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Survey on Health Care Reform

Emergency Physicians Monthly just published the results from a survey that it performed on health care reform. The results show something that most physicians already know.

ED physicians were asked how many tests they could have eliminated in an 8 hour shift without compromising the quality of care. Most said that they could eliminate at least 1 or 2 CT scans, and 27% said that they could eliminate more than 4 lab tests per shift. Two thirds of physicians responding to the survey estimated the potential cost savings at more than $500 per shift.

The survey also explores suggestions that emergency physicians have for improving health care, including creation of physician boards to determine the standard of care, tax rebates for charity care, copayments for all medical services, and implementing caps on non-economic damages in lawsuits.

Interesting read.

20 Responses to “Survey on Health Care Reform”

  1. throckmorton says:

    In the issue of defensive medicine, tests are often used as the measure. I wonder though what a survey would show if it asked about obtaining consults for defensive medical reasons. Where I practice, there seems to be a huge over utilization of consulting physicians both in the inpatient and outpatient setting. So many times the primary care physician is extremely able to take care of the issue but gets a consult to have someone else assume responsibility for that particular problem. It is as if instead of “consulting for specialty help” it is “Consulting for codefendants”. Their view becomes “it isnt worth the risk to take care of the patient, pass the risk on”. So, every patient with Diabetes ends up with endocrinology, hypertensives with cardiology, constipated with general surgery, I had a headache once with neuro. All of these could be handled by the internist or family doc, but the first thing that is asked in a lawsuit when one of these is sued is “why didnt you consult a specialist?”

  2. Max Kennerly says:

    Other than simply drinking the Kool-Aid, I wonder why EPs are so hot on capping non-economic damages. EPs are unique among physicians in that they are effectively immune from personal liability for large judgments, since the hospital’s far larger policy and deeper pockets will be the target of the plaintiff’s efforts. Most physicians don’t have that cushion.

    “Could you have eliminated any of the following tests and/or treatments without compromising the quality of care” is too ambiguous — what is meant by “compromising the quality of care?” If the use of a particular x-ray or test served no purpose at all, then, sure, it could be eliminated without compromising care.

    But most often “compromising care” means to physicians “I thought what we had was good enough and didn’t really need more.” E.g., the examination I performed gave me 90% confidence that there was no problem, so I thought getting 99% confidence from an x-ray was unnecessary. That may be what “without compromising care” means to that particular physician, but not everyone agrees.

    • throckmorton says:

      Mr. Kennerly:

      Here is an example of trying to be 100% sure. A college student comes to the ER with a headache. You are 99% sure that it is a migraine. You still get the CT because you “want to be more sure”. It is negative. Still since the patient may have meningitis you decide to get a spinal tap (again to be sure). This is negative. The patient however now gets a spinal fluid leak that requires multiple patches. Later the EP doc is sued because the patient claims “the spinal fluid leak exacerbated her migraines”. This is a real case. This is the “D” if you do and the “D” if you dont. What we need is to allow evidence based guidelines that can be followed and will be upheld in court. With the system now, bad outcomes mean possible suits. Good outcomes no suits. Problem is people die. So, how do you want to establish what is and what is not “defensive” medicine.

      • Max Kennerly says:

        Plaintiff’s lawyers have been shouting for evidence-based guidelines for decades now, each time being told my hospitals and physicians that such was a terrible, terrible idea, and that they obviously didn’t understand medicine.

        I’d be fine with guidelines and immunity for following them, unless the guidelines are unscientific gibberish designed to create blanket immunity. I think the guidelines will both increase patient safety and made liability easier to determine.

      • Fyrdoc says:

        Max,

        The lawyers can “shout” all they want – it won’t prevent suits. The problem is one of “public health” versus “medicine”. EBM is public health. A guideline is developed that effectively treats a population at risk. For example, following the Ottawa ankle rules identify ~97% of all ankle fractures in the population. Following them prevents roughly 30% of patients who present with forced inversion / exversion ankle injuries from needing radiographs. Which saves $$$. As a population, this works great. Unfortunately, if I judiciously apply these rules and I miss an ankle fracture, I can not defend that action by pointing out that I have detected all other ankle fractures I have seen and that this patient was just statistically “unlucky”. The public will simply not accept 3% risk of a missed fracture for the greater good. And that is only dealing with a missed fibula fracture which is highly unlikely to result in any life long problems. Now apply EBM to myocardial infarction (best scenario 98.5% detection without expensive admission and advanced testing), CVA (best scenario 95% detection without admission and advanced testing), Non-traumatic subarachnoid hemorrhage (best scenario 95% detection with 3rd generation CT without lumbar puncture).

