outer rims...

 

Boss had declared the we would be joining the “outer rim scheme” of the national health insurance bureau plan next year few days ago.

The NHI bureau had started on a claim-pay basis initially. The hospitals submit their bill and the bureau pay as submitted. The bureau has no man power to go through all the cases so it would choose 1 chart per 1000 or per 100 and review the chart. Inappropriate item would be crossed out. The amount of such item would be x 100 (or x1000) and deducted from the payable claim to hospital; that means the chart represent x100 or x1000 of the case note.

The bureau has however allowed the hospital to write appeal for the deduction.

So proper charting is essential, every drug prescribed/exam ordered should be accompanied by appropriate charting.

Under such scheme, some of the hospital had tried very hard to pile up the claim. The annual growth had been enormously high and the govt. had decided to restrict it growth. The bureau had implemented a budget system. 2 schemes were set up -> he inner rim and the outer rim. The budget is separated into 2 pieces. 70% was limited to the budget limit group(inner rim) and 30% to the unlimited group (outer rim) . In the inner rim group, the hospital claim per quarter is set (with reference to claim done during the same period in the past), and a growth of 3-5% is allowed provided the hospital attained the working target set(eg. Total drug cost/total claim <30%....). Any claim beyond the amount would not be paid and the bureau would not deduct any inappropriate item from the claim.

The outer rim portion means the hospital would follow the old rule – claim – review – deduct.2 months before the next quarter, hospitals would have to decided if they wanted to join which portion. If less then 70% of the hospital(counted on claim amount basis) join the inner rim than there would be only one scheme - > the old rule.

Most of the hospital would opt for the inner rim as it is safer and the burden on charting is less. However when a hospital expanded it beds or equipment, the hospital would opt for the outer rim and tried to out perform it past result and gaining chips for bargain in the future.

in the outer rim the deduction rate starts from 20%. That means no matter how good your charting or setting, one would face a minimum deduction of 20% initially and with luck it could be reduce to 10% after appeal.

Not a burden for me but still more time would be spent on typing case note. But I would tried to modified my program. Each time a drug is prescribed an automated generated case note would be done…..and the only job is to print it out….cross my finger……

Instructor Course --- Disaster Medicine Training Course

 

Ving had complained that I was hooked onto gaming for the past few weeks…indeed, I am currently playing 3 version of advance war – the advance war, advancewar: black hole rising and advancewar:dual strike. I am playing them on 3 different console of coz. The advance war:blackhole rising on the GBA SP, the Advancewar : dual strike on the NDSL and the advancewar on the WII(vgb:on homebrew, striking experience on the 46’ LCD of coz…)….

Indeed, I played game to divert my anxiety….I had gone for the instructor course for the basic disaster medicine. In Taipei 2 weeks ago….

The society of disaster medicine was set up about 10 + years ago around the peri-921 earthquake period. Most of the core founders were from the SKMH in Taipei. One of the senior ED physician had later held the office of Health Director in Taipei City during the tenure of President Ma as Mayor. I had joined the society 4-5 years ago when I got my certificate for advance and basic disaster medicine course. The society held several teaching course for NBC(natural, biological and chemical) disaster management and disaster medicine course every year. Completing a credit of 24 would eligible one to sit for the disaster medicine specialist test. The specialist cert was unfortunately not gazette by the law as specialties(The GI is not a gazette specialty but still it was recognized by the national health insurance bureau)

But any way, who cares…

I had intended to join the course as I wanted to run the course in our hospital. Our hospital is currently situated in a disaster prone location. We are 70+ km away from the nuclear power plant and we are under the threat of tsunami if a large quake hit the Manila trench. There was a preparation meeting held 1 months ago in one of the govt. hospital in K city. Local officers from various related agency were summoned and there meeting had broken the news that a severe quake leading to tsunami would be expected on Jan 13-15(peri Voting Day for President). The meeting had warned the officers to be prepared for such disaster. Just after the meeting one of the village which suffered from heavy loss during the 88 flood had undergone a tsunami warning exercise. One of the officers who happened to attend the meeting had warned the elder of our church. He had told me the news.

I had done some research and found that although the prediction was a crap..(nothing/no one could give such prediction…except GOD), but the threat is still there, the southern part of Taiwan would be affected by tsunami if the Manila trench suffered from a heavy quake. If sliding occurred on the whole 900+km length of Manila trench -> there would be tsunami with wave of 3m high…. Just if….but still it could occur….

