March 11, 2010
WhiteCoat

Medicare Cuts Delayed Again — PHEW

March 11th, 2010
fat-cat4
I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare.

While perusing the morning news, I discovered that once again the Senate has made a last-minute decision to delay the Medicare pay cuts — this time until October 1, 2010. I’ll be linking back to my Brinksmanship article somewhere around September 15, 2010, I’m sure.

According to one Senate Republican, this means that the federal deficit will increase by $100 billion.

Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion.
That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12)

Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars.

Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year.

Lets say that there are 50 million Medicare enrollees (these Kaiser numbers are from 2008, so I increased the estimate from 44.8 million to 50 million).

Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year.

Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country.

So what are all of us rich doctors complaining about?

How about politicians who are full of hot air.

Where’s the money really going?
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Healthcare Update — 03-10-2010

March 10th, 2010
If you like this, you’ll also like the satellite edition of this week’s Healthcare Update with more links over at ER Stories.
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Dirtbag emergency department technician steals credit cards from plane crash victim’s wallet while other personnel try to save the man’s life. Then he buys himself some Armani clothes using the patient’s credit cards while the patient is dying in the hospital.
HIPAA violations that occur for personal gain are punishable by up to $250,000 in fines and 10 years in prison. You’ll have to make an awful lot of license plates to buy an Armani shirt in the Big House, there dimwit.

Emergency nurses: They’re overworked, underpaid, they get spit on, kicked, threatened with scissors, and are the front line for disasters. You’re paying them less than surrounding hospitals. Now their benefits are getting cut. It’s a tough economy.

When there aren’t enough specialists willing to provide on-call services, patients often have to be transferred to other facilities for specialty care. In some cases, finding a hospital with a proper specialist that is willing to accept a patient in transfer can take a long time. This patient with aortic dissection wasn’t able to get timely transfer for surgical repair and a suffered cardiac arrest before the dissection was fixed. An emergency nurse noted that the receiving hospital refused to accept the patient because he had no insurance. Now the patient is blind and disabled. Who’s to blame? The system? The hospital? The physician? The patient? (thanks to Max Kennerly for the link)

Down side of going to help Hatian earthquake victims: If you get sick, you may not be able to get the health care you need. Condolences to the family of this 38 year old Seattle nurse who suffered a heart attack and died while helping Haiti’s injured.

You hospitals want to save money? Stop treating low income patients in your emergency department. After implementing its Urban Health Initiative, the University of Chicago doubles it operating profits for the year. During that same time period, ED visits dropped 22% and admits dropped 8.5%.
One problem, though. If more hospitals take this approach, where are the poor patients going to get the more “mundane” medical care?

Minnesota Governor Tim Pawlenty suggests that one way to cut health care costs is to change federal EMTALA laws so that “not every ER is required to treat everybody who comes in the door, even if they have a minor condition.”
He’s now getting flamed all over the internet. See here, here, and here for examples.
The thing is, EMTALA laws don’t require every “ER” to treat every patient. Hospital emergency departments are only required to provide a screening exam to everyone and to treat emergency medical conditions. Pawlenty already has his wish, and it’s not so radical, folks. To wit: (I saw that phrase in a lawsuit brief and am getting a kick out of using it, so leave me alone)

More hospital emergency departments are jumping on the “pay before you see the doctor” bandwagon. Burke Medical Center in Georgia stated that it was “following the trend of other facilities” when it implemented a policy of paying your insurance co-pay or $100 before receiving treatment. If you don’t pay and don’t have an emergency condition, you’ll be given a list of outpatient clinics where you can go for care.

In the same vein, do doctors in America turn away the uninsured? Absolutely. Read this HuffPo article to get a good idea of how and why. Good insights.

Nebraska physician advocates personal responsibility as one way to improve this country’s health care problems. I agree.

