‘Obamacare’ has not changed medical care
by RUSS STEWART
Question: Where can you TURF, BUFF, BOUNCE, WALL, SIEVE, PLACE, and PING-PONG, have LOL in NAD, TOUGHIES and NPC, and find TERNS, RESIDENTS, PRIVATES, GOMERS, SLURPERS, GONZOS and GONERS?
Answer: Not at an amusement park, forest preserve, flower shop, beauty salon, carnival or dance club. You will find the above, which are not acronyms, but rather verbs and nouns used in the medical industry to connote procedures and personages, at your friendly conglomerate hospital. Their motto is: Bring us the untreatable, intractable, unplaceable and unwanted, and we will squeeze some money out of Medicare, Medicaid or private insurers.
The "delivery of medical care" has more to do with billing than curing. As the Obama in "Obamacare" fades into history, the fact remains that the Affordable Health Care Act of 2010, either in whole or in part, will never be repealed. A bureaucracy has been created. Health care has now become a right" and rights are inviolate and never rescinded.
That right has created an expectation. People, meaning voters, have come to expect perfect health, expect an immediate cure if it’s not perfect, and expect it to be free. They want government or private insurers pay for whatever procedures or medications are necessary. There is an illusion that there is no deterioration with age, that the body can be forever young if nipped, tucked and stuffed with vitamins or "miraculous" supplements or drugs, and that waves of vitality can be medically induced.
This column does not do book reviews, but I happened to unearth a yellowed and tattered copy of "House of God," a witty, sarcastic and insightful novel published in 1978 by Dr. Samuel Shem, based loosely on his experiences. It chronicles the trials and tribulations, and some horrors, of a Jewish medical school graduate (the author) undertaking his first year of internship at a renowned Jewish hospital ("House of God") in a major U.S. city (New York). In the book, the TERN quickly concludes that "everything learned in medical school is either wrong or irrelevant."
I also base this column on my personal experiences dealing with ailing and aging parents and hospitals and on anecdotal comments made by legal clients over the years, their primary concern being wealth conservation, not parental care. How do I get my parent on public aid, on Medicaid, into a nursing home, and not have him or her pay for it? No way. Among lawyers, suing nursing homes for patient negligence is a booming business.
Physicians, then and now, operate under the assumption that any disease can be cured. The GONZO doctors in the fictional House of God operated under the philosophy that the hospital and staff must "do everything always for everyone forever to keep the patient alive," regardless of cost, patient pain and curability.
A TERN’s term is 1 year, paid contractually on an hourly basis, with a second year as a RESIDENT. The year is divided into 2-month segments, in six specialty wards. A TERN, coming out of medical school, has no experience (other than slicing up cadavers) in practicing medicine on humans, only in learning medicine. The TERN is assigned a ward, under the supervision of a RESIDENT; they are usually EW (emergency ward), Gastroenterology (bowels), Urology, Pathology (autopsies), Medicine (cardiac), Neurosurgery (brain), Radiology (X-Rays), Dermatology, Psychiatry, Ophthalmology (eyes) and Orthopedics (bones). They learn as they go, work 16-hour shifts, sleep at the hospital, and have no life.
In the book, the TERN and his fellow TERNs are called into a meeting with the chief of medicine, who rules the SLURPER bureaucracy, above the chief RESIDENT and all the ward RESIDENTS, who tells the TERNS that "every intern makes mistakes. You must neither make the same mistake twice, or make a whole bunch of mistakes at once." Maybe PATIENT should be redefined as GUINEA PIG.
The delivery of medicine, the TERN soon learns, is controlled by a bureaucracy. There are the PRIVATES, meaning the private doctors who have admitting privileges for their patients, the SLURPERS, the administrators who are paid exorbitant salaries due to the billings for the TERN’s hard work, plus Nursing, Patient intake and monitoring, Social Service, Communications, Pharmacy and Housekeeping. The TERNS are the slaves, at the bottom of the pyramid, with no control of their workplace.
