Graham-Cassidy Bill Doesn’t Add Up

The latest Republican health care bill meant to replace the Affordable Care act comes from Senators Bill Cassidy (LA) and Lindsey Graham (SC). This one presents a more substantial change to the way things are run. Most of this comes from an article in the 9/23/2017 issue of the Economist.

  • The Federal government would play a much smaller role, giving money to the states proportional to the number of inhabitants between 50% and 138% of the Federal Poverty Level.
  • The decisions on how to structure care is passed down to the states. They can petition Health and Human Services to drop ObamaCare provisions such as the Essential Health Benefits that were meant to provide a basal level of care in each plan.

The thought is that this may encourage experimentation in each of the states, however three problems exist.

  1. States are now responsible for structuring care. There is no guarantee they can do a better job. States are also required to have a balanced budget, so the Medicare money may go instead to paying other debts.
  2. There is no increase in money if conditions change. If a state is hit with a disaster, say an opiate epidemic, and requires more money to address this… there is no more money.
  3. Doesn’t fix existing problems with the health insurance marketplace. Premiums have already risen under the ACA and insurers are leaving markets. This new plan has the potential of further raising premium prices (with healthy people leaving the market without the pressure of a mandate) and discouraging insurers from participating (with less healthy people, they are taking more risk).
Graham-Cassidy Bill Doesn’t Add Up

My Email Rules

Email consumes hours upon hours stealing opportunities to do real work. Several people have devised plans to reclaim this time, so I stole the ones that work for me.

These rules have two goals: to respect my time and that of the receiver.

1. Keep as short as possible.

“I’m sorry to write you a long letter, as I did not have time to write a short one.”

Mark Twain

Invest a little of time upfront to ensure the reader can spend as little time as possible dealing with your email. Re-read and edit harshly. Aim for FiveSentenc.es or FourSentenc.es or Three or Two.

2. Answer in batches.

Process emails at set times (9 am, 4 pm and 9 pm) leaving the rest of the day open for deep work. Many emails work themselves out before I get to them without my interference.

Turn off notifications. Email is not instant messenging. It’s meant to be asynchronous.

During this batch processing, collect all replies to the same person to be sent in one email. Use the iPad’s Split Screen with Drafts and Mail to collect all the responses in Drafts, then send from there.

3. Don’t send work emails on the weekend (or in the night).

Save your nights for sleeping and weekends for rejuvenating.

Plus sending email at odd hours might set the expectation you expect a response. If nights and weekends are the times you can go through email, Airmail (and other programs) have “Send later” features that let you compose at night and send in the morning.

4. Don’t expect immediate replies.

If you’re not responding immediately, don’t expect others to do the same.

5. Aim to close the loop.

Avoid emails volleys that bounce back and forth yet go nowhere.

  • → “let’s have coffee?”
  • “great, when are you free?”
  • → “how about 2?”
  • “no good, have a meeting. Three?”

Provide enough information so both the receiver and I can be done with the issue. Offer some options “Let’s have coffee. I’m free Monday at noon, Tuesday at 4 pm or Thursday at 10 am. If none of these work, call me and we’ll figure out a time.”

If more information is needed, don’t send a placeholder “I’ll get back to you with this info.” Postpone sending the email until I have the information to send.

If there are more than 5-6 back and forth messages, just call/message/slack the person.

6. Everything doesn’t automatically warrant a response.

Don’t jump on the “Congratulations” email chain when someone blast emails a group about a new promotion. And don’t feel guilty about not responding. Sending “Congrats!” is literally the least you could do. If you did any less, you’d be doing nothing. Congratulate them in person instead. That will be much more meaningful.

7. Reply to the minimum people necessary.

Don’t use reply-all unless it’s absolutely necessary. Eliminate any CC’s and BCC’s unless they’re needed. You’re doing them a favor.

8. Make the subject as informative as possible.

A subject of “FYI” means nothing, but “FYI: TPS reports you asked for, no response back needed” is much more informative. If I can fit the whole email in the subject line, even better: “SUBJECT: I’m free for coffee Monday at noon. See you there.”

9. Get rid of quotes

Unless these are needed for context, just delete the pages of nested quotes.

10. Minimize attachments

Don’t send graphics as signatures. Don’t send text in an attachment (Word) that could have easily been included in the body of the email.

11. The best email is the one not sent

Enough said on that one.

References

  1. http://five.sentenc.es
  2. http://www.emailcharter.org
  3. http://calnewport.com/books/deep-work/
My Email Rules

Discharge Instructions

The October edition of EM-RAP had a great section on how to write good discharge instructions. This is not the pre-printed stuff that comes with the EMR but instructions written specifically for each patient. I modified my DCI (discharge instruction macro) to make those points more obvious.

 
You have been diagnosed with ***, this is ***. Your evaluation in the emergency deparmtent was significant for ***.

1. FOLLOW-UP: Please see your primary doctor within a week. If you do not have a primary doctor, call the number above to arrange to establish a relationship with a doctor. Your condition may change and so it is important to have your condition re-assessed. 
2. RETURN IF: Please return immediately if you get worse, if you don't get better, if your symptoms change, if you have any new or concerning symptoms. If your symptoms change, then we need to reassess potential causes. 
3. MEDICATIONS: You have been prescribed ***. Take the medicines as described in the instructions provided by teh pharmacy. In taking this medicine, you should note ***.

It is also useful to build some specific macros for things that come up often (e.g., more than once). For example, for Levaquin.

the antibiotic LEVAQUIN is associated with tendon rupture in some patients. Please rest from strenous activity while on this medication. If you have questions, ask your doctor or pharmacist.

Or for narcotic medications.

the pain killer NORCO has an opioid mixed with Tylenol. The opioid can make you drowsy, even to the point of stopping breathing. Do not opeate heavy machinery, drive or perform any potentially dangerous tasks while on this medicine. Also do not take it with other sedating substances like alcohol or even Benadryl. The medicine also contains Tylenol, so do not take any othe Tylenol containing products while on this medication. You can run the risk of severe liver damage. If you have questions, ask your doctor or pharmacist.

I also make a practice of talking to every patient before they leave to explain the instructions. I dont typically document that conversation, but it is a good habit. Include the following in the ED COURSE SUMMARY macro.

Additional discharge verbal instructions were given and discussed with the patient. Patient had the opportunity to ask questions and these were answered.
Discharge Instructions