Do you know where your son spent the night?” College students go to emergency departments for intoxication and college calls parents to narc on them. “Sent to the hospital.” “Alcohol poisoning.” “Not the first violation.” The schools also call home every time a student is caught with alcohol. Some schools allege that “telling mommy” decreases the amount of binge drinking on campus, but isn’t there some type of privacy issue going on there, though? What’s next, a voice mail message at mom’s work if you don’t finish your carrots in the cafeteria?
If an administrator did this to me when I was in college, I would have followed him all over campus and followed him home, calling his mommy and his wife every time he rolled through a stop sign or looked at me crosseyed. Then I would have written an article to the school newspaper chronicling all of his transgressions. Then I would just randomly go to his office with a notebook, wait in the waiting area, sit there writing for 30 minutes at a time, then get up and leave. Can’t be too careful about those college administrators, you know.

Reserved parking for the four pronged canes to the left, leave your brown paper bags of medicine on the counter. A geriatric emergency department – the wave of the future or a flash in the pan? Will they remain viable with Medicare cuts to physician payments or will hospitals use them as a loss leader to draw in patients for more profitable procedures?

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Raisins OK, Grapes … Not So Good

March 9th, 2010

Allergies

Come on. Allergies to fresh fruit and vegetables?

Guess all the chemicals used in processing are good for the immune system.

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The Escape

March 7th, 2010

I’m in Washington DC doing some lobbying for emergency medicine.
It’s near the end of the day and I’m sitting at a conference surfing the internet between lectures.
I log in to this blog to jot down a quick post. As I’m writing, I get the feeling that I’m being watched. I look over my shoulder and there’s some guy watching me type. He remarks “YOU’RE WhiteCoat?!?!?”
I close up my computer. “Not cool, buddy,” I said.

After the lecture I’m walking back to my hotel room and this guy starts walking next to me trying to make small talk. I get out my phone and pretend like I got a phone call. He still doesn’t get the hint.
I walk in the hotel lobby and down the hall to the room. The guy stops in the lobby.
As I get to the door of my room, I hear the phone ringing. I got inside and walked over to answer it but it stopped ringing before I got there.
I tossed my bag on the bed and went to the bathroom. While I’m in there, someone knocks on the door.
“Dammit. Who is this guy?” I think to myself.

I get done in the bathroom, flush the toilet and hear someone say.
“He’s in there. I just heard him flush the toilet.”
Screw this. I grabbed my computer bag, opened up the window and started to climb out onto the fire escape.
Then someone grabbed my shoulder.
I yelled.
The security guard yelled.

“Wake up you lazy ass. There’s a patient with a toothache waiting to be seen.”
I sat there with a blank stare.
“You didn’t answer the phone and you didn’t answer the knock on the doctor’s lounge door. What’s the matter with you? There’s a patient.”

Damn. Why couldn’t I have made it out that window a little quicker?

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Need “Entirely Free Health Care?” Go to the ER!

March 5th, 2010
BelomorkanalAfter hearing Mitt Romney’s views of emergency medical care during a recent interview, I’ve concluded that he is a dope.

He was recently interviewed on MSNBC’s “Morning Joe” about some book he’s peddling and his response to one of the questions just shows that he has no clue about the economics of health care.

Question: Do you believe in “universal coverage”?
Answer: “Oh, sure. Look, it doesn’t make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way.”

Can’t embed the video here, so you’ll have to go to MSNBC and start the video at about 5:35 to cut to the chase.

Hospital emergency departments provide medical care to patients just for the heck of it with no expectation of payment? Businesses just give you services and you don’t have to pay them for it? Great business model! Why didn’t I think of that?

In fact, I like that business model so much that I’ve decided to go to Massachusetts to take out a loan at a bank. Then I can get some “entirely free money for which I have no responsibility.”
On the way, I’ll stop at a car dealership where I can get an “entirely free car for which I have no responsibility.”
And I’m going to enroll my kids in some Massachusetts colleges where they can get an “entirely free education for which they have no responsibility.”

Oops. Better watch what I say before I get thrown in the Gulag.

Don’t laugh, using Mitt Romney’s logic, the “emergency room” docs in Massachusetts are already there.

