December 12, 2013
How can I make this less painful? I think the best way is to just say it. The Centers for Medicare and Medicaid Services (CMS) is in the process of telling patients to bend over and prepare to be screwed. I don't mean just literally, but factually as well.
If you wonder why doctors will be cutting Medicare patients and moving many out the door, just read this blog by Dr. Jordan Grumet. Then read the press coverage of what the CMS has planned for 2014. The CMS intends to pay flat rates for Medicare visits to outpatient clinics instead of payments that vary with the severity of the patient's condition.
That's right, with the CMS proposed change, a healthy sixty five year old with a cold will lead to physician charges that are the same for a ninety five year old with congestive heart failure, emphysema, and out of control diabetes. What does this mean? Physicians, fatigued and overwhelmed with patient care, will be much more likely to avoid sickly seniors. It pays the same, why not select for the most healthy of the Medicare population? Yes, doctors will be forced into this and seniors with many comorbid conditions will be forced to use emergency rooms instead of seeing their doctor.
What upsets me even more is this is what CMS is doing to doctors, this parallels what the Affordable Care Act is doing to many doctors, and this will likely force many doctors out of the practice of medicine, as we know it today. This will cause many doctors to open contract medicine offices and not serve Medicare and Medicaid patients. Contract medicine encompasses “boutique”, “concierge”, “retainer”, and “direct care.”
For the present, hospital emergency rooms have been left untouched, but when CMS moves into this area, look out Medicare patients. Patients that have multiple medical conditions may be facing euthanasia because no doctor will be able to afford to treat people with multiple medical conditions.
This is serious enough that writing your members of Congress should be your goal in the month of December. It would not hurt to write letters to the editor of your local newspaper.
December 11, 2013
This is a delicate issue for some people. Until you have been in this situation and had to deal with the threats from doctors and nurses, this is not always a situation with clear answers. I am talking about patients who do their own discharging from a hospital. Hospitals call this “discharges against medical advice.”
Even the figures are estimated because hospitals do not want this public and is why doctors and nurses threaten patients who attempt to do this. Patients are told that their insurance will not pay the bills and all will fall to them. The estimates are that as many as two percent of all US hospital discharges or approximately 500,000 per year are designated as against medical advice. Most insurance will cover costs, but to be safe, always check with your insurance.
Yes, patients need to be careful when doing this as it can be detrimental to their health and well-being. Compared to patients that are discharged by order of the doctor, patients discharging themselves have an estimated 20% to 40% higher readmission rate. Also, their mortality rate is estimated to be 10% higher. Physicians and health care staff report feeling distressed and powerless when patients choose suboptimal care.
Well, I have been there and done that and the threats against me were real and did not hold any water. Since I was already under the gun as I was admitted to the hospital for observation, the bills were mine to begin with since I was not admitted as an inpatient, but as an outpatient for observation. When all the tests for heart problems came back negative, and no further tests had been ordered, I was feeling like why should I allow my bill to escalate because they wanted to keep me for observation.
I had told the nurse to start preparing me to be discharged and all I got was the threat that my insurance company would not pay my bills. I told the nurse that since the bills were already mine, what did she care. She walked out and did not return. So I got up, disconnected my IV's and got dressed. Next, in walks my primary care doctor and asks what I am doing. I said I was leaving since I was only on observational status and was not running up the bills I would not be able to pay.
He calmly told me that he was discharging me per orders and that if I would calm down, he would get started. It took him about 30 minutes considering the interruptions by the nurse. Twice, he politely asked her to return to her station and I would be discharged. The third time the nurse interrupted to ask to see the place where my IV's had been and the doctor did look at the back of my hands to see no indication of where the IV's had been. The nurse said I should never remove them as this could cause me health problems. I just said that I have witnessed removal enough times to know how to remove them. All I had forgotten was having gauze available to prevent bleeding on the first one.
When the doctor finished, he asked if I wanted a wheel chair and I answered no because once I was taken to the hospital door I would need to walk out in the parking lot to get to my car. I also stated that I had not been sedated to cause me to be unsteady on my feet or to be concerned about driving. He agreed and called another nurse to walk with me to the door of the hospital. When we entered the elevator, I warned the nurse to hold on, as the elevator would jerk pretty good when it started to drop and when it arrived at the floor we needed to get off on. Needless to say, she took a fall because she ignored me. She regained her feet and I told her if it stopped on any other floors and when we reached the main floor, it would repeat this. She did grab the bar and when it stopped, the braking almost caused both of us to lose our balance.
