Wednesday, February 27, 2013

AUDIT REPORT+HEALTH CARE UPDATE.



AJ has made available a Synopsis of the Transitional Fiscal Year 2011 audit report.
These are its   RECOMMENDATIONS:
Purchasing:
*That all City purchases be made through the Purchasing Agent. (Vacant most of 2012)**
*That the encumbrance accounting system required by the Division of Local Government services be adequately maintained.
*That open purchase orders be reviewed periodically and cancelled if no longer valid.
Tax Collector:
That all tax receipts be deposited within 48 hours of receipt.
*That a detailed analysis of tax sale premiums and outside lien redemption balances at year end be maintained.
*That third party lien redemptions be remitted to the outside lien holders in a timely manner.
That the Tax Collector’s monthly reports be filed with the Finance Office on a timely basis.
That the detailed billing ledger be reconciled with the actual tax requirements.
That all tax stubs be available for audit.
Finance:
*That the Current Fund General Ledger be accurately maintained.
*That the City obtain the necessary actuarial information required to report the long-term liabilities related to its Other Post-Employment Benefits (OPEB) Programs.
*That grants receivable and appropriated grant reserves from prior year be reviewed and cleared of
Record where appropriate; the grant appropriation ledger should then be reviewed for proper disposition.
*That all grants be properly appropriated in the budget prior to the commitment or expenditure of funds.
*That Dedication by Rider approval be requested from the State of New Jersey for Trust reserves and that Trust reserves not eligible for rider approval be cancelled of record.
*That interfund balances be cleared of record.
*That unsupported balance sheet items in the sewer utility fund be cancelled of record.
*That efforts be made to collect delinquent Payment in Lieu of Taxes (PILOT) receivables.
That all cancellations approved by the City Council be reflected on the financial records of the City.
*That all the County portion of PILOT payments be remitted to the County of Union.
Payroll:
That the City’s use of payroll processing and disbursement services be brought into compliance with the requirements of N.J.A.C. 5:30-17.
Departments:
*That monthly animal control State reports be reconciled with license fees collected.
That all City Departments maintain accurate records of monies collected.~~
That receipts collected by the City’s Departments be reconciled with the amounts recorded by the
Finance Office.
*Unresolved prior year recommendations
~~ Could this refer to Recreation among others?
** My comment

Noteworthy are the unresolved deviations from acceptable accounting practice that were carryovers from FY2010 and most from many prior years. Interim FY 2011  was when we had that rare individual a CFO in situ; what can we expect this year ?

How many were changed in 2012 when we had only a part time CFO ?  Since all Certificates of available funds are supposed to be signed by the CFO were instead had his name initialed by an employee who I have been told is the spouse of another City employee; one wonders what actual input the acting CFO had in controlling city funds, or if a forensic audit would reveal some major irregularities?

Will we have to wait until past the June 2013  Primary Mayor election before we have answers if any? We know the Council will do no more than  pass its annual resolution stating that they have read the report. That is all that is required, no one is forced to do corrective action or even prove that they have read or understand the audit.

Don’t hold your breath waiting for my status Health Care report which is going through birth pains. However, I will assure you that it will be on the Internet long before there is a resolution of the above deficiencies.

Meanwhile; if you click on the links I suggested yesterday; you will note that I wrote a very comprehensive and  edifying series of blogs in 2009/10. If I may say so most are still worth reading.

IN THE PAST

I am still overwhelmed by the complexity of the Health Care issue. I am still trying to organize my blogs before  posting. An appointment this morning will also delay any extensive blog.

However in June and July 2009 I posted a very comprehensive series of about 12 blogs on the issue. If you wish to read them; go to the right sidebar an d  click on 2009, the on June and/or July . There will be a list of all the blogs posted that month.

I may be back this afternoon.

Tuesday, February 26, 2013

SPACE FILLER



I am planning to write a blog or two about Health Care in the second decade of the 21st Century. My problem is in organizing what I wish to say into a concise coherent document.  There is such a multitude of facets involved in today’s health care and most of those that have the greatest impact have no relationship to the patient or the “provider”.