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What’s in Your Pocket?

March 4th, 2010

In My PocketThere are certain things that I always carry in my pocket.

1. Mini Mag Light – for looking down throats and into other dark places, also very useful for finding dropped toys in movie theaters
2. Pocket knife – indispensable for multiple things, used most often for opening packages
3. Chap Stick – for softening my lips right before I walk in the door and say hello to Mrs. WhiteCoat
4. USB drive/SD card – I have a MicroSD card with a USB reader and a MicroSD to SD adapter so I have a backup for my camera. On the MicroSD card I keep an encrypted file with all my important data/PowerPoint lectures/etc., and I have an installation of PortableApps all set up as a backup for my keychain thumb drive if I need it.

At work, I also keep my Palm Pre loaded with Epocrates and MediPDA (plus internet bookmarks for other sites) and I keep my trusty stethoscope which doubles as a reflex hammer. That’s about all I carry with me.

Someone commented that they thought it was strange that I always have a flashlight with me. So I started wondering …

What do you carry in your pocket?

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Healthcare Update – 03-03-2010

March 3rd, 2010

Bad debt causes Arkansas hospital to implement unpopular policy – make a $50 down payment before you can see the emergency physician. What!?!?! That’s more than a carton of smokes and a case of PBR combined!

Anger management classes are down the hall. Cape Cod punk getting treated for cuts to his hand he sustained when he punched a mirror then puts emergency department security guard in headlock and starts punching him in the face when security guard started “staring at him.” Lighten up, Francis … oh, and enjoy your stay the Greybar Motel.

Deaconess Hospital emergency department closure “disastrous” and isn’t addressing “critical problems facing emergency patients” according to ACEP president Angela Gardner. Spot on, doc.

Michigan’s Medicaid system is out of control. One in 6 Michigan residents qualify for Medicaid and it covers 40 percent of all births and 70 percent of all nursing home care. How will Michigan close the Medicaid budget deficit? Tax doctors on their gross receipts. Yeah. that will work. Up to 45% of Michigan docs already refuse Medicaid patients. Watch that number jump.

Good news: Visits to Canadian hospital emergency department decrease during Olympics. Bad news: Number of patients suffering from drunkenness and assaults spiked. During the Olympic games, hospitals in downtown Vancouver were seeing an average of 17 assault victims per day – triple the usual number.

Medical malpractice cases at all time low and total malpractice expenditures only 0.6% of total healthcare budget … according to Public Citizen. Oh, tort reform in Texas is a failure and a 1999 IOM study showed that doctors kill 99,000 patients every year due to avoidable errors. Yeah, that about covers it.

Phil Howard speaks on tort reform. Inspiring – at least to the non-lawyer commenters. (Thanks to Mad Rocket Scientist for the link)

When everything is an emergency, nothing is an emergency. Pittsburgh man calls 911 ten times in two days complaining of abdominal pain. Unfortunately, Pittsburgh just got socked with a snowstorm, there was two feet of snow on the ground, ambulances were unable to get through the roads, and paramedic calls were at twice their usual volume. At one point, 30 calls were waiting for ambulances to arrive. The man took pain pills and ended up dead.
Now the city plans to have firefighters respond to some 911 calls … between fighting fires, of course.
One commenter to a report of this incident on Medscape blogs noted that tax cuts can have the same effects of decreasing available personnel and increasing wait times. Another commenter stated that services in his area had been cut so thin that patients were better off taking a taxi.

Inner city emergency departments have nothing on Haiti after the earthquakes. Emergency physician Scott Plantz describes his experiences in a USA Today article.

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Focus On The Cost

March 2nd, 2010

Yeah, I agree with Howard Fineman. You got a problem with that?

Read his Newsweek article about his experiences being admitted to an Argentinian hospital and how he believes we should be focused on the costs of health care in this country.

His bill for a hospital stay with dehydration in Argentina: About $1500. Similar hospitalization in the US: $10,000 to $15,000 – if he was lucky. Money quote: “Most Americans have no idea how much their health care really costs, nor do they know how well it really works ….”