        Now there is a bit of math to do to see the cost of “defensive medicine”. Let’s look at non-traumatic subarachnoid hemorrhage as an example. It is a rare entity. For the sake of easy math, let’s say that one in every one thousand people presenting with a new onset severe headache has it (it is actually less). Now, if I work at a center with a third generation scanner, I will miss one SAH in every 20,000 new onset headache patients scanned. However, because that patient may suffer mightily from that miss, I will likely perform between five and ten thousand lumbar punctures (with the other patients refusing the procedure) to find him or her (at a very large cost per procedure). Now, if I am that person who has this disease, I say “so what”; but if I am a public health administrator who is spending several million dollars out of a limited supply of funds to find that person I say there are more effective ways to spend that money. As a doctor I say that I want my kids to go to college and I am far more afraid of the trial lawyer than I am of that administrator so kick that amp up to “11″ and pass me the needle! (Pardon the “Spinal Tap” joke). It would be extremely hard to stand in front of a jury and say that I knew the CT would miss one SAH in every 20 patients with the disease but that EBM states it was safe to let the patient go home without the spinal tap as there was only a one in 20,000 chance he or she would have this disease and this “miss”. Am I to plead “I am truly sorry (and I would be) that Ms. Johnson, the previously well employed, highly educated, beautiful mother of three toddlers who used to spend her weekends volunteering at the local no kill animal shelter has been left largely paralyzed and unable to speak, but hey we did save enough money to provide blood pressure medications to 20,000 senior citizens for one year because of Ms. Johnson’s sacrifice.”? As a medical professional, I could live with that rationalization, but the U.S. public won’t stand for it.

        I do disagree with my colleagues a bit. While I personally find lawyers to generally not be worth the $1.79 worth of organic chemicals they are comprised of, they are not the base problem preventing EBM from truly being practiced in the U.S. The public’s lack of willingness to assume some measure of personal risk (however small) to provide for the greater good is. Lawyers just exploit that problem for personal gain to a degree that prevents physicians from even drawing what might be seen as reasonable measures of risk (say > 1 in 100,000 of untoward outcome) for fear of “losing everything” in a suit. Most of my colleagues and I would sooner spend “someone else’s money” than assume that personal risk on the patient’s behalf (which is what practicing EBM in the current medicolegal environment is asking us to do). Putting EBM guidelines into place and following them rigorously would save money, there is no doubt about that. Heck, even freeing physicians to stop testing at some widely agreed to level of risk would save money. But as your colleague Matt has pointed out, the standard of care has now become so “overprotective” that it requires testing each patient to a ridiculously low probability of untoward outcome. Those standards can’t and won’t change without tort reform. I also agree with you (and Matt – {shudder}) that caps are not very effective in this regard. A more effective reform (that would not be tolerated by the public or the trial lawyers) would be to allow a “public health” defense – that is to say that a physician would be granted immunity if they proved that the care they provided was to a level that there was less than 1 in X thousand chance that the patient would have undiscovered (thus untreated) pathology. Allow physicians to demonstrate that their patient was just “unlucky” and that would be enough reform to really change how medicine is practiced. Professional societies could write and publish true EBM guidelines, backed by science, to guide effective treatment and the physician would be free to stop the ridiculous overtesting we now perform.

      • natural selection says:

        fyrdoc,

        Max is probably smart enough to understand all that. Maybe. But if he did, and will willing to abide by EB guidelines it would mean much less for the vultures to eat. He believes the legal fiction that all bad outcomes can be prevented — even with EBG.

      • Matt says:

        If lawyers believed that there would be mre claims. Lost lawyers who do that work reject far more cases than they take regardless of outcome.

