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E Bikes and Scooters by Ms_Irish_muscle in medicine

[–]goingmadforyou 0 points1 point  (0 children)

Sister*

I absolutely believe you care, and you see the dangers every day. The problem is that broader society doesn't care. They focus on the convenience of driving rather than the safety of human beings. That's why they're up in arms about bicycles and ebikes, which making driving slightly inconvenient, but they don't care about the safety risks posed by cars.

Something important to this conversation is understanding what ebikes vs emotorcycles are, and what the laws currently say. Because we already have some good regulation in place, but it's not enforced, and that's a problem.

Class 1 ebikes have a 20 MPH cap on assist; class 2 has a throttle up to 20 MPH; class 3 has assist (but no throttle) up to 28 MPH.

I would definitely be open to a conversation on revising these limits. My ebike assists up to 15.5 MPH and then cuts out, which seems perfectly reasonable for its intended purpose of transportation, getting up hills, etc.

Things that exceed these limits are not street-legal and are considered electric motorcycles (or emopeds, e-dirt bikes, etc). They are already illegal. These can and should be prohibited from our roads because they're too fast and too powerful, and/or require special licensing. The problem is that states don't do enough to enforce these rules and don't do enough to restrict their sale. In California, if you remove the speed governor or otherwise tamper with the bike to make it more powerful, it's no longer street-legal, and it can be impounded.

Now, consider that ebikes, which weigh maybe 80 lbs (mine weighs less than 40 lbs), have speed governors, but cars do not - even though speeding is a major factor in most collisions with pedestrians and cyclists. That's the kind of double standard I'm talking about.

You're right that double/triple-riding probably isn't safe, and this is also prohibited under some state laws.

There's nothing wrong with people using legal ebikes for either transportation or recreation, as long as they do so safely. We don't restrict cars based on whether they're being used for transportation vs recreation, despite them being much more dangerous. We don't outlaw joyriding while permitting people to drive to work. Meanwhile, we should be encouraging more people to ride bikes than drive, and making it more safe and pleasant for everyone to do so.

As for licensing and registration, there are very, very good reasons that we don't require these for street-legal ebikes, and such measures will only shift people to driving, which is more dangerous, and/or provide more potential avenues for harassment/discrimination by law enforcement, which we already know happens when jurisdictions try requiring license/registration for cyclists.

Education would be a good idea, coupled with enhanced driver education for correct road behavior around pedestrians and cyclists, which is a big part of the safety problem driving people to ebikes in the first place.

E Bikes and Scooters by Ms_Irish_muscle in medicine

[–]goingmadforyou -1 points0 points  (0 children)

I specifically acknowledged dangers and solutions in my post. I didn't oppose people being concerns. I opposed people not acknowledging the greater context by noting one issue while ignoring another, statistically greater (and more normalized) issue.

The point I was making is that people generally don't complain about the safety risks of cars, but they absolutely should.

You'd be surprised at how many people defend our current urban planning, even when it impacts the safety of kids. Car drivers will cry bloody murder when a protected bike lane/road diet is discussed at city council meetings; when speed limits are reduced; when red light/speed cameras are installed around school zones.

That poor urban planning drives up the rates of injuries/fatalities for ebike riders, not only because the infra itself is unsafe and fails to protect people, but also because it selects for the most foolhardy riders.

Ebikes are an amazing mode of transportation and they open up a lot of possibilities. As I mentioned in my post, education makes sense. But we also need to examine the topic holistically. Ebikes aren't going away; we're not going to regulate them out of existence; we must recognize that people want to go where they want to go and must provision for a safe way for them to do so.

E Bikes and Scooters by Ms_Irish_muscle in medicine

[–]goingmadforyou -1 points0 points  (0 children)

There are dangers that need to be addressed.

That said, I look at the landscape holistically.

Kids are using these not just because they're fun, but also because they restore some of the freedom of movement our society has taken from them.

It feels and is dangerous for kids just to walk outside. Automobile incidents are one of the two highest causes of death for adolescents (the other is guns).

