WhiteCoat

Archive for September, 2009

WhiteCoat Challenge #5

Wednesday, September 30th, 2009

Haven’t done a challenge in a while. Cynical’s comment from my post yesterday gave me an idea.

Finish this sentence:

You know you’re a frequent flyer when …

Three best responses as chosen by EP Monthly editors will get their choice of any one of the products at EP Monthly’s Online Store.

Cynical’s comments start us off

… you comment on your doctor’s new haircut or shoes
… your doctor knows your med list and PFSH (past family and social history) by heart
… your doctor can recognize you by your feet hanging out of the sheets

The Germiest Profession Is …

Wednesday, September 30th, 2009

According to a post in the Wall Street Journal’s Health Blog, a study from the University of Arizona’s Department of Soil, Water and Environmental Sciences shows that the job exposing people to the most germs is … a school teacher. Surfaces regularly used by teachers had 10 times more bacteria per square inch when compared with other professions.

So kudos to all you school teachers for not only raising our next generation of good citizens, but also for being able to put up with 30+ out of control kids at the same time and for having some damn fine immune systems to boot.

Want to cut the number of germs at work? Use disinfectants. People who said they used disinfectants dropped the bacteria counts in their work areas by more than 75%.

By the way, know what the “least germiest” profession is?

Lawyers.

Really. Check the link above. I’m not kidding.

Probably a professional courtesy from the other germs.

Bwwwaaaaaahahahaha

How You Know You’re a Frequent Flyer

Tuesday, September 29th, 2009

The doctor walks in the room after being on vacation for a few weeks and the first words out of your mouth are …

“Gee. Haven’t seen you in a while. What, have you been on vacation or something?”

How Payments Affect Care

Monday, September 28th, 2009

When an unconscious intoxicated multiple trauma patient was brought to the ED, we did a bunch of CT scans to look for injuries. Fortunately there wasn’t anything life-threatening. He was admitted and was later discharged in good condition.

I then got a memo from the hospital several days later stating that Medicare would not pay for the CT scan of the patient’s cervical spine. There is a list of diagnosis codes for which Medicare will reimburse hospitals for performing a CT scan of the cervical spine. That list is contained below. If one of the selected codes is not on the patient’s final diagnosis list, then Medicare tells the hospital “tough luck” and pays the hospital nothing for the scan. As part of Medicare’s Conditions of Participation, the patient may not be charged for the exam unless the patient specifically agrees to the charges. When Medicare doesn’t pay, almost always the hospital gets stuck holding the bag.

If a patient is a victim of multiple trauma and is unconscious, CT scans of the cervical spine are more likely to show significant injury. This study showed that in multiple trauma patients, CT scans picked up on 98.5% of fractures while cervical x-rays only picked up 43% of fractures. It is uncommon to pick up ligamentous injuries on x-rays or CT scans – generally need an MRI for those.
If physicians choose to do a CT scan on an unconscious or poorly responsive patient, according to the “permissible” diagnosis codes, in most cases hospitals have to hope that either an injury or some type of cancer shows up on the CT scan. Otherwise, the CT scan won’t be reimbursed and the hospital eats the cost.

What are the other options in multitrauma patients?
We could just do only x-rays of the cervical spine, and, if negative, tell patients that everything is OK because the government won’t pay for CT scans unless you meet certain criteria. The 57% of patients with cervical spine fractures missed on x-rays will have all their medical needs met under the new health care reform measures anyway.
Or, while bleeding to death and strapped to a backboard wondering if they’re going to live or die, we could give patients an ABN form to sign. “Medicare might not pay for this test, if Medicare doesn’t pay for this test, do you agree to pay the cost of the test yourself — assuming that you live, of course?”
We could always perform x-rays on everyone’s necks first and make up notice some “abnormality on radiological or other exam of the musculoskeletal system” to justify the CT scan. That will be a 793.7 to all you CPT coders.
We could just say that notice that the patient winced in pain when the neck was palpated – causing “cervicalgia.” That’s CPT code 723.1.
Or we can just practice good medicine and let the hospitals get shafted by the system.

Of course, if hospitals get shafted enough by the system, they end up closing or reducing services. Then access to care suffers. You get what you pay for. Do a search for “hospital bankruptcy closures” and see how often it happens. Here are a few examples.