      • Max Kennerly says:

        Frydoc, I agree with most of that, which is why I am (and have been) in favor of comparative effectiveness research, and even safe harbors for physicians. Though it’s not why I support it, I wouldn’t be surprised if safe harbor guidelines actually increased the number of medical malpractice recoveries, since they would make the standard of care clearer and thus easier to prove the breach thereof. Contrary to popular myth, medical malpractice cases do not all involve a physician making a faulty choice between options. A good chunk involve the physician making no decision at all or making a patently bad one.

        I disagree that liability concerns is the only motivator of ‘excessive’ care. Profit and simple diligence also create incentives towards over- rather than under- care.

      • Fyrdoc says:

        Max,

        I will admit that I see this through the skewed eyes of an emergency physician. And while I can’t say never in the entire profession of emergency medicine is over treatment performed for profit, it is exceedingly rare. Most physician salary structures are not set up that way. But then you raise the question of “simple” diligence. The definition of adequate diligence is exactly the point of my argument.

      • Max Kennerly says:

        Salaried doctors, like the vast majority of EPs, have little incentive to overtreat. Such salaried doctors are in the minority; most doctors are in small or solo practices, and many own their outpatient / ambulatory surgery facilities, with which they can reap enormous profits even just from routine scans and labs, not to mention surgical procedures.

        I don’t think evidence-based guidelines would wholly remove all non-financial, non-liability (i.e., “simple diligence”) incentives to overtreat, though they would reduce them. There would be plenty of times when a physician understood what the guideline said but though, in their judgment, that more was needed to confirm, and so would order it anyway.

      • natural selection says:

        Max,

        Have you not heard of Stark Laws against self referrals?

        Also most ER docs are not employees. California is a fairly large state. and in fact, it is against the law for hospitals to employ physicians except for the VA and academic institutions. I think it is important for the patient for the doctor to have their interest in mind and not the employers.

      • Max Kennerly says:

        I didn’t say EPs were employees. I said salaried. It’s my understanding most are, including in CA.

        As for the Stark laws, I’m quite familiar with them — they (1) apply only to Medicare, not private insurance and (2) don’t apply to one physician referring to another physician in the same group practice (except where the latter physician “directs” the referral, which never happens formally, precisely because of the Stark laws). They similarly do not prohibit informal referral networks between physicians (e.g., the same informal referral networks that exist in every industry).

      • cynical says:

        No, the majority are not salaried. Maybe those at Kaiser, VA, academics and maybe some contract groups, but I think it is reletively few

  3. Doc99 says:

    Bottom line … Lawyers become lawyers because they want to go to court. Doctors, who certainly have the grades for law school, choose medicine instead in part because they don’t want to go to court.

    • Matt says:

      Silliness. The vast majority of lawyers will never try more than a couple jury trials. And of those that do? An even tinier percentage will handle any kind of personal injury claim. And an even tinier percentage will handle a med mal claim.

      • DensityDuck says:

        So your argument is that it’s extremely unlikely that any particular lawyer would be involved in a med-mal case, and so it’s okay for med-mal cases to exist?

        Gosh, that sounds like an argument in favor of replacing the med-mal industry with evidence-based medicine. After all, it’s extremely unlikely that EBM would fail to recognize a fatal condition…

      • Matt says:

        No, my point is that lawyers do not go to law school simply because they want to go to court. Some want to do estate planning and never see a courtroom, some want to have the degree just to improve their credentials for business purposes. Saying that the bottom line is that people go to law school because they want to go to court is an uninformed position.

    • cynical says:

      OK, so it what you say is true then I know more than you and 99% of lawyers on med-mal court and general issues. Make you look sort of silly for constantly whining that we don’t know what we are talking about

  4. Matt says:

    “so it’s okay for med-mal cases to exist?”

    I don’t know that it’s good or bad. It’s a mechanism for resolving a dispute about either the cause or the value of a harm caused. We will always need some mechanism for doing that.

    If you want to adopt EBM as the standard of care, I’m all for it.

    “OK, so it what you say is true then I know more than you and 99% of lawyers on med-mal court and general issues.”

    If you’re a physician, you probably do know more about the details of the facts in most cases. About the procedure, evidence, etc. it’s doubtful.

  5. [...] the situation, the emergency physicians themselves.” [KevinMD, Emergency Physicians Monthly, White Coat, WSJ Law Blog] Relatedly: “Just to be sure: an ER slippery slope” [MedRants, WhiteCoat] [...]

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