Anyway I had filled in the form months before the pre-tsunami warning meeting.

There society had sent us a set of slide(700+) and we would be requested to present two 8 mins session on selected topic. Not an easy stuff as the slide was prepared by others….

I had bought The Fundamental of Disaster Medicine from the Society of Crital Care Medicine -> cost me around 3000NT(shipment via airmail..)….However I had gotten this pdf version of Koenig’ Disaster Medicine which I could install in the Kindle…

Most of the slide came from text book written by the Society but still some of the slides lead you to no where. I spend sometimes reading the above 2 textbooks during the 1+months of preparation.

Some of the slide was confusion as I did not know what the author wanted to present on the topic... for example – I just don’t know what is MCMS..

on a quick glance and I couldn’t find it in all the 3 references textbooks…. But with the help of google, I managed to trace it to a manual produced by the WHO…

The preparation was not smooth as I had to prepared a talk on tsunami and disaster planning in the church 2 days prior to the course and Ving was not feeling well …

The course was held on Saturday and it started early at 8:30am. The earliest high speed rail hit Taipei at 8:20am – SKMH was 25 min drive from the Taipei Station…so I decided to put a night in Taipei…

The kids had complained that it was so good for me to stay in the hotel as we had been camping for the last few trips… they missed the sensation of staying in a hotel… I felt a little bit sorry but still they had been pampered too much in the past….

It was tiresome Friday. Post call and govt clinic rounds in the mountain area. I came home at 1:00pm after a 20 hrs of overnight work. Catch a little sleep and drove to the HSR station in K city. I wanted to take the 5:00pm train but unfortunately it was fully book. I took the HSR instead. (RM100 difference in price...)

Although no reservation was done I got a small room with the price of RM300….it came with a luxury buffet breakfast….A hotel run by Japanese firm. I noticed most of the guests were Japanese during breakfast on the next day…

I ended my study at 1am and hit the bed. I felt peace though as I had prayed to the LORD for the passing this time….

The breakfast was Japanese orientated but still I had a good bite despite of the hanging over from poor sleep.

I took the monorail and managed to get to SKMH in time. I was surprised as there were only 12 candidates…

I was not surprised when I saw the topic allocated to me, those topics which were not in the 3 references textbooks. I was an outsider from no where; candidate to be failed with the excuse of “Don’t know what you are teaching..”

Apart from the topic I mentioned above, I got a topic of confined space rescue …. Some of the slide of which I just don’t know how; I had neglected it as I thought I would not be such mishap to get it…

just don't know how to described them....

this was original text....

the classroom was situated in B4(basement 4 -> no signal for my 3G card…) so I had a very fast lunch and hit to B1 where I could get a signal.. I managed to get the origin (it was from FEMA US&R task force medical training manual).. and I was quite confident I could impress the examiner…

The oral presentation went great as I could mention the origin to the examiner…

The result was not published on the spot, although I was given a good remark by the examiner, I was still feeling a bit of anxiety…the returning trip was smooth and I managed to get Yun’s Licca Baskin and Robins set, and I got a motion plus for the WII….

I was checking email and mail for the next 2 weeks hoping for the result… I finally got the letter yesterday, it came with a small certificate …..

The next step would be preparing the course... need to get approval from da Boss and I would run the course in the church as well....

hard one...

A church member had passed away 1+ week ago. He was a case of lung cancer with brain metastasis. He had joined our church 1+ years ago months after he was diagnosed… A simple man with no “carcinogenic” habbit, non-smoker + non-drinker; he worked as a clerk in the land office. I did not have any close contact with him initially but later on he had gone into coma after a severe pneumonic episode. He was admitted to hospice ward in the K metropolis (previous K county but later merge with K city and become K metropolis). On most of the Friday night, I used to travel to the hospital bringing his children over to see him. After a miracle recovery, he was still in coma though but he was transferred to a smaller hospital as the National health insurance prevented for him to continue for staying in the hospice ward(in the same hospital) after he was stabilized.

Weeks later, he had suffered from a diarrhea episode and his wife had accepted our suggestion to stop the milk feeding and switch to soy bean and grain base liquid diet. Another miracle occurred as he had regained conscious and able to communicate. However he was still paralysis due to the brain metastasis.

