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In room six sat a typical 78-year-old nursing home patient with the history of a cough and low grade fever. She was pleasantly confused but followed instructions; grey and wrinkled but otherwise she looked better than most. Her vitals were normal. We found no fever at the time of triage and she had received no antipyretics. On exam her lungs were clear. Her throat was moist without any exudates. The only thing I noticed was some rhinitis. I was unsure of why she was sent. Due to her age, I suppose, I ordered a CXR, CBC, CMP and UA, all the while knowing there was probably no real indication for any of it. I called the nursing home and spoke to the charge nurse, an LPN with a heavy accent of indeterminate origin. She related that she heard the patient cough and felt warm to the touch. She had called the nursing home doctor, as required, prior to transport.

However, he refused to come see the patient until his usual rounds in two weeks. He complained that he only gets paid $15 a visit and needed to group all the patients into one visit a month. If he came in for an extra visit and couldn’t document it as a true emergency he would get paid nothing. The L.P.N. stated she didn’t know what to do. So she called EMS.

While I was seeing other patients, the elderly woman walked by me on her way to the bathroom. She gave me a big wink and a smile. I felt bad for her. I felt like I was making her yet another victim of our medical culture. At least she received the dinner tray I ordered and ate it with gratitude. To no one’s surprise, the diagnostic tests were all normal. She had rhinitis. All I could think was, “I’m an emergency physician in a busy ED. Surely she has to have more than this. So I hedged. Discharge diagnosis: bronchitis; treatment: Zithromax.

A few minutes later, I was asked to sign a medical necessity form for the ambulance transport back to the nursing home. There was no family who could drive her back. If I refused she would be stuck with the transport bill, which could be sizable.

But I looked at the form trying to find justification. Unable to sit without assistance? No. Needs constant monitoring? Not really. Needs constant oxygen or IV fluids? Definitely not.  My conscious asked, “Should I sign it?”

This is a very simple, everyday case in the ER, yet it is fraught with a multitude of ethical dilemmas. Let’s break it down decision by decision.

1. The LPN orders an expensive ambulance ride and hospital evaluation.
LPNs, depending on the state, have a skill set restricted to taking vital signs, medication administration, general diet, hygiene care, and care for non-acutely ill patients such as those in nursing homes, assisted living facilities, and home health situations. These types of facilities hire LPNs because they make 10 to 20 dollars less an hour than RNs. The LPN in charge did not have the ability to evaluate the patient. While this cost saving measure saves the nursing home in operational expenses, that cost gets shifted to acute care centers and tax paying citizens. It also has a great potential for harm and discomfort to the patient. In fact, the LPN was more concerned about her own liability than the patient.

2. Does every ambulance call have to result in a transport to an emergency department?
I think not. Assuming that a paramedic in consultation with the physician is a higher order of care, wouldn’t it be appropriate, ethical and legal for the paramedic to be able to decline transfer to the hospital? In fact, paramedics in many systems have protocols to refuse transport for non urgent cases. This is generally initiated by the dispatcher. Some systems allow transport to urgent care centers. But the bottom line is that the system needs more flexibility. Paramedics need to be able to refuse to transport non emergent patients to the ED.

3. The nursing home physician refused to come in and evaluate the patient.
While some might fault the physician for refusing to make the nursing home call, I would not. Consider this: All nursing homes are required to have physician coverage 24 hours per day. They are required to do an initial exam, routine visits (every 30-60 days), and acute visits based on medical necessity. Although governmental regulations require this, they refuse to pay adequately for it. So who’s being unethical here, the physician or government with its unfunded mandate? In my opinion, the fault lies with CMS. But there are several alternatives: increased reimbursement to the physician or substitution of interim visits by PAs and NPs.

By heading off needless visits to the ED, this kind of change could provide major cost savings for tax payers, patients and their families. It could add more revenue for primary care providers, a specialty our country needs to start valuing more.

However, while the primary care doctor may have been within his rights to refuse to come out, to leave the LPN with no guidance on whether to call 911 was, in my humble opinion, part of this ethical dilemma

4. The ED doc decides to order an expensive work up.
Any competent physician should be able to diagnose rhinitis or upper respiratory infection based on history and physical. However, some EPs seem to have a personal need to do something more...technical. But this diagnostic testing has no indication; it fulfills the ED doc’s needs and does not benefit the patient. Even worse, the testing has more potential for harming than helping the patient. What does the EP do when an incidental abnormality is found? Subject the patient to even more invasive diagnostic testing?

And finally, the sleazy element. Every EP knows that labs and X-rays increase the level of complexity, which increases RVUs, which increases the EPs salary, the facility and nursing charges, and makes everyone rich...

