "earned". The sad thing is, people who really could benefit from social safety nets can't get a doctor to take their Medicaid because system abusers have ruined it for everyone.

What doctor in their right mind would sign up for $.10 on the dollar? Their clinic would shut down in a month. I make $1 on every Medicaid patient I see in the clinic. If I see four Medicaid patients an hour, I make $4 an hour. I don't work for $4 an hour.
---Physician speaking the truth about not accepting Medicaid

Medical Chart Review Sign As A Marker of Prognosis.

As a hospitalist, I can say with confidence that taking care of an elderly patient with volumes of medical records is easier than taking care of a young patient with volumes of medical charts to review. I find the medical conditions, the psychosocial issues, the family relationships and the complexity of the medical plan much easier to navigate for our elderly sick than for our young sick population. In general, I find the coping mechanisms of our young and chronically ill patients to be more difficult for health care providers to navigate. Perhaps that has to do with a level of immaturity that only experience can overcome by both.    When young patients get sick, doctors and nurses are often forced outside of their comfort zone of communication.   Young patients with thick charts and frequent health care contacts will be considered complex patients for the rest of their lives.

By definition, any attempt at reviewing their medical records will end in sighs of defeat by doctors and nurses.    Think of it as the chart thickness : age ratio. The thicker the medical chart and the younger the patient, the more likely the patient will be referred to every medical and surgical subspecialty known to man. That's because physician, patient, and family expectations and confidence in the medical plan is inversely proportional to the age and thickness of the medical chart that needs to be reviewed. Most physicians, who are being honest with themselves, will agree. Are you only 22 years old and have a medical chart with only 10 pages to review? Your internist will more than likely attempt to tackle your complex set of circumstances with a combination of confident watchful waiting and routine standard of care evaluations. Are you 22 years old with 14 charts, no diagnosis, a history of seeing 12 subspecialists all saying they have nothing to offer and 42 unanswered questions at 5pm on a Friday afternoon? Than I am confident your internist will deploy this medical chart review sign and send you to the nearest ER to make them your problem.

To better help other health care practitioners understand the big picture, no longer should the astute internist document, "Patient appears older than their stated age", a time honored tradition of stating some patients have lived a hard life. That statement alerts the physician that patient age should not be used for prognostic purposes in this case.    Instead, I recommend the astute physician start documenting, "Patient's chart appears thicker than their stated age". That statement alone alerts other physicians they should plan on canceling their clinic to bath in the sea of pain they have been asked to participate in. If you are young and you have lots of medical records, it's important for you to be aware of the personal emotional toll thick charts take on the physician's psyche.

More is not always better. The thicker your volume of records, the less likely physicians are to tackle your problem and the more likely they are to refer you on to other physicians, thereby creating a positive paperwork feedback loop that can have devastating consequences to your health and prognosis. If you don't believe me and you are this patient I am describing, I am more than willing to refer you on to another physician who can better help you understand the dilemma you find yourself in, as this original Happy Hospitalist medical ecard helps to explain.

"Patients chart appears thicker than her stated age."

Patient's chart appears thicker than her stated age doctor ecard humor photo.

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

Drug Therapy Requiring Intensive Monitoring For Toxicity (List) For High Risk Medical Decision Making (MDM) in E/M Explained.

In addition to history and physical, determining the level of medical decision making (MDM) is necessary to define which CPT® code to correctly submit for payment. The American Medical Association's CPT® manual is the authoritative reference for all CPT® related questions and should be available for all physicians to quickly reference. Evaluation and management (E/M) rules are complex and are often open to interpretation, including the high risk MDM component of "drug therapy requiring intensive monitoring for toxicity". The same data presented to different coding experts or auditors will invariably be interpreted differently. It is up to the physician to thoroughly document their thought processes to reduce the possibility of denial of payment during an audit process. The Happy Hospitalist has archived a series of E/M coding lectures through the years to help doctors better understand this complicated process. While I am not a certified coding expert, I have spent years studying the rules and regulations of evaluation and management medicine. Make sure to review all the lectures and the bedside E/M pocket card (picture shown below) to help you with your clinical practice needs.

The Centers for Medicare and Medicaid Services (CMS) has previously published the Evaluation and Management Services Guide. This publication is mandatory reading for any physician wishing to fully understand E&M coding correctly. On pages 16-21, this document provides detailed information on determining risk in the medical decision component of E/M coding. In addition to the three components (history, physical, medical decision making) of E/M, MDM also has three components, the highest two out of three of which are used to determine the overall level of medical decision making. I will in the future be providing a comprehensive discussion on this process. The discussion here shall be limited to understanding the intensive monitoring for drug toxicity of some drug therapy and how it qualifies for high risk medical decision making.