The article in the Journal of the American Medical Association (JAMA) has much more information about discharges against medical advice and is very informative. It also covers several items I did not get into and why hospitals and doctors need to change policies in the way this is handled and documented.
December 10, 2013
In the three weeks since the meeting that bombed on me, I have not felt like going to other group meetings. Therefore, Tim, Sue, Rob, and A.J. were the members that went to talk to the group on December 7. According to Sue and Tim, they had a good reception and were happy to hear about the “Choosing Wisely” points from the AACE and ACE. Many were happy to see the slides of the Health Central Blog by David Mendosa.
Sue said that they had no one interested in getting off medications, but they had some good questions. The doctor for the group did say that he appreciated the discussion and the information they had used. He did say that he was originally opposed to people coming off medications, but if people would follow the rules that she and A.J. had given, he would have a discussion with these patients. When he asked for a show of hands, none were raised.
Tim said the copies of Rob's email were well received and generated a good discussion. Then Tim surprised me when he asked if I would go to another meeting with them after the first of the year. I asked what they wanted us to talk about. Tim said they just want to ask me questions about the oral medications and why I was writing a lot about insulin and especially my blog here.
I asked Tim if he was joking. He replied that the doctor was the one asking and several of the group wanted to ask you questions about oral medications and insulin. Tim said he had talked about the problem we had encountered and that was why I had not attended this meeting. Tim added that at one time, the doctor said he was working with a CDE, but did not appreciate some of the comments he was receiving about her recommendations. When her family moved out of town, he was happy to have no one to work with and this may have caused him some of the problems he was forced to deal with when he was forced to move people to insulin. Plus, he did not feel comfortable with patients' testing and just did not bring it up during patient appointments.
I asked Tim if he would go and have his projector available. Tim asked what I was thinking about. I explained that I would put together a set of slides to present the material and handouts for them to have for reference. I told Tim I would use some of my blogs and other material for the slides and handouts. I added that I was thinking about a few blogs by other bloggers, but that I wanted to review them first.
Tim asked what I thought about bringing several of the groups together for one meeting and not doing two or three meetings. I told Tim I thought this was a great idea and we should present it as a trial to our own group and then have three or more available to assist with the larger group. We talked some more and Tim was in agreement to bring as many as possible from the group we had the bad meeting with and let them see a large group in action.
I told Tim that we could have the weather to contend with and I wanted to bring Jason into the discussion and see if he agreed and we could take a few pictures to send to his doctor friend. I added that we could send this information to him and a list of topics to see if this could help motivate some of his patients into a support group. I said yes, this could mean a long trip, but Tim was in agreement and we called Jason and asked if he had an hour or more for an impromptu meeting. Then we called Allen, Sue, and A.J.
When we were together, Tim explained what we had tentatively planned. Jason and Allen agreed, but Sue and A.J. were concerned about weather problems. Tim said we could set a date and an alternate and if weather was a problem for both, we could reschedule for a later date. Sue was still not in favor and we decided to postpone until April or May and Tim and I would handle what we could for the presentation we had been asked to do.
Allen asked if he could go and we agreed. Jason did ask if he could still contact his doctor friend with a list of topics and see if there is a positive response. We agreed and Tim said he was asking for a written statement from Sue and A.J. and we would convert it to slides. Sue said she would not have time until after the first of the year. Tim said if possible by the end of January and Sue agreed. Tim said he would show them the slides long enough before a meeting to make changes if necessary. With this, we ended our impromptu meeting.
December 9, 2013
This is a continuation of my last blog. The fellow had more to do that day, but wanted to continue our discussion. He asked to meet me the next day and I asked if he minded if I included a second person if he was available. He agreed and we set the following afternoon to meet. Then I called Allen and asked if he might be able to be present after explaining what was happening. Allen asked if I had said anything about the VA and I said that I had not, but that was part of the reason I was asking him to help.
We met the next afternoon and the fellow said he would feel more comfortable away from his house as his daughter would be there shortly. I asked if he had any of his lab tests available and he said he had them in the packet in his hand. He had a note on the refrigerator for his daughter and we went to Allen's for the rest.
After we got there, he pulled out quite a number of test results and we went over the most recent ones very carefully. Allen asked him if he had a computer and he said he did and I asked if he had interest in putting them on a spreadsheet or in a database. He said he was comfortable with a spreadsheet and Allen pulled up his and because I had taken my wife's portable, I brought mine up for comparison. He told Allen he liked mine and asked to see how it worked. He said it was the same version that he had and felt he could adapt it quite easily.