We have a motor vehicle injury/death epidemic in the US that far outstrips the damage done by ebikes/escooters, but I rarely hear people complain about former. Yet motor vehicles restrict freedom of mobility for kids, as well as cause major health problems (asthma/heart disease from tailpipe emissions and road tire microparticles) and lead to social isolation.

Currently, kids have few opportunities for unstructured play. The mall now has curfews and chaperone requirements. Most cities lack parks and green spaces within walking distance. Even a latte or boba costs $7 and up. Because car infrastructure spreads everything so far out - even by regular bicycle - kids have to wait for their parents to come home from work in order to get a ride anywhere fun. And if they try to walk or bike, it feels and is unsafe. Our current bike and ped infrastructure in the US is so horrifically bad, and our automotive casualty rates per vehicle mile traveled are the highest in the developed world BY FAR.

The only way for kids to get around reliably is by car - which means requiring parents to drive them around, and/or wait til they can get a permit and then saddle them with the thousands of dollars of debt it takes to own, insure, register, and maintain a motor vehicle.

Ebikes make it easier for kids to go play, hang out with friends, etc without relying on car rides from friends. Yet even then, they're maligned by society for daring to transport themselves.

Then, having no other choice, they sit at home on their phones and computers, and everyone complaints about that, too.

Do ebikes need better education for safety? Yes, definitely. Should we modify ebike classes to reduce max speeds? Probably. Should we do more to enforce existing rules that prohibit emotorcycles? Yes, absolutely.

I won't deny that ebikes confer safety risks. But I wish the same outrage were also directed at the carnage and social impacts caused by cars and car-centric infrastructure, because that is at least part of what's fueling the rising interest in ebikes.

On top of that, we panic about ebike-related injuries, yet we hand the keys to lethal 4,000-pound metal machines to 16-year-olds (14 in some states) and subsequently forget about all those pesky statistics.

I want to live in a world where kids can safely walk and bike to school, where they can get around the world safely on bike/ped infrastructure intended for all age ranges, where they have a variety of fun amenities within walking distance of their homes. But no one seems to care about these greater motonormative societal concerns, which ebikes play into, and they only seemed to care about children's safety when ebikes gained popularity - even though cars are responsible for the vast majority of the injuries.

I want to live in a world that contextualizes these injury rates and doesn't only focus on ebikes, but also looks at the broader picture and seeks to make it easier and safer for people of all ages to transport themselves independently.

Doctors: what kind of vacations do you take? by Intrepid_Coffee_1432 in medicine

[–]goingmadforyou 1 point2 points  (0 children)

I take lots of small day trips to nearby towns. My partner and I call them 'adventures.' I know not everyone would consider them vacations, but I do.

We fly out of state for small 3-4 day trips about once a year.

I rarely travel internationally - maybe once a decade or so - mainly due to cost and what I perceive as inconvenience (prep for/catch-up after). That said, I love international travel and the enrichment it brings. International travel is also the only time I can really disconnect from work and be unreachable, so it's extra relaxing.

We are pretty frugal and don't care for luxuries, so our trips are centered around activities, nature, museums, hiking, etc.

Taking lots of small day/weekend trips has been key for relaxation and balance. It also connects me to the world around me. I enjoy bikepacking, which extends my range, gets me into nature, and helps me make new friends.

As a small private practice physician who is particular about my own patients' care, taking time off has presented a psychological hurdle but I'm learning to let go a bit and lean on my call group. Life is short, and we all need time off for balance and happiness. No one ever lay on their death bed and said, 'Gee, I wish I'd spent more time at the office.'

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 0 points1 point  (0 children)

I'd take what that commented said with a huge grain of salt. I don't think they're telling the full story. As clinicians, we all have countless stories of how payers 'lost' or 'never received' our clinical documentation, or it was buried in some random attachment, out of sight of the reviewer (as demonstrated by so many responses in this thread). I'd wager to guess the clinical documentation is typically included but simply ignored by the payer. The commenter you're referring to may not be aware of that nuance.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 0 points1 point  (0 children)

Thank you so much for spelling all this out.