The third component of medical decision making is the risk of complications, significant morbidity and/or mortality, otherwise known as the risk table. The table of risk is presented on on page 20 with the following clarification:

The table...may be used to assist in determining whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.

If you review this very important table of risk in the management options selected component on the far right, you'll find drug therapy requiring intensive monitoring for toxicity in the high risk category. This publication by CMS is the basis for defining high risk E/M coding for some drug management. Does CMS help us by defining which drugs are considered high risk and which ones are not? Does CMS provide us with an important list to stay in compliance with our documentation supporting high risk drug management?

If you came here looking for an absolutely defined, with out a doubt CMS list of drugs allowed for high risk drug management, it doesn't exist. Even CMS states in their discussion of medical decision making that absolutes do not exist. They only provide clinical examples to help guide the clinician in making a determination of what CPT® code to submit for their E&M charge. Some drugs have been identified by the FDA as having a narrow therapeutic index (NTI) which requires intensive monitoring for toxicity. One reference suggested coders use an NTI drug list as their basis for auditing drug therapy requiring intensive monitoring and to add on other drugs physicians felt were warranted. This is a decent starting point. Many coders don't have the clinical experience to understand when some drugs not on an NTI list are high risk in certain clinical circumstances. I believe the most important take home point for physicians is thorough documentation. Documentation is key to helping auditors understand when drug management is and when it isn't high risk. Every patient is different and some drugs may be considered high risk in some clinical situations but not others.

The variability in different opinions from different coders or auditors has roots in the vague E/M language. Drug therapy requiring intensive monitoring for toxicity is a classic example. How does CMS defined intensive? Is hourly monitoring or daily monitoring or weekly monitoring considered intensive? And how is toxicity defined? Does CMS intend to mean toxic drug levels or toxic surrogate side effects? Do they mean complications of treatment? I believe the answers to all the questions can be yes, if given the correct clinical circumstances. One Medicare health administrator, Palmetto GBO, states that cytotoxic chemotherapy is always considered high risk when blood cell counts are used as the surrogate for toxicity. That says to me that drug levels by themselves are not necessary to qualify for high risk drug therapy with intensive monitoring for toxicity. And as far as intensive? What if the CBC isn't ordered until a week after the dose of chemo. Does that meet the threshold for intensive monitoring? Apparently so. This Medicare health administrator provided the following table at the link above with the following clarification. This is the only example on the internet I could find actually presenting a potential list of drugs to be considered for high risk on the E/M risk table.

"The table below lists examples of drugs that may need to have drug levels monitored for toxicity. This is not an all exclusive list. On medical review, to consider therapy with one of these drugs as a high risk management option, we would expect to see documentation in the medical record of drug levels obtained at appropriate intervals."

Even their explanation is vague as they choose not to define "appropriate intervals" for drug levels. My take home point from this list of drugs is we should treat it just as we do using critical care codes CPT® 99291 and CPT® 99292. Just because someone is in the ICU does not mean you can bill critical care and you can bill critical care even if someone is not in the ICU. Just because the drug is on this list does not mean prescribing it qualifies for high risk and just because a drug is not on this list does not mean it isn't considered high risk. Again, I believe documentation is the key to the helping the auditor understand the thought process. This is one more example of how EHR documentation is becoming more about billing and coding for non physician third party payers and less about what is important for communicating a patient's condition to other members of the medical team. Unfortunately, this level of documentation takes time and that time is taken away from face-to-face communication with the patient, another unintended consequence of E/M rules and regulations.

Let's consider warfarin therapy for discussion. Is Coumadin considered drug therapy requiring intensive monitoring for toxicity? As a hospitalist, I take care of a lot of patients on anticoagulation. I believe the answer is yes. Do I directly measure warfarin levels? No I do not, but I do not believe such a lab exists for routine clinical use. The measurement of PT/INR is the clinician's tool for making medical decisions on warfarin therapy. Does the lack of an actual measurement of a drug level exclude Coumadin from the high risk category of MDM? I could find no reference to CMS rules stating only drugs with actual drug level management qualified for drug therapy requiring intensive monitoring for toxicity. Again, I believe aggressive physician documentation is key to help nonphysician auditors understand clinical risk. CMS rules clearly state their intent is to identify conditions which define a high level of risk of significant complications, morbidity and/or mortality.

