Comments on: My View http://www.epmonthly.com/whitecoat/2009/04/my-view/ A blog from inside the emergency department Wed, 08 Feb 2012 04:31:06 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Bali http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-8321 Bali Thu, 14 May 2009 04:41:15 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-8321 Great post as usual, long time lurker here, first comment! Thanks for the great blog. Great post as usual, long time lurker here, first comment! Thanks for the great blog.

]]> By: WhiteCoat http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7974 WhiteCoat Mon, 20 Apr 2009 00:25:18 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7974 The question should be whether the expense and radiation involved in catching an "early" appendicitis in a patient with unimpressive exam and normal appetite would have changed the outcome versus just having the patient come back for a re-examination in 12 hours. How many dozens of CT scans have you ordered with unimpressive exams that were entirely normal? If the exam is unimpressive, why order the test to begin with? Is making a diagnosis 5% more or less likely worth the inordinate amount of money spent on low-yield testing? How would it change the outcome if we treated many problems conservatively? No one knows because right now FREE=MORE. Your comment makes my entire point. People don't tolerate not ordering the latest and the greatest because they aren't paying for it. Require a patient to pay $200 each time they get an MRI for their back pain or pay a percentage of the $250/month cost of the newest hypertension medication and they'll eventually make a value judgment - "am I willing to pay for the latest and the greatest even though it will probably make little difference in the outcome of my condition?" Maybe exercise and something off the $4 list at WalMart will work just as well. Part of making medical care more accessible and less costly is changing the paradigm of diagnosis and treatment. Either we'll do it ourselves or someone else will do it for us through rationing. The question should be whether the expense and radiation involved in catching an “early” appendicitis in a patient with unimpressive exam and normal appetite would have changed the outcome versus just having the patient come back for a re-examination in 12 hours. How many dozens of CT scans have you ordered with unimpressive exams that were entirely normal? If the exam is unimpressive, why order the test to begin with?
Is making a diagnosis 5% more or less likely worth the inordinate amount of money spent on low-yield testing? How would it change the outcome if we treated many problems conservatively? No one knows because right now FREE=MORE.
Your comment makes my entire point. People don’t tolerate not ordering the latest and the greatest because they aren’t paying for it. Require a patient to pay $200 each time they get an MRI for their back pain or pay a percentage of the $250/month cost of the newest hypertension medication and they’ll eventually make a value judgment – “am I willing to pay for the latest and the greatest even though it will probably make little difference in the outcome of my condition?” Maybe exercise and something off the $4 list at WalMart will work just as well.
Part of making medical care more accessible and less costly is changing the paradigm of diagnosis and treatment. Either we’ll do it ourselves or someone else will do it for us through rationing.

]]> By: Matt http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7962 Matt Sun, 19 Apr 2009 16:23:36 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7962 Why would "good nationwide tort reform" do anything when "good" (from a physician's perspective) statewide tort reform hasn't? Are physicians in California, which really screws the injured and has for a couple decades, doing anything differently than physicians anywhere else? Why would “good nationwide tort reform” do anything when “good” (from a physician’s perspective) statewide tort reform hasn’t? Are physicians in California, which really screws the injured and has for a couple decades, doing anything differently than physicians anywhere else?

]]> By: ERDoc http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7957 ERDoc Sat, 18 Apr 2009 14:22:36 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7957 I don't order the "megaworkup" on everyone to cover my tail. Didn't mean to imply that. I use clinical suspicion and current evidence as best I can. But I've been surprised enough by people who had CT evidence of appendicitis, with an unimpressive exam and a normal appetite, to have a low threshold. This is just one example that comes to mind. Two people in the last year, after I told them they had appendicitis asked me if they could eat something..... My entire point is when you go to a "free market" it could be a pandora's box in many ways. Good nationwide tort reform could limit some of the problems. But people in our society just don't have a tolerance for not ordering the best tests available in a given situation, if there is even a small chance they may have X or Y---without looking for it with the appropriate studies. I don’t order the “megaworkup” on everyone to cover my tail. Didn’t mean to imply that. I use clinical suspicion and current evidence as best I can. But I’ve been surprised enough by people who had CT evidence of appendicitis, with an unimpressive exam and a normal appetite, to have a low threshold. This is just one example that comes to mind. Two people in the last year, after I told them they had appendicitis asked me if they could eat something…..

