Sunday, April 18, 2010

Paying For Healthcare

In the 25+ years I have practised medicine, I have rarely had to charge a patient for anything. While I bill each patient individually, my bill goes either to the provincial health plan, Workers Compensation Board or in the case of the military to Blue Cross.

25 or so years ago Canada passed the Canada Health Act. One of the provisions of the CHA was portability. This means that while health care is a provincial responsibility, one provinces coverage has to be honoured in another province. In response to this, 9 of the 10 provinces agreed to reciprocal billing. What this means is that if I see a patient from Saskatchewan, rather than sending a bill to Saskatchewan, I send the bill to Alberta Health which pays me and bills Saskatchewan on my behalf. This is done electronically and painlessly.

As I mentioned one province decline this arrangement. Quebec. This would be fine if I could easily send a bill to Quebec and expect to be paid. Unfortunately Quebec usually does not pay for its residents when they travel out of province, when they do they pay pitifully low rates, even less than what they pay their own doctors. I once got a cheque from Quebec for $7 for an evening emergency visit. I thought about sending it back, reasoning they obviously needed the $7 more than I did. Alberta however is a long way away from Quebec so I usually don't have to deal with this.

A couple of weeks ago while covering the case room, I got a phone call from the nurses. They told me that a young lady from Quebec was in labour, might need an epidural in the future, and possible might need a Caesarian Section. They asked my to visit the lady and tell her what the fees might be. Now her Obstetrician who is Quebecoise, speaks French knows who to phone in Quebec and what forms need to be filled out and had already arranged for HER fees to be covered. Naturally she hadn't done this for me or any of my colleagues.

Anyway I visited her and through an interpreter (she actually didn't speak French or English) that I would not deny her any essential service based on her ability to pay, but however a labour epidural is not an essential service and if she wanted to have one, it would cost her $100 which is what I get paid for an Albertan and this would have to be paid in advance. I told her that there would be other fees that I would invoice her for and that if she required a C/S it would cost $300 which is roughly what I get for a C/S. I did tell her that she would eventually get reimbursed for at least part of it. Now I didn't feel comfortable doing this but my time is valuable. If the OB had approached me and asked me nicely, I might have taken my chances with billing Quebec but while she was pre-arranging her fees, she didn't both asking about anaesthesia fees.

What happened, was that my intervention stopped the poor lady's early labour, she was sent home and I am sure one my other colleagues had to have the same talk with her sometime later.

Friday, April 16, 2010

Playoff beards

I know everybody in the NHL reads my blog so...

Think of the great moments in Stanley Cup History:

Jean Belliveau hoisting another Cup
Maurice Richard driving towards another goal
Bob Baun scoring in overtime
George Armstrong sliding the puck into the Habs' empty net
Bobby Orr flying through the air
Bob Nystrom tipping the puck into the net
Any one of Gretzky's or Messier's highlight moments.

They all have one thing in common. All clean shaven.

Playoff beards were a novelty. They have become old. You play for three hours every 2-3 days. You have lots of time to shave.

Reqiem for a Heavyweight

One of the things I get to do now as department head is to advise pharmacy on formulary additions and deletions. Today I got an email asking me to comment on whether we should keep Sodium Pentothol on the formulary.

Now Pentothal AKA Thio AKA STP has been used in anaesthesia since the late 1930s. Despite a bit of trouble after Pearl Harbour when its use in sub lethal doses by untrained personnel lead to allegedly more deaths than caused by the Japanese Pentothol was the undisputed champion of induction agents until the mid 1990s. There were challengers along the way, methohexital, ketamine, etomidate, alphathesin (which I would love to see formulated in intralipid), midazolam, sufentanyl and alfentanyl all came and were unable to supplant Pentothal as the dominant induction agent. Millions of people went to sleep (and woke up after) hearing, "You'll get a taste of onions or garlic...."

Propofol finally supplanted Thio. It wasn't easy though. I remember in the early 1990s when Propofol was first introduced. We presented it to our pharmacy committee who balked at the cost of $8 vs 50 cents for the equivalent dose of Thio. Propofol was unquestionably better but not 16 times better. At first pharmacy allowed that we could use it for Pentothal allergies or porphyria. Later they allowed us 6 vials per person per week. This lead to my practice of what I called "President's Choice" propofol (President's Choice was the house brand at a grocery chain) where I took 10 cc of propofol and topped it up with enough pentothal. It also lead to a lot of stealing from other people's carts.

It was later understood that while propofol was clearly better for day surgery, pentothal should be used longer cases. Gradually propofol became used more and more, pentothal less and less. A few years ago the multidose bottles of pentothal disappeared, leaving only single dose bottles which were a hassle to reconstitute.

Currently while propofol now generic costs $3 for 20cc the equivalent dose of pentothal goes for $14. The question was, whether we should keep pentothal. I felt that for a drug which is clearly not as good, only used on principle by a small group of diehards and which costs almost 5 times more, it would be hard to justify it. That doesn't mean I don't feel guilty about it.

Pentothal joins a large list of anaesthetic drugs which have fallen into the dustbin during my lifespan including Halthane, Enflurane, Isoflurane, Curare and Pancuronium (still available but only ever used to scare residents).