In the hospital setting, Coumadin use will almost always meet this standard. The potential for excess anticoagulation or under anticoagulation due to drug-drug interactions, under absorption, changes in diet and the constant adjustment in dosing of the medication has the potential to create thrombosis or bleeding complications with catastrophic results. In addition, daily monitoring of Coumadin would most certainly meet the threshold for intensive monitoring. Is there a cut off for how often Coumadin should be monitored to meet the threshold for intenisive monitoring? I don't think a defined time period has ever been established. I think any hospitalized patient on warfarin requiring frequent monitoring (perhaps identified by the hospital's safety protocols) would define Coumadin as high risk drug management because hospitalized patients on Coumadin risk significant morbidity and mortality. If Coumadin use in the hospital is denied by an auditor for not being drug therapy requiring intensive monitoring for toxicity, then I think all drugs should be.

Take the example of chemotherapuetic agents used in cancer. Most certainly these drugs would be considered high risk. But do we actually measure drug levels? Frequently, this type of drug therapy is monitored with electrolyte panels and complete blood counts due to the high risk of electrolyte disturbances, renal failure and bone marrow toxicity from these agents. The Medicare administrator stated above categorically stated cytotoxic chemotherapy was high risk. As I indicated above, if lab data isn't drawn until a week after therapy, does that mean cancer chemotherapy drugs are excluded from meeting the threshold of drug therapy requiring intensive monitoring for toxicity? The Medicare administrator implies no in their discussion linked above. Is it possible to only monitor lab a week after administering a drug and for it to be considered intensive monitoring. It appears so. If chemotherapy agents are excluded from high risk drug management, then I think all drugs should be.

Let us consider a heparin drip. This continuous intravenous medication has a high risk of creating bleeding complications if not monitored with frequent blood draws, often every six hours when first initiated. The monitoring of heparin involves checking partial thromboplastin times (PTTs) or factor Xa levels. Does the failure to monitor actual heparin levels mean this medication cannot be considered drug therapy requiring intensive monitoring for toxicity? If a heparin drip is not considered drug therapy requiring intensive monitoring for toxicity, then no drug should be. The same goes for an insulin drip, amiodarone drip, lasix drip and any other continuous infusion that requires monitoring of a surrogate marker (telemetry, laboratory, radiology).

The list can go on and on. Many drugs may be considered high risk in some clinical situations but not others. How about insulin management in the hospital? We don't measure actual insulin levels, but we do measure glucose to determine whether our insulin dosing is appropriate. Would all hospitalized patients on subcutaneous insulin be considered high risk drug management requiring intensive monitoring for toxicity? One could make an argument that many hospitalized patients are at risk for frequent changes in diet, NPO status, malabsorption, changes in metabolism and many other clinical scenarios that would significantly increase the risk of experiencing complications, morbidity and/or mortality, especially for elderly patients with multiple comorbid conditions.

This is why I think aggressive physician documentation on thought process and analysis of the data is important. In many circumstances, subcutaneous insulin, I believe, deserves to meet the threshold for drug therapy requiring intensive monitoring for toxicity. Is the patient NPO? Do they have an ileus? Are they starting tube feeds? Are they in renal failure? Do they have fever, infection or cardiac issues that are significantly affecting stable blood sugar management and increasing the patient's risk of hyper or hypoglycemic events? Then I believe even subcutaneous insulin should meet the threshold for drug therapy requiring intensive monitoring for toxicity. If insulin management for patient's in these clinical situations do not meet the threshold for high risk drug management, then no medications should.

At the end of this discussion, it should be readily apparent to all that no one list fits all for drugs that can be included in the high risk therapy profile. Because of the failure of CMS to provide clear guidance, I believe the physician has been given a grey area for which thorough documentation will allow work we do every day to be considered high risk and subsequently provide a higher level of E/M coding a payment. The key is for physicians to provide enough documentation for auditors to understand why high risk is present and why the visit meets the criteria of the highest level of medical decision making. If you look closely on my E/M pocket card below, you'll find drug thereapy requiring intensive monitoring for toxicity as one of the reminders to consider high risk for your daily E/M charges.