My entire point is when you go to a “free market” it could be a pandora’s box in many ways. Good nationwide tort reform could limit some of the problems. But people in our society just don’t have a tolerance for not ordering the best tests available in a given situation, if there is even a small chance they may have X or Y—without looking for it with the appropriate studies.

]]> By: WhiteCoat http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7955 WhiteCoat Sat, 18 Apr 2009 02:35:30 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7955 I challenge you to examine the utility of your "megaworkups." How often do they result in finding something requiring intervention in a stable patient? Perhaps doctors *should* be required to describe the utility of each test and the likelihood of finding a positive result to patients before extensive testing is ordered. How often do radiologist over-reads change the initial ED physician's reading? If more than a couple of times per month, the emergency physician needs some remedial training. So you tell the patient "This is my impression. If you'd like, you can pay to have a radiologist expert double check my reading. Otherwise, you can sign this informed refusal stating that you'll go with my interpretation." Do you get a cardiology consult on every chest pain patient or every patient with hypertension? Call trauma for every bump and bruise? Pulmonary for pneumonias? Ortho for every sprained ankle? You're taking on liability in each of these cases. Granted that there are complicated cases where consultants are necessary, but most ED physicians get along fine without consultants for most ED problems. Why should radiology be any different? You discharge patients all the time with a higher likelihood of disease than 1 in 100. Look at PE patients. A negative CT is only 83% sensitive in detecting PEs. You order pulmonary angiograms on everyone? Even those will get you only to low-90% range. I don't believe that "megaworkups" serve the interests of a lot of patients. Low yield testing is not the "standard of care" and shouldn't be. I'm not saying that we should go to a strict fee-for-service system. You're right that there would be many more people falling through the cracks. But any system that is created must let patients control the spending. Not doctors. Not insurers. Not the government. Until that happens, whoever controls spending will ration care. Guaranteed. I challenge you to examine the utility of your “megaworkups.” How often do they result in finding something requiring intervention in a stable patient? Perhaps doctors *should* be required to describe the utility of each test and the likelihood of finding a positive result to patients before extensive testing is ordered.
How often do radiologist over-reads change the initial ED physician’s reading? If more than a couple of times per month, the emergency physician needs some remedial training. So you tell the patient “This is my impression. If you’d like, you can pay to have a radiologist expert double check my reading. Otherwise, you can sign this informed refusal stating that you’ll go with my interpretation.” Do you get a cardiology consult on every chest pain patient or every patient with hypertension? Call trauma for every bump and bruise? Pulmonary for pneumonias? Ortho for every sprained ankle? You’re taking on liability in each of these cases. Granted that there are complicated cases where consultants are necessary, but most ED physicians get along fine without consultants for most ED problems. Why should radiology be any different?
You discharge patients all the time with a higher likelihood of disease than 1 in 100. Look at PE patients. A negative CT is only 83% sensitive in detecting PEs. You order pulmonary angiograms on everyone? Even those will get you only to low-90% range. I don’t believe that “megaworkups” serve the interests of a lot of patients. Low yield testing is not the “standard of care” and shouldn’t be.
I’m not saying that we should go to a strict fee-for-service system. You’re right that there would be many more people falling through the cracks. But any system that is created must let patients control the spending. Not doctors. Not insurers. Not the government. Until that happens, whoever controls spending will ration care. Guaranteed.

]]> By: WhiteCoat http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7954 WhiteCoat Sat, 18 Apr 2009 02:19:11 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7954 "an all-private system simply won’t give us universal coverage" Exactly my point - hence the "legal system" example. On the other hand, FREE=MORE and always will. Are you suggesting that those who have unlimited free access to medical care will not demand more care? If so, you're misinformed or disinformed. Our system is far from "private". In our ED, we see 0.5% patients with commercial insurance. About 15% have HMO or are worker's compensation. More than 60% have either Medicare or Medicaid. The rest are self-pay. How exactly does that translate into a "private" system? We need to create a system where everyone "prudently diverted a reasonable amount to insure themselves" - that system does not exist now. If people have a choice between receiving time-rationed "free" care and quicker, higher quality "paid" care, the value of investing for one's future medical care will become apparent. “an all-private system simply won’t give us universal coverage”
Exactly my point – hence the “legal system” example. On the other hand, FREE=MORE and always will. Are you suggesting that those who have unlimited free access to medical care will not demand more care? If so, you’re misinformed or disinformed.
Our system is far from “private”. In our ED, we see 0.5% patients with commercial insurance. About 15% have HMO or are worker’s compensation. More than 60% have either Medicare or Medicaid. The rest are self-pay. How exactly does that translate into a “private” system?
We need to create a system where everyone “prudently diverted a reasonable amount to insure themselves” – that system does not exist now. If people have a choice between receiving time-rationed “free” care and quicker, higher quality “paid” care, the value of investing for one’s future medical care will become apparent.