CT scan payments are just one example of the cat and mouse game that constantly goes on between those providing the services and those “paying” for the services.

It is also an example of the “Golden Rule” – he who has the gold makes the rules.

Things aren’t going to get better.

(more…)

I Think you are in the Doghouse

Sunday, September 27th, 2009

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OK Ladies, how would you feel in this scenario? Suppose you were standing in an examining room with your husband, fully clothed, waiting for the ER doctor to come in and examine you for a slightly embarrassing problem. Suddenly, your husband, who is getting frustrated with waiting, opens the door and grabs the nearest doctor who is walking by. Leading him into the room, without any chance for an introduction or for you to change into a gown, your husband takes hold of your pants, and apparently not caring that you are not wearing any underwear, yanks them down to your ankles while asking the startled doctor “What do you think this rash is?!?!?!”

I bet he is sleeping on the sofa for at least a few days.

A Classic Dr So-and-So Patient

Saturday, September 26th, 2009

ERP from ERstories.net  here again today and tomorrow… You know, WC needs a weekend off now and then…..

Why is it that certain doctors (usually primary care) attract a certain subset of patients? Our community is very heterogenous but I still find that several MD’s have tapped into certain subpopulations whether intentionally or unintentionally. Often, I find myself guessing (usually correctly) about who a patient’s doctor is before asking them. Clues like the med list, the last name, the insurance (or lack of it) they have, and PMH all give clues. I chuckle to myself when I ask them who the MD is and find I am correct. For example:

One doc seems to have about 90% of all the living Holocaust survivors in the US as his patients. (and he was not one himself) – usually on BP meds and Coumadin for Afib.

Another guy seems to have only patients with chronic pain, nebulous psychiatric diagnoses, and poorly controlled hypertension and diabetes. They often have Medicaid (which is honourable of him). However, even those with private insurance tend to be extremely challenging to deal with. Most are on Oxycontin, Wellbutrin, benzos, and Metformin.

One group sees only super rich entitled people who never have serious emergencies. However they often seem to have diagnoses of fibromyalgia and IBS way above the national prevalence. Hmmmm. Usually on Cymbalta, Xanax and something for chronic diarrhea.

One guy sees 90% patients from South America with no insurance – but they all have money and pay him cash. Often on random drugs they purchased on their last trip to Columbia.

One woman has a large non-English speaking, Russian population. They always seem to have some major issue going on. Often on no meds despite the acute MI they are having.

Another guy who is Asian seems to have all the really sick Koreans and Chinese in the area. Usually they are on dialysis and have a med list a mile long.

Another Asian doctor seems to only have the healthy ones. They tend to be on ziltch.

Of course none of this really matters since they ALL eventually become my patients! But thankfully they don’t REMAIN my patients until their next visit when I am on!

Effects of Saving Money

Friday, September 25th, 2009

In 2008, St. Johns Hospital and Mary Immaculate Hospital in Queens had a total of 119,883 outpatient department visits.
In February 2009, the two hospitals went bankrupt and closed.
In June 2009, the New York City Office of Policy Management published a paper showing that once St. Johns and Mary Immaculate Hospitals closed their doors, the patients that previously went to those hospitals didn’t just vanish. Instead, the patients flocked to other nearby hospitals which were already operating at capacity.
Guess what happened?
Those nearby hospitals – such as Jamaica Hospital in Queens, are now “overwhelmed.” According to the report, Jamaica Hospital’s daily census went up 50% — from 350 visits per day to “well over” 500 visits per day. On May 27, 2009, Jamaica Hospital had 663 visits – more than double its usual number. Other area hospitals such as Elmhurst Hospital, Queens Hospital Center and New York Hospital Queens noted increases of at least “an extra 100 patients a day.”
The number of patients being boarded in the Emergency Department of nearby hospitals also “soared.” Jamaica Hospital, Queens Hospital Center, and Long Island Jewish Hospital all noted dramatic increases in the numbers of patients being boarded in their EDs.
One emergency physician with twenty years of experience was quoted as saying “the state of emergency medicine in the borough of Queens is the worst I’ve seen it in my career.”