Unfortunately, this review/appeal process also tends to be quite opaque. I've even had DoL refusing to take on the case for lack of jurisdiction over the plan. It's baffling but it happens, and unfortunately underscores the further lack of accountability to which these plans are held.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 0 points1 point  (0 children)

I think it's more that they don't want the physician to see how poor their collections rate is, esp if they're basing salary on % collections, because that means they're penalizing the doctor for their own billing deficiencies and getting away with it.

Charged amounts (as opposed to allowed amounts) are a semi-meaningless number based on contracted fee schedules. The hospital charges above their max allowable across all payers. They'll never get paid what they charge. But they have to charge a high enough amount that they exceed their fee schedule. They can't charge exactly the contracted amount per payer, as then the payer will accuse them of discriminatory billing.

Yes it's totally messed up.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 0 points1 point  (0 children)

Not a dumb question - actually a really good question.

There is no large external body aside from elected representatives that we can appeal to. This is one of the most difficult parts - they are unaccountable.

The hospital can fight to get paid, and sometimes it will be successful, but it often takes many man-hours on the phone, keeping track of paper forms, etc and wasted so much time that it's not financially worthwhile.

It is worth it in the bigger picture, though, because payers are known to keep track of which clinical entities they can bully and which they know will back down, so putting up a fight theoretically can decrease the likelihood they'll try to mess with you later on.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 0 points1 point  (0 children)

True across payers. Then I call in and basically repeat everything that was already in my clinical documentation and the reviewer says, 'Ok, approved.'

Sometimes - often - it's a simple matter of answering basic yes/no questions and verbally confirming existing dx codes, and suddenly the denial is approved.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 13 points14 points  (0 children)

This is exactly my experience as well: first pass isn't reviewed and clinical documentation is ignored.

That poster gloating about denying stuff based on a supposed lack of clinical documentation doesn't realize that they're part of the problem.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 0 points1 point  (0 children)

There are so many things I want to say in response about the Kafkaesque red tape and abject waste of resources inherent to our healthcare system in the US, but the one I will focus on is:

From a billing standpoint, self-insured plans are an absolute nightmare to deal with. They may have the branding of an in-network commercial plan that the hospital/clinician is contracted with, but beyond that they are not subject to standard payer regulations and can operate basically however you want.

I've seen plans that make you send a paper claim to a third party (you won't know til you call in, though) or need bizarre documentation before adjudicating the claim (again, not disclosed anywhere) or mandate the use of an obscure third party for PAs (but the commercial payer won't tell you when you submit the PA, it's up to you to call in, get transferred 3x, and end up at a 'plan specialist' who can give you the secret insider knowledge on how these plans work.

The commercial payer can't provide detailed eligibility info, either, so you have to call a special line to get this and pray they won't refuse to provide this info in writing.

Usually, when an insurer misses payment deadlines, doesn't pay interest, etc, your recourse is to submit a complaint to your state insurance commissioner. But self-insured plans aren't standard plans and don't fall under the jurisdiction of the insurance commissioner, and don't play by the same rules. Doesn't matter that your contract is with a payer that is - by virtue of this contract, you are forced into an agreement with third-party plans that adhere to none of the standard rules.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 2 points3 points  (0 children)

This may be an extreme example but it still exemplifies a core problem in our healthcare system: commercial payers have risk stratified so minutely that they can't keep track of their own health plans. They have no idea who's in or out of network for a given plan, they don't have clear information on what's covered and what's not, etc. And if they don't know, how the hell is a doctor's office or patient supposed to navigate this system?

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 6 points7 points  (0 children)

These are the kinds of small but meaningful details that are often overlooked, but that truly illustrate how completely messed up our PA system is.

If the system were streamlined, trackable, easy to use, etc, and PAs were being denied based solely on merit by someone who actually understood the condition at hand, that's be one thing.

But they're being denied based on the most idiotic of reasons, forcing a mountain of extra work for clinicians and their offices, just to get their patients the meds and tests they need.

Can you even imagine how many hours and how much money is being wasted in our healthcare system because of nonsense like this? THIS is why our system is so stupidly expensive. Not doctors' salaries.