]]> By: ERDoc http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7951 ERDoc Fri, 17 Apr 2009 02:58:53 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7951 How does a "free market" healthcare arrangement reflect on our society? I'd argue it's not progress at all, but a sad day in our nation if we were to go this route. See every third world country as evidence of how this works. Whether mandated by the government or self imposed by a "free market", patients will have to accept a system where cost is considered before the "mega-workup" is ordered, and be willing to tolerate some small risk on themselves. Every day in the ED we all order a lot of tests on people, which are low yield in a good fraction of our patient population. Why do we do it? Because it's the standard of care. Because we can't afford to miss anything, from a medicolegal standpoint. It's not acceptable in our culture to say, "well we didn't do the test because it's expensive, and I'm sorry you had a bad outcome. This is probably a 1 in 100 type situation. You were the unlucky one." How this can be accomplished is beyond me. I'll agree that many medical blogs (not only yours) have so much of the "the sky is falling" type rhetoric that at some point people just don't listen. But I suspect you'd have PLENTY of issues with a free market system that you may not even fully grasp. Imagine having a lengthy discussion with every patient as to why their Chest X Ray is a necessary expense, when it is clearly indicated. That's going to run them several hundred dollars after all, and for the average hard working American that's a lot of money. Are you prepared to have those discussions? Only the wealthiest segment of society will not care about costs such as these when it's coming straight out of their pocket. "Doctor, I'm OK with getting the chest X Ray, but does the radiologist have to read it? I'd rather not pay for the extra radiologist's fees and let you read it yourself" Are you going to turn this patient away and lose the revenue, or take the liability on yourself as the one and only X Ray interpretation? How would you defend that in court, if you're not board certified in radiology? Would your hospital have a strict policy about radiologists reading ALL X Rays? Does a free market mean such policies are good for business or bad for business, when your facility is advertising to offer cost effective care? This is only one example as to how this can of worms could be more than you know what you are getting into or asking for..... How does a “free market” healthcare arrangement reflect on our society? I’d argue it’s not progress at all, but a sad day in our nation if we were to go this route. See every third world country as evidence of how this works.

Whether mandated by the government or self imposed by a “free market”, patients will have to accept a system where cost is considered before the “mega-workup” is ordered, and be willing to tolerate some small risk on themselves.

Every day in the ED we all order a lot of tests on people, which are low yield in a good fraction of our patient population. Why do we do it? Because it’s the standard of care. Because we can’t afford to miss anything, from a medicolegal standpoint.

It’s not acceptable in our culture to say, “well we didn’t do the test because it’s expensive, and I’m sorry you had a bad outcome. This is probably a 1 in 100 type situation. You were the unlucky one.”

How this can be accomplished is beyond me.

I’ll agree that many medical blogs (not only yours) have so much of the “the sky is falling” type rhetoric that at some point people just don’t listen. But I suspect you’d have PLENTY of issues with a free market system that you may not even fully grasp.

Imagine having a lengthy discussion with every patient as to why their Chest X Ray is a necessary expense, when it is clearly indicated. That’s going to run them several hundred dollars after all, and for the average hard working American that’s a lot of money. Are you prepared to have those discussions? Only the wealthiest segment of society will not care about costs such as these when it’s coming straight out of their pocket. “Doctor, I’m OK with getting the chest X Ray, but does the radiologist have to read it? I’d rather not pay for the extra radiologist’s fees and let you read it yourself” Are you going to turn this patient away and lose the revenue, or take the liability on yourself as the one and only X Ray interpretation? How would you defend that in court, if you’re not board certified in radiology? Would your hospital have a strict policy about radiologists reading ALL X Rays? Does a free market mean such policies are good for business or bad for business, when your facility is advertising to offer cost effective care?