At the heart of the hospital closures was funding.
New York City was subsidizing St. Johns Hospital and Mary Immaculate Hospital to the tune of $61 million over the years leading up to the hospital closures. The City was unable to sustain that commitment. Without the city’s support, the hospitals went bankrupt.
Availability of ambulance services is also now in question. When St. Johns and Mary Immaculate hospitals closed, the ambulance services operated by the hospitals also ceased operations. None of the remaining hospitals was interested in providing ambulance services to the area served by Mary Immaculate Hospital, so ambulance service in that area was temporarily taken over by New York City Fire Department EMS. NY City is cutting the budget for the EMS service by $3 million which will result less ambulance availability. One mother noted that it took 25 minutes for an ambulance to reach her home after her son had a seizure. A $60 million Medicaid reimbursement reduction anticipated in the near future will likely result in even less care being available.

Whatever health care reform package that is chosen will necessarily involve an attempt to cut this nation’s health care costs. This country simply can’t sustain its current level of health care spending.

But we need to be very judicious in where spending cuts are made.

Many hospitals are not “rolling in the dough.” Cut funding for health care too much and we risk further hospital closures. The decrease in the quality and availability of care in Queens, NY is just one example of the impact hospital closures can have on the medical care in a community.

Remember this point in the health care debate: We can talk all we want about providing health care insurance to everyone in this country. Health care insurance means nothing if there is no one available to provide the care for you.

Lucky in More Ways Than he Knows

Thursday, September 24th, 2009

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Hey all, I this is ERP from ERstories doing a guest post on Whitecoat’s Blog. I want to give him and the EP Monthly staff my thanks for accepting some of my occasional ramblings.

Drunk people are often victims of their own stupidity. However, just as often they manage to avoid disaster by some miracle. For example, intoxicated persons have a tendency to end up face down in the street and often manage to avoid getting run over. Sometimes they are even luckier. Of course they never really realise this since after all, they are drunk. Hopefully when they sober up they count their blessings but often they simply can’t remember enough!

Anyway, we had a guy who was brought in by police intoxicated outside someone’s house. Apparently he was visiting the area and was staying with someone in the neighbourhood. Unfortunately, when he stumbled home from the local watering hole, he went up to the front door of the wrong house. Frustrated by the fact that his key did not work and upset that no one answered his knocking, he preceded to kick the door in. He flopped partially into the doorway and nearly passed out. This of course triggered the house alarm and the police were notified. The responding officer sped rapidly to the scene for more than one reason. The door that had been kicked in belonged to the chief of police’s house! Expecting the worst, the cops showed up with Glocks drawn. Knowing the chief’s love of firearms and the fact that he was not afraid to use them, I imagine they thought they might encounter some OK Corral- type scenario. Fortunately for the guy, the police chief was not at home at the time. Otherwise, he would have likely been brought to the morgue instead of the ER! One more of his nine lives used up I guess….

Late Night Surcharges

Thursday, September 24th, 2009

Beth Israel Deaconess Medical Center and the Harvard Medical Faculty Physicians are drawing criticism for a $30 fee that is being instituted for patients who are seen between 10 PM and 8 AM.

The hospital system says that the surcharge “is designed to offset the cost of 24-hour, 7-day access to emergency medical services.”

The SEIU, who is behind the protests, claims that “a fee based on the time of [a medical] emergency crosses the line.” As an aside, the SEIU is apparently trying to increase its presence in Boston and its modus operandi is to make things difficult for hospitals just prior to organizing drives.  See also here and here and here.

First of all, most visits to the ED aren’t “emergencies.”
Second, hospitals will have difficulty collecting the fees from many patients.
But those two issues are aside from the point.

We’re a nation of fees. We’re charged a “convenience fee” for purchasing concert tickets online. We’re charged fees for luggage that weighs too much. We’re charged fees for using ATMs. We’re charged fees if we use our cell phones before 7PM. We’re charged fees if our lawyer calls us and we pick up the phone. We’re charged fees if our lawyer calls us and we don’t pick up the phone.

Why should a hospital emergency department be any different?

UPDATE SEPTEMBER 25, 2009
Poof!
Even though the late-night fees are common practice according to ACEP, the Boston hospitals dropped the late-night fee after news of the fee hit the newspapers.
Game … SEIU.

Kanye West is Everywhere

Wednesday, September 23rd, 2009

Apparently he just interrupted Patrick Swayze’s funeral

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