Click image for high definition view

Sign On in Support of SB 34 - A State Run Exchange in Illinois

Illinois Senate Bill 34 establishes a robust, pro-consumer and pro-small business Health Insurance Marketplace in Illinois. The Health Insurance Marketplace will be the one-stop insurance shop for more than a million Illinoisans. SB34 ensures that the Marketplace is governed by a diverse board that represents women, small businesses, communities of color, labor, public health, people with disabilities, and consumers. It is scheduled to be heard in subcommittee of the Senate Executive Committee today.

Please help signal broad support for this important health care bill by taking these 2 actions:

1. Sign on to the list of organizations supporting SB34

Click here to add your organization to the list of supporters for the passage of SB34.

2. Call the toll-free Marketplace Action line, 1-888-801-4426, and ask your state senator to cosponsor SB34!

If your state senator is already a cosponsor, please call him or her to thank them for their support. Here are the current co-sponsors:

David Koehler, Heather A. Steans, Don Harmon, Toi W. Hutchinson, William Delgado, Jacqueline Y. Collins, Michael Noland, Emil Jones, III, Julie A. Morrison, Steven M. Landek, Dan Kotowski, Patricia Van Pelt, Iris Y. Martinez, Mattie Hunter, Kimberly A. Lightford, Daniel Biss, Ira I. Silverstein, Thomas Cullerton, Terry Link, Melinda Bush, Donne E. Trotter, Bill Cunningham, Kwame Raoul, Napoleon Harris III

Please especially ask Senators Trotter and Clayborne and members of the Senate Executive Committee to pass SB34 out of committee.

SB34 must first pass out of the Governmental Operations Subcommittee and then the Executive Committee before going to a full vote.

Advocacy Materials:

You can find these materials and many others on our Health Insurance Marketplace page:

SB34 Fact Sheet
Health Insurance Marketplace Q&A
State Senator Co-sponsorship Form
Template for Co-sponorship request letter to senator
Template for Co-sponorship thank you letter
Multiple briefing resources

Jim Duffett
Campaign for Better Health Care

And Many Happy Returns: The Affordable Care Act Turns Three

The Affordable Care Act (ACA) is a historic law and its third birthday should be celebrated.
The law, each day, helps move the country from a 'sick care' system to a real health care system. Some of the lesser known but most important provisions of the ACA focus on preventing disease instead of treating people only after they become ill. Millions of Americans are already healthier because of the prevention portions of the law, including Community Transformation Grants (CTG), expanded coverage of preventive services and other measures focused on improving health in the ACA.

The law has also ensured that:

Every new health plan, beginning in 2010, must include coverage of evidence-based, effective preventive services, such as screenings for type 2 diabetes, immunizations and mammograms, without co-pays;
Seniors on Medicare receive many preventive services, starting January 1, 2011, with no co-payments - these services include annual wellness visits, cervical cancer screening, diabetes screening, mammograms and important immunizations such as for the flu and pneumonia; and
The Prevention and Public Health Fund will invest $12.5 billion over 10 years (FY2013-FY2022) in locally-determined, evidence-based community prevention programs and will support public health job creation and training programs. The Fund will provide a coordinated, comprehensive, sustainable and accountable approach to improving the nation's health outcomes through the most effective prevention and public health programs.

One of the law's great prevention successes is the CTGs program -- one of the hallmark initiatives of the Prevention and Public Health Fund. CTGs provide communities with resources to focus on their top health priorities, including smoking cessation and obesity prevention.

In just three short years, the law has been an enormous benefit to Americans. In 2011, the Centers for Disease Control and Prevention (CDC) awarded $103 million in CTGs to 61 state and local public health or related organizations, and, in 2012, CDC funded CTG programs with $226 million, including approximately $70 million in CTG funding to 40 additional communities.

To commemorate the third anniversary of the Affordable Care Act, we at the Trust for America's Health (TFAH) released a story bank featuring stories of successful prevention initiatives in action from around the country. Many of the stories focus on CTG awardees and show how this new program, made possible by the ACA, is already helping to improve the health of Americans. TFAH's Prevention and Public Health Stories in the States story bank includes more than 50 profiles in 28 states, including:

The launch of the first Accountable Care Community (ACC) in Akron, Ohio, which builds on the idea of an Accountable Care Organization. In 2011, the nonprofit organization Austen BioInnovation Institute (ABIA) brought together a wide range of 70 different groups to coordinate health care inside and outside the doctor's office for patients with type 2 diabetes, and received500,000 per year for 5 years for a capacity building CTG. The ACC reduced the average cost per month of care for individuals with type 2 diabetes by more than 10 percent per month over 18 months with an estimated program savings of3,185 per person per year. This initiative has also led to a decrease in diabetes-related emergency department visits.
Oklahoma is using a CTG to work with a range of sectors to make healthier choices easier in the state. Nearly 70 percent of Oklahoma County's premature deaths are largely preventable, and the county spends about920 million every year to treat chronic disease. In September 2011, Oklahoma City was awarded a3.5 million CTG. Using a portion of those funds, along with additional outside resources, the Oklahoma City-County Health Department (OCCHD) created the "My Heart, My Health, My Family" program to provide prevention programs and services, specifically focused on cardiovascular disease. The CTG money will also support expanded walking and biking trails, a push to help schools offer healthy menu options and a physical education coordinator for city schools.
Operation UNITE (Unlawful Narcotics Investigations, Treatment and Education) in Kentucky received a capacity-building CTG to help support this program which has delivered important results for a holistic, community-based approach to address substance abuse. UNITE was created a decade ago, however the CTG will help expand its work to support public health efforts aimed at reducing chronic diseases, promoting healthier lifestyles, reducing health disparities and controlling health care spending, and will serve 119 of the state's 120 counties. UNITE works to rid communities of illegal drug use and misuse of prescription drugs by coordinating treatment, providing support to families and friends and educating the public about the dangers of drug abuse.
The West Virginia Department of Health is using CTG support to help local health departments in every county in the state implement targeted initiatives including: safe places in communities to work and play, Farm-to-School Initiatives to improve nutrition in school settings, Child and Day Care Center Nutrition Programs to educate and empower children to choose healthy lifestyles through physical activity and healthy food choices, and community coordinated care systems that link and build referral networks between the clinical system and community-based lifestyle programs so people can manage their health.

The ACA began a new era for public health. The law paves the way toward ensuring public health is no longer separated from the rest of the health care system. The ACA supports common-sense community approaches focused on connecting the care people receive in the doctor's office with opportunities to stay healthier beyond the doctor's office, where we all live, learn, work and play.

As the Affordable Care Act continues to benefit the country, in another year, we'll have an abundance of stories to share of communities turning their health around by focusing on preventing illness and thereby creating happy, healthy and thriving neighborhoods.

Jeffrey Levi, PhD

Associate professor of health policy, George Washington University

Executive Director, Trust for America's Health

(This article was originally posted in the Huffington Post blog here.)

PCA Morphine Dosage Protocol For Severe Pain Management In the Hospital.

PCA morphine is a common method used to achieve pain control in the hospital setting. PCA stands for patient controlled analgesia. This therapy usually involves intravenous opiate therapy. Intravenous opiate management should be taken seriously by hospital nurses and doctors as too much medication can result in a life threatening iatrogenic drug overdose. In most situations, patients will respond rapidly to Narcan, the antidote in opiate overdoses. This complication happens everyday in the hospital, even during optimal monitoring conditions. Many foreseeable and unforeseeable variables are responsible. In fact, IV opiate management is even considered high risk drug management for physicians trying to calculate their medical decision making on their daily hospital E/M codes.

Many hospitals have standard protocols for initiating PCA morphine or other intravenous opiates. In addition to morphine, intravenous hydromorphone (Dilaudid) and fentanyl are other common medications used to achieve pain control. All intravenous opiates that should be prescribed with caution. How does a physician choose one medication over another? Considerations include patient preference and experience, physician preference and experience, patient drug allergy profiles, hospital wholesale costs and availability, trial and error for patient response and side effect profiles are just some of the most common reasons to choose one intravenous PCA opiate over the other.

Why is PCA morphine dangerous? Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea. This is the cause of death in a heroin overdose. This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news. Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms. This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside.

How does the PCA morphine protocol work? The intravenous medication is placed inside a special pump secured to an IV pole. The pump is set to deliver medication through a patient's IV at the rate based on the physician's order. Doctors may or may not prescribe a continuous infusion dose (basal rate) in addition to an as needed (prn) dose for patient comfort. Patients are given a button to push for on demand delivery of medication for management of their severe pain. This button tells the pain pump to deliver intravenous morphine at a dose determined by the doctor's orders.

On the PCA morphine protocol orders, the doctor will write for a prn bolus dose with a lockout period. In other words, if the doctor only allows 1 mg of morphine every 8 minutes, then the patient will receive a maximum of 1 mg every eight minutes, if they push their pain button at least once every 8 minutes. If the patient pushed their button 100 times in that eight minutes the pain pump settings will only allow one 1 mg bolus dose to be delivered every eight minutes. This is the lockout period.