This is only one example as to how this can of worms could be more than you know what you are getting into or asking for…..

]]> By: Max Kennerly http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7948 Max Kennerly Thu, 16 Apr 2009 20:00:58 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7948 Glad it made you think. I've posted some longer thoughts about EMTALA in particular at my blog (linked via my name) for anyone who is interested, but I want to address a particular issue here: "Every medical provider would have free choice to choose who to treat and who not to treat" is fundamentally incompatible with a concern about "the ability of every American citizen to access healthcare." A wholly-private medical system will no better ensure every American access to healthcare than a wholly-private retirement system would ensure adequate savings for every America. It'd be great if everyone had well-paying, stable jobs from which they prudently diverted a reasonable amount to insure themselves against illness, injury and old age. But that's not the case. Moreover, we already by and large have a private system, which is why over 40 million Americans don't have any health insurance at all, and a larger number are inadequately insured. Do you believe they are all purposefully trying to freeload, despite the obvious risks to their lives? Ensuring everyone's welfare requires collective action. Whether that's fair or efficient isn't the issue; an all-private system simply won't give us universal coverage. Glad it made you think.

I’ve posted some longer thoughts about EMTALA in particular at my blog (linked via my name) for anyone who is interested, but I want to address a particular issue here: “Every medical provider would have free choice to choose who to treat and who not to treat” is fundamentally incompatible with a concern about “the ability of every American citizen to access healthcare.”

A wholly-private medical system will no better ensure every American access to healthcare than a wholly-private retirement system would ensure adequate savings for every America. It’d be great if everyone had well-paying, stable jobs from which they prudently diverted a reasonable amount to insure themselves against illness, injury and old age. But that’s not the case.

Moreover, we already by and large have a private system, which is why over 40 million Americans don’t have any health insurance at all, and a larger number are inadequately insured. Do you believe they are all purposefully trying to freeload, despite the obvious risks to their lives?

Ensuring everyone’s welfare requires collective action. Whether that’s fair or efficient isn’t the issue; an all-private system simply won’t give us universal coverage.

]]> By: SeaSpray http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7943 SeaSpray Thu, 16 Apr 2009 10:36:43 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7943 Well said WC. It all seems so logical and yet so complicated. Well said WC.

It all seems so logical and yet so complicated.

]]> By: k http://www.epmonthly.com/whitecoat/2009/04/my-view/#comment-7938 k Thu, 16 Apr 2009 01:02:56 +0000 http://www.epmonthly.com/whitecoat/?p=2414#comment-7938 Rationing exists, whether you want to call it 3rd party preauthorization, unintended consequences (e.g. EMTALA abuse), or something else. EMTALA abuse can take the form of UCMC dumping Dontae Adams onto County's ED because the poor kid had Medicaid (not to mention Blago's spat with the legislature meaning reimbursements averaging 9 months late), or it can take the form of the 6 TX patients(presumably mentally ill and not receiving community care) racking up $millions of ED bills, averaging at least one visit/week. In an ideal world, there wouldn't be any of this 'negotiated rate' nonsense where Provider X bills 3rd Party Payer Y some ridiculous amount for Service Z, and the EOB you get shows Y paid X $5 as the negotiated rate for Z. Cut that crap out of the equation and set reasonable rates most people can afford that allow a reasonable profit to the provider. This is as likely to happen as my winning the lottery, but hey, everyone's got a right to dream! Rationing exists, whether you want to call it 3rd party preauthorization, unintended consequences (e.g. EMTALA abuse), or something else. EMTALA abuse can take the form of UCMC dumping Dontae Adams onto County’s ED because the poor kid had Medicaid (not to mention Blago’s spat with the legislature meaning reimbursements averaging 9 months late), or it can take the form of the 6 TX patients(presumably mentally ill and not receiving community care) racking up $millions of ED bills, averaging at least one visit/week.

In an ideal world, there wouldn’t be any of this ‘negotiated rate’ nonsense where Provider X bills 3rd Party Payer Y some ridiculous amount for Service Z, and the EOB you get shows Y paid X $5 as the negotiated rate for Z. Cut that crap out of the equation and set reasonable rates most people can afford that allow a reasonable profit to the provider. This is as likely to happen as my winning the lottery, but hey, everyone’s got a right to dream!

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