His wife had tried every possible excuse to keep him in the hospital as the insurance claim was RM 300 per days for admission. After a wild goose chase of moving from 1 hospital to another, they had decided to return for home care.

They had hired a indon maid but unfortunately the wife had misused the maid. She had asked the maid to help out with the house hold job instead of staying beside the brother and taking care of him…He had vomited while the maid was working back in the garden planting tomato he had choked and aspiration pneumonia was noted.

He was very dyspneic later on and the families were unbearable to see his suffering and  sent him for admission. He was admitted to ICU in my ex working place. Do-Not -Attempt-Resuscitate order was signed on admission by his wife.

It was a hard decision for me when the wife and mother had seen his condition worsening on D2 - he was experiencing severe shortness of breath. They had asked me for opinion regarding intubation. Unlike working in the ED, the opinion was though. The ICU did not provide any strong sedation and narcotic for the patient despite of the 40-50/min tachypneic condition. Under the counter, the mother had complaint to me that the wife had asked the maid to leave the patient for some gardening job leading to the pneumonic episode….

I had recommended for intubation as the aspiration is an acute episode hoping for recovery after antibiotic therapy. That could also buy some time for the mother to undergo her anger…. The wife forfeited the DNAR order and proceeded with intubation.

Despite some improvement on D3, the patient had gone into severe respiratory failure c high O2 use. He finally passed away on a morning....

It was a difficult choice for me to give such recommendation. I was standing on the side of the family despite of the patient… from the point of practice, it is against what I believe… but still watching your relative in a stat of shortness of breath and passing away is something very suffering….

Well, anyway with the grace of LORD, things just went fine and everyone were happy….excluding me of coz…

I had wandered what would be my decision when the time comes for me to decide…

 

 

a path I had taken...

Both Xian and Yun had gone through their examination 1+ weeks ago… A new milestone for both of them….

Yun was doing averagely in the past, most of the mistake was due to carelessness instead of not-knowing… I did not push any pressure on her as a happy life is what I hope for…. Xian was improving though he was still bottom of his class.

Xian was attracted by the Xbox Kinect during one of our visit to Taipei. He had asked me if I could buy one for him. I was too tired during the request and answer session and I told him if he could hit the target of average of 90, I would buy it… well, He got an average of 81 in his last examination. He was darn dedicated and I felt regret of giving such demand… Then Yun came and asked if she could get a similar deal as her brother -> Licca Baskin and Robin icecream stand set…I told her yes and set the target at 470(she got 460 in her last attempt).

Yuns.....	Xian choice...

Both of them was dedicated but it does not mean they studied hard in the past like I did… Playing and watching “Black Jack” TV series (by Dr Tezuka Osamu…) were still on the list of activities….

Well, Yun was so easy few days prior to her examination. She hovering around and I told her that her weak spot was Chinese language and asked her to write the vocab again and she said she was fine with that….Xian did badly on his nature and sociology on his last test and I focus on that.

I told them 2 days prior to the exam that I would not be rewarding them for their good result as I felt it is not right to do so….I had seen their effort and I decided to buy it for them but not immediately after the exam as we need a cool down period….

Xian had a strike back for his nature and sociology but surprisingly he was knocked over by the practical question of math…he got a 60+ and stumbling his effort despite a great improvement for his other subject…Yun was 1 mark away from the preset target and she was a few marks away from the award; most of her loss was due to mis-writing…

The did well… and I feel their had gotten the hang of study…

Yun got hers last week during my trip to the instructor of Disaster Medicine Course last week….

Xian would be expecting his prior to Chinese new year if I got my bonus….(I told him just if, but still, he would get it anyway…)

 

pro and cons

Part of the facilities were moved into the new building despite of any CF. The old block A and B was demolished(including the old ED call room.). This 2 section would be converted into a parking lot. We were still situated in the old Block C but the environment is more comfortable than ever minus the 175 of coz. The size of 175 had shrunk 60% and lately our lockers were taken away. Rumors said that we would be given a table in the new medical staff room but still at the stage of rumor. The call was better as the call room was few steps away from the consultation desk. The air quality was far better and I was not the only one who share the same feeling. However there are some haze masking our future. No new physician nor surgeon is being recruited. We are worried as Boss had hinted lem few weeks ago that they might not be able to give our any. I have to cross my finger and hope for some miracle…..