Tuesday, April 13, 2010

More Species of Anaesthesiologists

Burnttoast commented on my last post.

His work is really too good to left in the comments section; I have further commented in italics

Dr. TrainedAtBigNameHospital Any conversation must include "When I trained at BIG NAME Hospital..." So why didn't they offer him a job?

Dr. Flirt whose main objective is to charm any attractive members of opposite sex. Usually must be paged to be found. Very useful guy, usually has at least one ex-wife, will take extra call.

Dr. StockMarket who would lecture daily on what a major killing his wise investments were making, often in the presence of those making a tenth of his salary. The recession was almost worth it, as it shut this stuff up totally. The interesting thing about these guys is that most of them work past their 70th birthday.

Dr. Perfect's sibling, Dr. PerfectFamily. Kids all utterly amazing from their Apgars of 15 to their brilliant grade school careers, a shoo-in for total Ivy scholarships in either academics or athletics. Spouse equally perfect. You wonder how they got stuck with someone like him. I used to not be able to stand working with these people or attending social functions especially the child-friendly ones they insisted on. They made me feel so inadequate as a parent.

Dr. WatchtheBoard. Obsessed with the flow of the OR schedule. (guilty of this myself) Some people bet the ponies, I like to forecast OR scheduling collisions. I usually try to fix them ahead of time.... Some colleagues of mine like to do this when on call on the basis that they feel the need to reduce (on enhance) their evening workload. Everybody who has cases dropped into or taken out of their room is not impressed.

Dr ShouldaHadaTrustFund. Doesn't like doing short cases. Doesn't like doing long cases. Doesn't like doing hearts. In America, these guys wind up supervising CRNAs. Not that they necessarily like doing it.

Dr. NotMe When on call, argues that call docs shouldn't be stuck with long difficult cases, because, they are on call. When on off list, argues shouldn't be stuck with long difficult cases, cause he is on off list. When neither, argues he shouldn't be stuck with long difficult cases because it may lengthen the work day. Probably a variant of ShouldaHadaTrustFund. Or Dr. Whiny.

Dr. Technical Carries a toolbelt. Knows specs of every monitor/machine ever built. Can fix anything. Unless it is biological ie human patient.

When do we get to do type surgeons??? (Evil of me I know)

Read this

April 12, 2010 12:35 PM

Wednesday, April 7, 2010

A Guide To Anaesthesiologists

A while ago I blogged on the various surgical personalities we all encounter. I really love slagging surgeons but lets face it, people who live in glass houses shouldn't throw stones.

Lets meet my department.

Dr. Perfect.

Dr. Perfect's shit doesn't smell and has never smelt. Every thing about his cases are perfect and only because he is doing them.

Dr. Cancel.

Dr. Cancel only likes to do ASA I cases. Anything else he will find some excuse not to do the case or he will make life so difficult for everybody involved including the patient.

Dr. Wallet.

Dr. Wallet can look down the OR slate and tell within $10 how much every person is going to make that day. AND he better be making more than everybody else! Dr. Wallet spends most of his days either complaining to the list assignor that he didn't get the most lucrative list or at the front desk trying to get cases moved into his room. Fortunately you will only have to deal with Dr. Wallet for a few years as he will soon leave your department to work in a private surgical suite.

Dr. Chatty.

Dr. Chatty loves to talk. This will include a long talk with the patient mostly unrelated to the patient's medical history or the surgical procedure before finally putting the patient to sleep. Usually Dr. Chatty has to be paged several times from the lounge where he is holding court.

Dr. Block.

Dr. Block loves regional anaesthesia. His enthusiasm for blocks is only matched by his lack of speed and ineptness in performing them.

Dr. Science.

Fortunately he only works in teaching hospitals. Dr. Science loves research. Unfortunately most of his research involves you doing your cases according his research protocol which means not doing things the way you find comfortable, having your case delayed by his research assistant and having to draw blood at intervals when you could be doing something useful like reading the paper. Dr. Science's papers are always published with himself as the sole author and no acknowledgments. He is always the co-author on all the research done by residents even if he didn't actually do any of the research.

Dr. Rambo

Dr. Rambo never has an easy case. Every of his (her) cases is the sickest patient being subjected to the worst horrendoplasty, brought back from the brink only through Dr. Rambo's skill. Dr. Rambo will give you a lunch break; when you come back your ASA 1 gall bladder has an art line, 7 French CVP and is on norepinephrine.

Dr. Bucket

Dr. Bucket carries a huge ice cream bucket filled with multiple ETT, stylets, bougies, syringes, minibags and who know what else. When you can't find a piece of equipment, you ask the nurses to search Dr. Bucket's bucket. There are variations including fanny packs and tackle boxes.

Dr. Whiny

Just like his surgical cousin, Dr. Whiny is never happy. If his list doesn't end precisely between 1500 and 1530 he will complain about working too long or not enough. Likewise call is either too busy or not busy enough.

Dr. Tightass

Dr. Tightass missed his calling as an internist. He rigorously interrogates each patient before surgery, and looks for lab work that hasn't been invented yet. Dr. Tightass's anaesthetic records are completely filled out on both sides to the point that you can't decipher anything anyway.