Allen said he did not like Lotus 123 and he could do the same in Microsoft Excel. I said if he has 123 he would need to work with mine and that if he gave me his email address, I would send him a copy of my blank spreadsheet and all he would need to do was start entering information. Since I had a blank in my wife's portable, I would rename it for him and we could start filling one in for him. First, we showed him what he was looking at on his lab tests and looked at the plasma blood glucose results and showed him the small variances he had.
Next, we went to the A1c results and showed him where they were on the lab reports. We showed him how consistent he was and that could be why the doctor was not looking at his blood glucose logs as he could see that there was small changes and not an upward trend. Allen commented that at one time he would have liked to have been that consistent. It was certainly better that the swings he had at that time.
We discussed the importance of being consistent and from what we could see; he was doing an excellent job of managing his diabetes. The fellow said we had only gone back two of the three years he had diabetes. I said that the last two showed that if he had problems the first year, he was now managing his diabetes very well. This surprised him and he thanked us for saying that. He was concerned about the lows he was having and said the doctor still wanted him testing only in the morning and he would ask for more test strips because of the lows, but could not promise Medicare would pay for them.
Allen stated that Medicare probably would not even with him being on a sulfonylurea. Allen said he was surprised they had not forced him to a different meter and test strips. The fellow said they had tried, but with him obtaining them from a local pharmacy, he was paying the difference after Medicare and his supplemental insurance covered what they allowed. He said that was the reason for his second meter, which he showed Allen. Allen said okay, that was why he was managing his lows so well and not burning up the more expensive test strips for them.
The fellow did say that the doctor had explained why he should not take his medication if he was not feeling well and would not be eating a meal or two. The doctor said if he was in the normal morning range, not to take his medication unless he was above 150 mg/dl. His doctor had said to use his meter if he felt like eating his noon meal and to take his morning pill at the noon meal if he was over 130 mg/dl, otherwise to only take his evening dose if he would be eating then.
Allen then asked if he had been in the military. When the answer was yes, Allen asked why he was not receiving VA assistance. The fellow asked what VA assistance was and Allen knew he had work to do. After finding out that he had his DD214 at home and could find them, Allen said for him to find them and he would take him to the courthouse, have them recorded at the Recorder's office, and then take him to the VA office to file for VA assistance. Allen asked if he would have them by Monday and they would do it then. The fellow said he would have them then, but he had a meeting in the morning and said he had the afternoon free. Allen said okay and he would be there at 1:00 PM. That was agreed and we took our leave and I drove him back to his house.
We talked briefly about the VA benefits and I said his testing supplies would not be a cost. His only cost would be for medicine and that would be means tested annually and his copay would be determined by that. I said he would need to talk to his pharmacist about his medications to determine which were generic and what their cost for a 90-day supply would be, as he would not want the additional cost from the VA. He said his two medications were already generic and he doubted he would need them from the VA for a copay. He said that his meter and test strips would be a great help. Before he got out of the car, he thanked me and reminded me to send him a blank spreadsheet. I just said I already had and it should be there or would be shortly. I said the email had my phone number as well.
December 8, 2013
For people with type 2 diabetes, having limits on the number of test strips can create real problems. Our medical professionals often do not tell us about blood glucose testing. Then our medical insurance companies limit the number of test strips they will cover. What makes me upset is the number of people with diabetes that refuse to learn the advantages of testing.
I have met individuals that are saying they are testing only for their doctors because this is what their doctors have requested. When I ask them if their doctors have looked at their testing logs or downloaded their meters, they admit that the doctor does not do either. At this point, I ask how many strips their insurance or Medicare/Medicaid pays for or reimburses them to use. Most have no idea and this tells me they don't care or don't understand the value of testing.
I even had two people say that they would not fill out and return the log required by Medicare to continue receiving testing supplies. Both had stopped testing as a result. I did take time to explain why Medicare wanted the number of times per day and month. One just said it was none of their business and clearly stated he would not do this. The other did ask for assistance and after I covered the first sheet, felt he could handle it. I took time to ask which medication he was using. He was on one of the sulfonylureas and had some days when he tested two to four times more because of a low.