The term “Provider” is one that the sociologists coined in the 70/80s to9 include all who rendered care. This meant primarily Physicians, Therapists, Nurses and Institutions etc.  All were no longer professionals but rather merchants of a particular product.

That one term represented the death of good health care in the USA. I am not referring to what can be done or to the great technical advances but rather to what it means to you as a potential patient.

Meanwhile while I turn and toss on this subject; knowing that the best jokes are the ones you can tell about yourself,  I would like to quit today with a few more anecdotes from those  early years.

House calls in those days (1950-60) were a way of life, as was 24hr. availability. The phone was by my bedside and even in deep sleep I became conditioned to picked it up on the first ring. Often my wife never knew that I had left the house during the night.

One night I had to make a house call on Hoes Lane in Piscataway, a very rural area in the 50s. I was given the location of a house and told that I should go to the rear. When I arrived, I saw a lantern light in the window of a building about 100 feet in the fields behind the house. I walked down the path with my bag and got close to the building when I heard a cow moo. It was a barn. The house had two apartments. They meant by” the rear” was that the entrance to their apartment on the second floor was by outside stairs in the back.

Another time, I was awakened by a patient’s phone call who said” I have bitten my husband. It is an emergency; and would I come immediately”. I dressed and was part way over there when I started to laugh, for the first time it dawned upon me what she had said. When I arrived, she met me at the door and repeated her comment. They were having a fight, and she had bitten him.  It was not serious and certainly not worth my losing sleep.

Of course there was the alcoholic who called about 2am and said;" Doc I can't sleep". I was rude and replied, " Now I too can't sleep". End of conversation but not that patient.

Monday, February 25, 2013

AN ANECDOTAL BLOG



This blog was posted Wednesday, October 22, 2008. I am re-posting it with some additions (in blue) since it is an anecdotal view of the practice of medicine in the post war period. Like McArthur; "I will return" to today's health problems.
A Doctor in the late 40s.
For most of 1946, I had no car; instead, I drove my mother’s pre-war Plymouth.

It was post war and no cars had been available to the public for several years. Production had not yet met demands. I had tried to buy one at the various dealerships but only the Ford dealer gave me any hope. I was too naive to understand that he wanted dollars under the table before he would deliver one at a premium. Fortunately, a Lion member owned the Studebaker dealership, and I bought one of the first postwar Studies, and many more after that from the same dealer.  Ray Torbush was a member of the Plainfield Lions Club and we had a close and personal relationship for years until he passed away.

The self-contained medical building or offices are a post war innovation. As was common in those days, the office occupied a portion of our house, on the corner of Fourth and Grant. It had been the site of my father’s practice since 1911.

A porch had been enclosed and became the waiting room. A new entrance had been built on 4th street. There was a small entryway between the waiting room and the consultation room, which you entered from the upper left. A door at the far end of this room led to a hall, which was closed off, from the living quarters by two doors. You turned left down the short hall and entered the examination room, which had formerly been a kitchen. An old outside pantry and rear entry had been converted into a rest room and storage space.

In my childhood there was in that hallway a large wall mounted wood telephone (with crank). It was accessible from the living quarters as well as the office. To call that phone you asked the operator to ring #22; it was the 22nd telephone installed in Plainfield. When I retired the number had evolved into 756-0022. The area code was not needed.

Most of my practice consisted of blue-collar families. Many were of Italian, Polish, or Irish extraction; the major population in the West End.  In those days, my practice was not specialized and included pediatrics, obstetrics, minor surgery as well as medicine. I also administered obstetrical anesthesia ^^to supplement my income.

In the 40s and 50s, there were a large number of area residents who were commuting to New York from a station on Grant Avenue

Many were patients and all too frequently, someone would ring the office bell before 7 o'clock in the morning. They wanted to see the doctor before catching their train. It did not matter whether I was asleep or not, they were awake.

Before the war, it was not customary for doctors to have female help, but I soon felt I should have a nurse. This was not only for my "protection" as well as the reassurance of the woman patient.

I hired a delightful young RN (Barbara Wilson) from the Hospital for $48.00** a week! I put her small desk and filing cabinet for the patient’s records in the entry hall by the door. She was the first of many of the most compassionate nurses that worked with me. Most stayed for many years and left only when they had children or their husbands were transferred out of the area. Most of my patients came to regard them as their friend and for years after the nurse left continued to ask about them.