5. Treatment and discharge
The ethical pit just gets deeper when the EP decides on treatment. Bronchitis has a higher level code than rhinitis. So who really benefits when the EP orders antibiotics? It’s easy to see that CMS has incentivized this situation through it’s billing structure, penalizing EPs for practicing good, honest, cost effective medicine. Plus there may also be some emotional overlay on the EP’s decision. We like to see emergencies, not clinic cases. It is safer to over-diagnose than to under-diagnose. But the truth is that this is fraudulent billing.
 

6. The medically necessary transfer
Should an EP sign the medical necessity form so CMS pays for the ambulance ride back to the nursing home? CMS is pretty strict on what is considered medically necessary. If the patient can sit in a chair unattended, they do not qualify for transport. But who’s going to pay to get her back? It is the responsibility of the nursing home, the patient’s family or the hospital to arrange transport. Signing the CMS necessity form is fraudulent. It clearly benefits the EP’s administration/employer. But signing also makes the nursing homes happy since it incurs no cost for them. But it also encourages additional unnecessary transports. Notice the nice circle of profit for ambulances, hospitals and physicians. It can all be stopped by the lack of one signature.

EPs have the fiscal and ethical responsibility to order what is medically necessary for the patient. Emergency physicians are care givers who like to please everyone. Besides, scratching the backs of the ambulance crews who bring us patients seems like a harmless gesture. It’s so easy to just sign it and so hard to say no. What would you do?

 

Comments   

# Amen!Eric 2013-06-05 06:39
Amen to that and thanks.
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# MDK 2013-06-05 06:45
Great post and illustrates the complexity of creating fiscal responsibility in our current system. Many who see it feel quite helpless to change it, as NOT signing will create strife for corporations which result in the physician being called "difficult" or "disruptive". The healthcare system needs some coordinated DISRUPTION by those at the bedside, but that is prohibited by law.
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# Transport from rural hospitalsBoatswain2PA 2013-06-05 12:15
I face dilemma #6 almost every night. Ill patient who needs definitive care at a tertiary hospital...but do they really need ambulance transport for the hour drive to the city for a (non-septic) abdominal abscess? A dose of Zosyn and pain control and patient certainly could have sat in passenger seat of a POV for the drive.

I signed the form (she needed IV fluids ) because it is still cheaper to send a thousand of these patients via POV than to have one adverse event and buy a lawyer (or two) a new house...but I didn't like the taste in my mouth as I did it.
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# Monday Morning Quarterback 2013-06-05 13:10
Isn't it easy to write an article about all the unnecessary things that happened in this chain of events when you're personally insulated from any liability as a result of a bad outcome? What are the odds that a 78 year old nursing home patient with a history of fever and cough merely has rhinitis? That's a rule out pneumonia. That gets a CBC, a BMP, and a CXR every single time. Your job in this practice environment is to make sure that the poor woman doesn't go back to the nursing home, get septic, and die. It doesn't really matter if you actually diagnose her rhinitis, or bronchitis, or whatever she actually has.
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# Kamal Gursahani 2013-06-05 17:32
Interesting point about this case....Since the patient never should have come to the ER in the first place, sepsis was really unlikely.

Nevertheless, if the ER doc really thought the patient had pneumonia, wouldn't it be HCAP, not bronchitis? And wouldn't it be treated something more substantial than a zpak? This middle of the road catch all diagnosis (bronchitis) to support prescribing unnecessary antibiotics is kind of ubiquitous...an d it's definitely upcoding, whether for the purposes of defensive medicine or billing, I'm not entirely sure.

And, you can't really make sure this woman won't go back to the nursing home, get septic and die, even if you do the unnecessary labs & give her a zpak. She's probably more likely to get a multidrug resistant bug in the nursing home being on unnecessary antibiotics, or better yet, suffer some adverse reaction to azithromycin than actually benefit from these management choices.
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# Jesse Belville,PA-C 2013-06-05 19:44
you did not design the system #2.) You cannot change the system all by yourself. #3)Once the patient gets brought in YOU as the ER Doc or provider have to do the Right things for this pt.#4) Many Nursing homes have transport vehicles. Do not place yourself at risk for falsely signing a federal form that will get you Screwed fined and put in Jail..Yes it can happen to MD's or DO's if a local DA wants to make a name as tough on Medicare crime or fraud.. Your article if true now opens you to investigation and review of all your stuff. Your facility and your fellow Physicians will NOT stand with you.. So do what you believe is right and hope you are not screwed because yes you did or did not.. Render unto Caesar what is Caesar's. or suffer possible consequences..
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