The customary lockout period for most of the IV opiates is to allow one dose of pain medication every 5-15 minutes, the exact time period of which is determined by the physician's order. This is a built in safety method to prevent a patient from overdosing on the medication. If patients become too sleepy to push the pain button, they will stop pushing it. This is also why families need to understand when it is safe to push the patient's PCA button and when it is not. Please consult with your nurse before you push your loved one's pain button. You may be killing them by doing so.

Hospitals are invested in optimizing severe pain control management because patient satisfaction scores depend on it. If patients believe their pain is not being adequately addressed, hospitals will get dinged on their HCAHPS surveys and they risk losing millions of Medicare dollars. PCA morphine is one way to give patients control of their severe pain management in the hospital and to ensure great survey scores on the back end.

How does the doctor determine the correct dosage of the basal and as needed bolus morphine? That's the wild, wild west of PCA management. Some hospitals have simplified the process, as these medical ecards explain. You can't get any more satisfied than less than one call light per shift, and by satisfied I mean nurses AND patients. Consider implementing these dosing protocolsfor your PCA morphine orders in your hospital today and experience great patient and nursing satisfaction scores in an instant!

"I have trained my doctors to write for PCA morphine with a basal rate of less than one call light request per shift. Hooray!"

I have trained my doctors to write for PCA morphine with a basal rate of less than one call light request per shift. Hooray! Nurse ecard humor photo.

"Morphine was named after Morpheus, the god of dreams. If you ask me for morphine, I will get you a pillow. For sleep. Just so you know."

"If Dilaudid was a Hamburder. Dilaudid is 7-10 times more potent than Morphine!"

If Dilaudid was a burger morphine comparison photo

"I haven't charted a true respiratory rate since nursing school. Just so you know."

"Admit for pain control patients usually go home the next day with orders to go to the ER if having pain. Just so you know."

"In an effort to improve patient perception scores, all nurses at my hospital are now trained to prepare freebase Oxy when 'nothing is working.'"

"If you tell me nothing is really helping your patient, I'm going to order nothing to help you. Just so you know..."

Nothing is really helping the pain ecard humor photo

I see here that you quit smoking the day you got admitted to the hospital. That's too bad. I was going to write you a script for medical marijuana to help with your pain."

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

Don't Restrict the Navigators!

The Affordable Care Act requires each Health Insurance Exchange to establish a Navigator program that will help people who are eligible to purchase coverage through the Exchange learn about their new coverage and enrollment options, including Medicaid, tax credits, and private insurance. In Illinois, the Navigator program will be paired with an In Person Assistor Program to help the 1.7 million uninsured residents in Illinois find coverage. The success of the ACA hinges on the ability of Navigators and In Person Assistors to reach eligible residents and provide culturally competent services.

Two pieces of legislation currently being heard in the Illinois General Assembly - SB1194 & HB2608 – create barriers to this massive enrollment effort. The two pieces of legislation establish overly restrictive criteria for organizations and agencies that wish to serve as Navigators, making it more difficult for vulnerable populations to be connected with their new options for affordable health insurance coverage. For example, the bills require that Navigators be licensed by the state despite the fact that the Federal regulations specifically do not require licensing.

Additionally, SB1194/HB2608 are written to address a Navigator program operated by a state-based Health Insurance Marketplace. However, in 2014, Illinois will run its exchange in partnership with the federal government. Therefore, this legislation is unnecessary because HHS, not the Illinois Department of Insurance, retains ultimate authority over the Navigator grant process, including selecting Navigator grantees and awarding Navigator grants, and the approval of grantee activities and budgets.

Over a million Illinois residents will be eligible for new health insurance starting October 2013. For a successful marketplace, rather than putting into place restrictions that would deter and prevent community-based organizations from serving as Navigators, we should work to ensure that broad efforts are in place to connect these individuals with coverage. For that reason, we ask that you OPPOSE SB 1194 & HB 2608. See here for a fact sheet on the bills.

SB 1194 will likely be called for a vote in the Senate Insurance Committee on Wednesday, March 20th @ 5 pm. Don’t restrict the Navigators; please slip in opposition to SB 1194 and HB2608.

Kathy Chan, Illinois Maternal and Child Health Coalition
Nadeen Israel, Heartland Alliance for Human Needs & Human Rights
Ramon Gardenhire, AIDS Foundation of Chicago
Stephanie Altman, Health & Disability Advocates

HEALTH FOR ALL

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