We desperately need price transparency in our health care system.

Look at the four systems in Pennsylvania that I reviewed in a previous post. If one hospital cost 4 times as much as another hospital for treating the same medical problem, would that affect anyone’s decision on where to go for medical care?

One commenter to the article noted that “Health services are often urgently needed and the consumer doesn’t have the time or inclination to shop around.” If people shop around for weeks to find the best deal on a car and spend all Sunday morning going through newspaper ads to find the cheapest head of broccoli at the grocery store, I have no sympathy for those who “don’t have the time or inclination” to research where they would want to go if their life was on the line or if they needed specialized surgery.

Regardless of what health care reform measures are taken, we still need to be educated consumers with our most important assets – our lives.

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The Patient Who Lived at McDonalds

February 28th, 2010

Yup. 7151 W. Main Street, Apartment 1 is not a residence. There’s not even an apartment there. It’s a McDonalds.

A patient came in with a “hard lump” on his stomach which ended up being an abscess with quite a bit of surrounding cellulitis. The doc did an incision and drainage on the abscess and started the patient on Bactrim, suspecting that the infection was MRSA.

We got the report back while I was working and the doc was right. It was MRSA. But the MRSA was resistant to Bactrim and the patient needed to be started on a different antibiotic to treat the cellulitis.

We called the phone number the patient gave us. Disconnected.
We looked up the patient’s address to see if there was an alternate phone. As a matter of fact, there was … Welcome to McDonalds, may I take your order?

Hey, bud. You may have waltzed out without paying for your treatment, but have fun with your McSepsis and your McSkinGraft – or maybe even your McCasket.

What goes around comes around.

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Brinksmanship

February 26th, 2010

colonel_sandersI may end up eating my words about this. We’ll see.

James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him.

I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now.

A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster.

Now the stakes just went up.

The Senate blocked the latest legislation to extend the deadlines for the pay cut. Pay cuts will take effect on Monday.

Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years.

So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand.

Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care.

Initially, that may be true. Then what happens?

First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them.

Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need.

If a lot of physicians opt out of Medicare, the health care system will turn chaotic. Maybe a few of the well-to-do elderly patients will pay out of pocket to continue seeing their current physician. However, most will start calling around to find other physicians who still accept Medicare. The wait lists with those physicians will grow from weeks to months.

In the meantime, elderly patients will go to emergency departments for their health care needs because we emergency physicians will always be there to help them when their doctors aren’t available (I’m already starting to see this happen in my ED) and because the hospitals won’t dare to opt out of Medicare.

Hospitals accept Medicare … Medicare pays for care rendered to seniors … seniors go to hospitals. Seniors who come to the emergency department tend to get BMWs (but remember, folks, defensive medicine doesn’t exist), therefore costs to Medicare go up, not down. Medicare goes bankrupt sooner than anticipated.

A crisis like this is what we need to get legislators back to the table to create a better health care plan. It needs to happen. Even the status quo is unacceptable.

I doubt it will happen, though. CMS has announced that it will not process claims for Medicare payments for the first two weeks of March, so my prediction is that Congress will eliminate the pay cuts next week and that all the physicians will get their “full” payments after March 14. We’ll continue in the same dysfunctional system until the next crisis occurs about 10 months from now.

Unfortunately.

Gutsy move by Congress letting things get this far, though. No matter what happens, this is turning into one helluva game of chicken.

UPDATE FEBRUARY 28, 2010
See Throckmorton’s blog for another good point – with the cuts to reimbursements also come a cut to reimbursements for medical care to all of our soldiers. What happens to Congress?
There are already reports that a bill will be introduced this week to delay the effective dates of the cuts for another 30 days. And the AMA is actually showing doctors how to drop Medicare, if they so choose, including samples of documents to file (.pdf file – also contains excellent explanation of options physicians have regarding participation versus non-participation)
The merry-go-round continues.

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