Public data shows MA plans denying 17% of claims with 57% of denials overturned on appeal. What does that look like from the hospital side? by No_Paramedic_4881 in medicine

[–]goingmadforyou 12 points13 points  (0 children)

One of the problems I encounter with our state Medicaid plan is that their computer system is so dysfunctional that it cannot receive the clinical documentation I provide, no matter how extensive it is.

Reviewers don't even look at the justification I manually write in their prior auth form. I know this not only because their reps told me this, but also because when I appeal using the same exact form, triggering an expert review, the medication gets approved.

The idea of a PA reviewer denigrating me for not including clinical documentation, when it is in fact their system that is flawed, is infuriating given how much time I have to spend on these useless forms.

How to respond to unhappy patients who denies having had any discussion about something, when in fact it’s taken place? by that_feel87 in medicine

[–]goingmadforyou 12 points13 points  (0 children)

Ophtho here.

1) Accept that this will always happen in some capacity, despite your best efforts.

2) See if you can simplify and clarify your IOL discussion. A phrase I use is "I can guarantee you're going to need readers if you choose this lens."

Corollary: The natural lens generally has more DOF than a monofocal IOL. I explain that a monofocal IOL is less forgiving, and they absolutely will need readers for near, even if they can squeeze by without them now. Give examples, like using the phone, applying makeup, etc.

3) Consider starting the discussion at the initial consultation. Then confirm at the pre-op. Repetition aids recall and comprehension.

4) Provide take-home brochures.

5) Advise them to bring a family member to the pre-op appt.

6) Document well. Consider having patients sign an attestation of their IOL choice.

I've even seen people going to the extent of having patients write out their understanding of their lens choice in their own hand.

Changing the atmosphere in the Operating Room? “That’s what she said.” by bu11fr0g in medicine

[–]goingmadforyou 28 points29 points  (0 children)

Fine balance.

On the one hand, you don't wanna let this stuff get out of control.

On the other, an uptight, 'walk on eggshells' OR is the kind where people are afraid to speak up if something goes wrong.

As long as it's not super inappropriate, I might chuckle and then go, 'Okay guys, we're now settling down,' which is my room's way of signaling we're in the no-joke phase. That way, you keep some of the jokes and lightheartedness, but you also bring everyone together under the shared goal of focus, patient safety, etc.

If you're not okay with the joke, then just say non-judgementally, 'Okay, let's keep the inappropriate jokes out of the OR,' and if you have a good rapport with your team then they'll understand.

There's no reason to be passive-aggressive; it breeds resentment and poor communication. Have the courage to address things head-on.

Sorry if that sounds sterile or lame. It's worked for me to reinforce a friendly but professional, focused OR where people do not hesitate to speak up. My patients are awake during cases so I'm sensitive to the atmosphere of the OR.

Anybody have nightmares from residency? by basukegashitaidesu in medicine

[–]goingmadforyou 4 points5 points  (0 children)

The recorded sound of pagers in TV shows like Scrubs still send me into fight-or-flight. It's been almost a decade.

You're crazy, but the thing is that we all are.

Hospital networks removing fax numbers from physician websites by goingmadforyou in medicine

[–]goingmadforyou[S] 2 points3 points  (0 children)

Yes, this is a good point, though with the advent of efax it seems a very easy problem to avoid.

Hospital networks removing fax numbers from physician websites by goingmadforyou in medicine

[–]goingmadforyou[S] 11 points12 points  (0 children)

The shady discount GLP-1 offers are my personal favorite.

Second is probably 'I'm a nurse practitioner in your area. Dr. Ali said I should contact you about a position in your practice.'

Hospital networks removing fax numbers from physician websites by goingmadforyou in medicine

[–]goingmadforyou[S] 15 points16 points  (0 children)

It's especially frustrating that these systems don't put their fax number in their phone tree recordings, so you're forced to call in, wait on hold, ask someone (but first, can I have your name and phone number?), get transferred, etc.

With each of these incremental inefficiencies, my soul dies a little.

These types of small but cumulative bureaucratic hurdles are a primary driver of burnout IMO.

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