By the 60s I needed two “girls” in my office  which was now on Park Ave.; one a nurse/office manager, the other a receptionist/secretary. In 1970 Nan Christmas, the wife of the then director of the Second Street Youth Center took over that position. I never had a better person in the office; there was no letter that left the office that was not grammatically and word perfect even if she had to correct me.

One day a young girl and her mother came rushing into the office. The girl while using the slicing machine in the family deli had cut off the extreme tip of a finger. The mother stayed in the waiting room while I, assisted by the nurse, repaired the wound.

When I went to tell the mother that everything would be okay, I found her lying on the floor, out cold. She had fainted. She was a greater problem then her daughter.

I had treated one of my patients, a young black man, (Clem Curry) who had pneumonia with ambulatory antibiotics. After examining in the office, I had discharged him as cured.

There were no other patients in the waiting room when he left. I remained sitting at my desk with the door to the reception area ajar. The outside door opened and this young man reentered and, knowing that I could hear, said to my nurse."I forgot to ask the doctor if I could play the clarinet now.” I called out “Clem, of course you can". "That's funny", he said, “I never could before".

I had fallen for an old saw and started laughing. Fifty years later, Clem and I still laughed at this joke.

Once I told the patient, who was not following my advice or taking his medication, that unless he did as I recommended he was wasting his money and my time. He never came back. I had lost a patient I could ill afford.

Twenty years later when he reappeared in my office with a serious illness. He told me that he had been afraid to come back since he was not complying with his treatment, and had seen other doctors. Because he felt that I was a superior physician, he had swallowed his pride and sought my help. He continued under my care for several more years ultimately passing away from intractable heart failure.

Among my patients was a family with two young boys. The older one had developed ileitis. I had referred the family to a GI specialist at Mt Sinai in NYC; however, his case had not only been missed diagnosed by them as ulcerative colitis but the treatment had resulted in a demanding invalid. The younger boy was uncontrollable, probably because his brother was receiving so much attention.

One day he along with his brother and his mother were in my consultation room, when I looked up and noticed that he had not only opened the door to the entry area, but had tied the window drapes' pull cords to the to the door knob. He was getting ready to slam the door closed when I stopped him. I do not think mother even scolded him.

One Italian family had several daughters. The eldest had severe mitral regurgitation a complication of rheumatic fever, which ultimately proved fatal. One of the other daughters was very obnoxious and nosey. Her younger but naive sister was able to conceal her several months’ pregnancy when married. Helen and I were invited to the family catered wedding.

A little over five months after the wedding towards the end of her 7th month, she phoned me hysterically complaining of severe pains in her stomach. Suspecting what was the problem; I immediately made a house call and had her transported to the hospital in active labor. I was her obstetrician, almost all physicians, even those who professed themselves to be surgeons, in the 50s delivered babies.

The baby boy weighed about 3 pounds and ultimately suffered from a hearing loss. Her older sister questioned me whether I thought that the baby had come too soon after marriage, i.e.: questioning if her sister had been pregnant before the wedding. I pointed out that the baby’s size showed he was premature which satisfied her curiosity.

That delightful young lady and her husband now live in Florida. She has many grandchildren and frequently e-mails me. She has never forgotten my birthday.

There was an Irish foundry worker who lived on West 4th Street near Monroe Ave and was employed at Hoe’s. He developed severe urinary retention at work as the result of an enlarged prostate. Although in severe pain he walked about six miles from Middlesex to my office. I had the Muhlenberg ambulance (in the 50s the Hospital still provided ambulance services) transport him to the hospital for the Urologist to treat. In those days that particular surgery was not only crude and brutal, but, there was a prolonged painful period of recovery most often complicated by urinary tract infection.

The distended obstruct red bladder was empty by forcefully inserting a trochar through the abdominal wall into the bladder. A tube was then passed through the trochar which then was removed. The drainage catheter was left in place until the prostate could be removed suprapubicly by manual dissection from the bladder wall. Now all this can be done painlessly without a scar through the urethra.