Further investigation revealed the lows happened on days when he was not feeling well and often did not eat a meal or two. I advised him to talk with his doctor and see if he should not be taking one or two doses of his medication. He said he normally tested his fasting blood glucose level as soon as he was awake in the morning and that he did not have another test that day unless he felt sweaty or shaky later in the day. I asked him what his blood glucose readings were in the mornings. He said generally in the 85 to 105 mg/dl range, but about once a week or ten days, it could get up to 115 mg/dl.
He stated that he was supposed to take one pill in the morning and one in the evening. I asked if breakfast was one of the times he would not eat. He indicated that it was. I suggested that he not wait to talk to his doctor, but call immediately so that the doctor could call him back that day. I said that his blood glucose levels were such that taking his morning medication would cause hypoglycemia and thus his sweating and shakiness resulted when he did not eat.
I also suggested that on the mornings he was not feeling well and might not eat breakfast that he forego his testing and test before his evening meal to see what his blood glucose level was. He stated that his doctor had always advised him to test in the morning shortly after getting up for the day. I said that is often the case, but with what you are experiencing; he should allow what I suggested. I said because Medicare is only allowing one test strip per day, and with you on a sulfonylurea, testing alternatives should be allowed by your doctor.
At that point he opened up and said that he had a second meter and purchased extra test strips from a mass merchandise retailer and they were what he was using for testing when needed for lows. He had not told his doctor about this and I said there is no need. I said what the doctor is looking for or wanting you to look for is trends in your morning readings. He said the doctor is not looking at his testing log to see if there are trends. I asked if his A1c levels had varied up and down from one test to the next. He asked what A1c tests were.
I knew then I had to do more education. That will be included in my next blog.
December 7, 2013
Part 3 of 3 parts
In this blog, I will cover daily health log, lab test log, and other logs. The daily health log is quite simple. I put the dates across the top and times (in hourly increments) down the left column. I normally leave three rows between times. This allows for longer notes or a reference to the bottom for lengthy notes. I also use the one of the rows to record pain numbers. If the pain numbers remain unchanged, there are days when the number is written when I arise and no further numbers until bedtime.
The lab test log is also fairly straightforward. I put the dates across the top and use two columns on the left side to list the test in column A and the lab recommended range for the test in the second column. Then is just a case of entering the data.
Occasionally I need to insert a new column when there is something from a different lab with a different recommended range, but everything else remains the same. The lab name or code is always a bottom entry. I like this as it shows trends or if I am consistent. I also like to see certain tests decreasing.
My next log is problem and procedures log. When I encounter diabetes and other health problems I indicate the date and time and describe the problem listing as many details and symptoms as I can. This I do print out and take to the doctor appointment to provide the doctor. I also keep track of medical procedures and dates. In addition, I make notes of what the results were. If there were things that upset this, my blood pressure and my blood glucose reading get recorded. The positive happenings also get noted.
I do keep other information that is of value to me and helps in my management of diabetes. I do keep a list of my medications with prescription numbers and expiration dates. I do keep track of when I stop a medication for a medical procedure. I have had several of these lately because of the procedures. Now that I am past or done with all scheduled procedures, I am back on track with my medications.
I wish I had done more of this shortly after I obtained my first computer, but that is past history because I did not. Not everyone wants or needs the detail I keep, but this is done for your information. I have the time and enjoy tracking my health information. Each month I start over and keep all files. Each file is named by month and year.
These three blogs are just suggestions and I hope that at minimum, you will keep a written log that fits your needs.
December 6, 2013
Part 2 of 3 parts
This is a take-off from a blog by Kate Cornell. She covers the way she likes to log her blood glucose. I like her way, but I do mine differently and I thought a comparison could be beneficial or give you ideas for your own log. I transfer any written logs to a spreadsheet. Some of my friends in the diabetes support group use a database.
In this part, I will cover blood glucose logs – oral medications or insulin in my case. For my blood glucose readings, I maintain a written log, which I then transfer to the spreadsheet on page two of the spreadsheet. Some information does go to page three. Occasionally I make a note that belongs on another page. This is because my written notes include most of the activity for each day. I use a spiral top steno notebook. On the each page, I write three dates across the top. Then on the left side on the next line I write AM and the on the next line PM. Since I split my Lantus injections, under each date I write the time and units of Lantus. If you get the full 24-hours effectiveness from your long acting insulin, then you will only need one line and the time and units under each date.