In the EW, or at an off-site immediate care facility, the TERNS quickly learn that the essence of medical care delivery is to TURF, BUFF and BOUNCE, and that the EW TERN is either a WALL or a SIEVE. Overwhelmed with patients, the EW TERN does not have time to do physicals, IVs or X-RAYS, or to insert feeding tubes or catheters. The TERN’s role is to TURF, which means getting the patient out of the EW and into a specialty ward, back onto the street, or to the morgue. TERNS must learn to separate the diseased from the hypochondriacs.
"Meet ’em and street ’em," is the EW watchword. Those who TURF them out, with a prescription or a "come back soon," are a WALL; those who let everybody into the hospital are a SIEVE.
Of course, there are the emergencies, the catastrophic accident injuries and the cardiac events, which basically are handled by the EW nursing staff, with the inexperienced TERN watching, and then TURFED to a ward, becoming a "House Patient." After several traumas, the TERN learns from the chaos what to do. House Patients are of two kinds, KEEPERS, which are money makers with private insurance, and PLACERS, who are too poor to pay, some of them TOUGHIES, with virtually incurable cases who must be gotten rid of ASAP.
A particular talent taught TERNS, both in the EW and other wards, is the art of BUFFING. That means doctoring a patient’s chart, inserting advantageous information and deleting disadvantageous information. If an EW admitee has a chart chock full of disease, he’s non-TURFABLE. Likewise, in the wards, if a TERN wants to TURF, getting the patient out of the ward, or PLACE, like getting the patient into a nursing home, the chart cannot have a BOUNCE. It must clearly state that the ward’s specialty is inappropriate and that the patient needs a PSYCH, ORTHO, GAS or NEUROSURG consult. Then the patient won’t be TURFED back.
A particular irritation to TERNS are the PRIVATES, meaning private doctors with hospital admitting privileges for their patients. These are non-emergencies or electives, meaning private pay. Hence, there are lots of LOL in NAD . . . Little Old Ladies in No Apparent Distress. These are people over age 62 whose bodies are in a degenerative state, besieged with real or imagined ailments, who cannot understand their plight.
They are a bonanza for the PRIVATES and the SLURPERS. It works like this. The PRIVATE admits a patient in NAD, with some complaint. They do a test, and find some other medical "complication" which must be diagnosed, and a work-up, which is a whole battery of tests, is done which invariably finds more complications, all of which must be treated, which means a bunch of procedures and a torrent of pills. Instead of a one-day stay for the LOL in NAD, she’s there for 30 days, in major distress, non-TURFABLE, with a huge profit for the providers. The money-making charade is that the more that is done, the better the patient gets.
Over-testing has become obligatory. First, to justify billings and overstay, some disease has to be found which can be cured, and second, all the tests diminish the viability of legal malpractice litigation should the patient die.
Another charade is PING-PONG. A discharged hospital patient can get 60 days of Medicare-paid nursing home rehabilitation. On Day 59, the nursing home TURFS the patient to a hospital, who quickly TURFS the patient back to the nursing home, and the 60 days start anew.
In the book, the TERN mournfully concludes after his first year that the best hospitalization is no hospitalization. Some diseases, like cancer, can be cured. For the rest, doing nothing for elderly or disease-ridden patients is better than doing something. Rather than the Hippocratic oath, the TERN’s goal is "Primum non nocere" — "First, do no harm."
Shem’s book coins the term GOMER, for Get Out of My Emergency Room. You won’t find that insensitive moniker on any hospital chart or any doctor’s lips. A GOMER is an elderly person who has lost what defines humans, and who constitutes most of the geriatric nursing home population. They have multi-system disease, are chronically ill, have an absence of feeling and cognition, are comatose, paralyzed, vegetative, motionless, or suffer from dementia or Alzheimer’s. They are hospitalized frequently, ending up in NEUROSURG or ORTHO, often from falling out of bed but often from simple body shutdown. They take up space, time and money, and by the time they’re ready to be TURFED and PLACED, their nursing home bed is gone.
It is known that 80 percent of Medicare and Medicaid hospital spending goes to keeping end-of-life patients alive for their final 12 to 24 months.
The premise of "Obamacare" was its affordability and accessibility, but when something is cheap or free, it is over-consumed or over-used, which is why premiums are rising. The premise of "House of God" is that after a certain age, expect no cures.
Send e-mail to russ@russstewart. com or visit his Web site at www. russstewart.com.