** Hey, an office call cost $4.00 and a house call $5.00.
^^ The fee for a delivery anesthesia was $5.00 in the 40s and had risen to $15.00 by the 60s.



Sunday, February 24, 2013

PUBLIC NOTICE





FOR IMMEDIATE RELEASE

First Annual Herbert Green Forum on Education Hosted by League of Women Voters of Plainfield

Plainfield, NJ (February 24, 2013) – On Wednesday, March 6, 2013 at 6:30 pm, the League of Women Voters of Plainfield will present its First Annual Herbert Green Forum on Education, with guest speaker Dr. Arnold L. Glass, Professor of Cognitive Psychology at Rutgers University. The talk will take place in the Anne Louise Davis Room at the Plainfield Public Library, located at 800 Park Avenue in Plainfield.

Dr. Glass, whose research focuses on cognitive learning, heads the Learning and Memory Laboratory of the Department of Psychology at Rutgers, and he has published widely in the American Journal of Psychology, The Quarterly Journal of Experimental Psychology, Memory and Cognition, and other professional journals.

The Herbert Green Forum on Education is named in memory of our beloved colleague, who died recently at the age of 87 after a brave battle with cancer. This event is free and open to the public, and the League especially encourages educators to attend to hear Dr. Glass's presentation. Refreshments will be served after the talk.
The League of Women Voters, a non-partisan political organization, encourages the informed and active participation of citizens in government, works to increase understanding of major public policy issues, and influences public policy through education and advocacy. Visit the website at http://plainfieldleague.blogspot.com.

CONTACT:
Rebecca Williams
League of Women Voters of Plainfield

HEALTH CARE-LOOKING BACK



As many know there was a massive FIOS failure last night sometime before 9pm; resulting in no telephone, TV, or Internet. About 9:45 am TV and Internet returned. The phone is still out. (9:50 AM).

It has been a generation since I last treated a patient. The changes in health care in that time have had a depressing impact on me. I am not referring to the modalities or techniques available but rather how they are implemented.

I was taught that a good physician had to do the following; Talk and listen, palpate, percuss and auscultate in order to make a diagnosis, or to follow up. With my trusty stethoscope I could even diagnose tuberculosis in the lung’s upper lobes where it usually started. Pneumonia and the affected portion of the lung was an easy diagnosis that could be confirmed by x-ray if desired.

A complete physical took more than 10 minutes since among the routine check of the pulse and blood pressure one also checked the ears, eyes including using the ophthalmoscope, the mouth, the neck both listening to the carotid arteries and checking the thyroid gland and feeling for lymph nodes visual exam of the chest and abdomen plus front and back. Then there was auscultation of all quarters of the chest including percussion of the lungs which could be very informative, as well as the heart for murmurs and rhythm abnormalities. We believed that to be effective this had to be done on the skin.

The abdomen was checked by palpation and again listening to the bowl sounds. The legs were checked including feeling for the pulses in the groin knee and feet. This included all the reflexes including the Babinski. 

With the annual physical of a male there was included that dreaded rectal exam which would check the prostate and sometimes find an asymptomatic early rectal cancer. Women did not get of scot free; they had a pelvic examine addition to the rectal. The cervix was visually examined and once the Pap smear became on the scene one was sent to the lab. The uterus and the area around were checked by palpation. Of course the office nurse was always present in the room as a protection for both the patient and the doctor.
Compare that to the so called complete physical most patients receive today. This I will mention in a later blog.

 For 45 years that was the basis of my practice and of my peers. Our patients felt we were their friend and could confide in us. At times we were forced to substitute for a confessor. Always there was a personal relationship which some survivors have maintained to this day. If you cared and enjoyed people you became a primary care physician either a GP or an internist.  Most who had trouble relating to people became Surgeons.

I will note that we were available 24/7 and I made house calls from Middlesex to Scotch Plains, from Warren to Piscataway/Edison. I even had patients come from as far away as Sparta.

This however is not what I set out to write; I am going to comment on my opinion about the effects of Obama care. At the same time I may have to interject some anecdotes or history of the changes that have taken place and the reason they have done so. That will also mean that I may have to devote a blog to answer questions. I will warn you that my answers may not be the popular one.