My blood glucose reading spreadsheet is set up for each day of the month with the same format at the top. On both the written and spreadsheet, I list the time of the test and the meter reading and for those that are premeal or pre-prandial I record the correction and the carb portion of the injection. Like Kate, I had long ago done my intensive testing to find out what my average time is post meal or post-prandial when the peak blood glucose time is. It was about 90 minutes in the beginning, but when I increased the amount of fat in my meals, I needed to repeat the intensive testing to discover that it was about the two hours after my meals. Further intensive testing made it about 135 minutes after first bite of the meal.
Then about three years ago, I was surprised again when I reduced the eating time and enjoyed my food at a slower eating time. My blood glucose peak post-prandial remained almost within five points from 120 minutes to 160 minutes. Now I have needed to do more intensive testing because of the food changes I was required because of GERD and gall bladder surgery. It seems that I will be back at about 100 minutes to 130 minutes.
I also record the time of first bite to know when I started eating. Some people do use last bite for determining post-prandial testing. Both ways work, and I advise just being consistent.
On the back of my blood glucose readings page, I write the food eaten and carb information. Occasionally, this includes health information. With all the medical procedures lately, this has been valuable to me. I have also adapted or co-opted the pain scale used by my doctors to indicate this on my written notes and I indicate the time. With the medical procedures and neuropathy, this has been helpful in tracking pain levels and has also helped in blood glucose level problems. I don't, but I am aware of several people that use a stress scale as well.
December 5, 2013
Part 1 of 3 parts
This is a take-off from a blog by Kate Cornell. She covers the way she likes to log her blood glucose. I like her way, but I do mine differently and I thought a comparison could be beneficial or give you ideas for your own log(s). I transfer my written logs to a spreadsheet. Some people only keep written logs and others don't even record their blood glucose readings. This loss of vital information does not help in managing diabetes.
I will admit; I think - to best manage your diabetes, some form of daily logs need to be maintained, whether on paper or on the computer. You may not need the accuracy I strive for, but there is certain information that should be kept to assist you in managing your diabetes.
I not only maintain daily blood glucose logs, but daily food logs, daily health logs, and logs for lab tests. Yes, these take time, but they do help when something is off or the information tells me that things are not right. There are days when I wonder why I am doing all this, but normally then I have a puzzle to solve and I remember why I keep the information. Sometimes the puzzle is easy to solve and other times it can take a few days. The spreadsheet pages include P1, general and special log for monthly notes of interest for me. P2. Blood glucose log. P3. Daily food log. P4. Daily health log. P5. Lab test log. P6. General and problem log (some call it a miscellaneous log)
I will start with my daily food logs and see how far I can go in this blog. First, I use a spreadsheet with pages and have each log on a different page. I have the dates across the top and the top margin (4 or 5 rows) and the left column is locked or as Microsoft Excel says, freeze panes. The daily food logs are my third page each month.
Down the left column I list Breakfast, Lunch, and Dinner. I leave normally 15 rows between each, but occasionally I will need to insert more. Then, in the last six rows below each, I have the following list.
#1. Known carbs – these are from individual servings where carbs were calculated or known from package labels or nutritional information with the recipe.
#2. Estimated carbs – For those times (too often) that a calculated guess is all you can do.
#3. Total estimated carbs – add #1 and #2 for an estimated total.
#4. Correction insulin – this is based on my correction ratio.
#5. Calculated insulin - this is based on my normal insulin per carb ratio.
#6. Total injected insulin – add #4 and #5 for total injected insulin.
Note: Insulin per carb ratio can create confusion for many people. Most in the medical profession and many patients consider a carb unit to be 15 grams of carbs. On the other hand, there are people like me that set up their ratio on grams of carbs. I scared my doctor the first time I stated what my ratio was. I quickly remembered he was talking a different number than I was and this cleared up the situation. Now I normally state that my ratio is based on grams of carbohydrates and not on carb units of 15 grams of carbohydrates.
This is not rocket science, but does require thought. When I end up needing no correction insulin and I am in the range I want to maintain, then I know my carb estimation was good. I do have a food scale if I need it, but I have stopped using as generally I stay in my range. When I have several days of corrections for insulin, then I put the scale back into use. This does not always solve the problem, but often helps.
In the rows above each calculation, I list the individual foods I ate for that meal. I list the approximate weight of meat in ounces, serving size of each vegetable, and fruits if any. At the bottom, I list snacks and carb count for each. Most of the time these are blank, as I seldom eat snacks. At the very bottom, I make comments for the day such as illness. If I do not eat a meal, this is noted in the appropriate meal area. It is my notes area that often help solve problems.
Next will be the blood glucose log