Archive for December, 2009
Saturday, December 12th, 2009
Healthcare insurance does not equal healthcare access. Physicians are suing the state of Florida because more than 1.2 million children on Medicaid are not receiving access to critical medical care. Some children covered under Medicaid are unable to find any orthopedists willing to fix their broken bones. More than 750,000 children received no dental care because “reimbursement rates are among the lowest in the country” and 30% of Florida counties have fewer than two dental providers willing to treat Medicaid patients. A Florida official stated that “We have a system that is growing by-double digits, where providers are paid less and less each year. Access is limited, outcomes are not measured … I’d say that’s a bad system.”
Oh, and Florida’s defense to the lawsuit? The plaintiffs don’t have legal standing to pursue the claims because “the Medicaid program promises money but not necessarily the delivery of health services.”
Hey, but at least all the Medicaid patients have insurance. Wonder how much their insurance will be like the insurance proposed in this new health care bill …
These insured patients still end up in the emergency department. Before state Medicaid cuts, many dentists would not accept Medicaid patients because of low reimbursement rates. After Michigan cut dental coverage to 400,000 Medicaid recipients, officials expect emergency departments visits to increase by 10%. One woman recently died from complications that went untreated due to loss of Medicaid dental benefits. Hey, but at least all the Medicaid patients have insurance. That’s what everyone needs from this health care bill. Insurance.
One way NOT to get faster care: Threaten to kill the staff in the emergency department because they aren’t seeing your child quick enough. Grabbing the security guard by the throat and attacking the nurse won’t help either. Enjoy your stay in the Greybar Motel, ma’am.
In other news, due to the throwdown given to the mom by the security guard during the incident, JCAHO is now mandating that hospitals remove all security personnel as a patient safety measure.
Should hospitalists be performing pelvic exams on admitted patients if those pelvics have already been performed in the emergency department? Do women prefer males or females performing their pelvic exam? And who goes singing “come out come out wherever you are” to the cervix when performing a pelvic exam?? These answers and more at Happy Hospitalist’s blog.
One lucky dude (or “dood” if you’re Nurse K). Man walks into emergency department feeling “sick and disoriented.” Shortly afterwards, his heart stopped beating and he collapsed. 47 minutes, 4,500 chest compressions and 8 defibrillator shocks later, he was back in the land of the living. Doctors kept him in a medically-induced coma and cooled his body with special cooling pads. Three days later, he woke up and started talking. Not many people survive codes and even fewer end up well enough to walk out of the hospital.
Ohio balances budget on backs of patients. Ohio legislators recently imposed a “franchise fee” on hospitals amounting to 1.5% of all operating expenses (not a percentage of profits, mind you). That fee amounted to $19 million for one hospital and $22 million for another hospital. In order to balance their own budgets, now hospitals are cutting staff and cutting services. “More layoffs and service reductions will mean longer waits and higher costs for all patients.”
Minnesota hospitals “shed jobs and services” as they brace for $43 million in revenue cuts when the state terminates  some programs for indigent care. Such cuts would “tip this hospital over” and “would mean unacceptable deaths for patients who can’t get care” according to one emergency physician. One hospital will no longer provide non-emergency care to uninsured patients from outside its county and plans to cut 150 to 200 jobs.
A spokeswoman for the Catholic Charities noted that “homeless shelters and community health centers — as well as police — will have their hands full with the drug-addicted and the mentally ill who will be off their medications and on the streets.”
A picture within the article of a man holding a sign says it all.
Health care reform ideas from a retired physician. Some good ideas, including mandatory co-pays for all non-emergent medical care, pre-trial malpractice screening panels, and committee review for treatment options of complex medical cases.
Will several Chicago hospitals close after a county sales tax rollback? Some Chicago area clergy members warned that closures were imminent.
A well-written story about the life of one Washington DC area “frequent flyer” in the Washington Post. The article also highlights how frequent flyers can harm themselves by reinforcing the “boy who cried wolf” phenomenon. It mentions how another intoxicated mugging patient was treated with a “sequence of blunders” after medics smelled alcohol on his breath and assumed that he was drunk. In reality, the patient had a head injury. The frequent flier in the story, Kenny Farnsworth, repeatedly called 911 for choking sensation but never followed up with a primary care physician. Eventually he was diagnosed with a deformed hyoid bone and the problem was corrected with surgery. Now, Mr. Farnsworth’s “911 call volume has fallen dramatically.” The comments section to the article is brutal.
Posted in Access to Care, Healthcare Update | 4 Comments »
Friday, December 11th, 2009
 
Fractured Distal Radius (see Arrows)
Complete Posterior Elbow Dislocation
Hello, guest poster ERP here.
If you read my blog, recently I posted about the first “Ice” day of the year. The day that always seems to surprise people, haplessly stepping out onto the stuff in their driveway, front steps, or sidewalk. We always get a big bolus of patients with falls – often with nasty injuries.
Anyway, one of the poor guys I saw that day was the unfortunate owner of the above x-rays (well, ones that were nearly identical to them). He slipped backwards and fell while trying to get into his car. He was in a world of pain (and yes, before everyone goes crayzee, he got PLENTY of IV narcotics!). Realising that I had to reduce that dislocated elbow, and since he had not eaten or drunk anything since the night before, he was a perfect candidate for Dr Conrad Murray’s favourite drug, Propofol (administered by an anaesthesiologist since myself and my PA were doing the reduction – it can be hard to monitor the airway and do a procedure at the same time). Since I had to reduce the elbow (you really should not wait very long to do this), I figured why not try to reduce the distal radius fracture as well? (Not being an orthopaedist, I have only reduced a few of them, usually with the assistance of one). I figured that worse case scenario, he would need another reduction when he followed up with ortho in a few days.
We put the guy out and the elbow reduced easily – return to full range of motion was achieved in short order. Then I bent and yanked on that smashed wrist. The crunching sounds always sort of make me queasy but that is the way it is. I splinted the whole arm from shoulder down to the fingers and ordered the post-reduction X-rays. I thought they looked OK but what do I know? I could tell the elbow was in but I don’t know all those myriad of angles that orthopaedists have to memorise. (for most fractures, there is an angle between the fracture segment and the rest of the bone that you shoot for – and that is what determines if the reduction is successful and not requiring another attempt). About an hour later, the orthopod came in – he had a slew of patients as you can imagine that day – and looked at my handiwork. He deemed the reduction “acceptable” and appeared to be thankful that I had made his day a little easier. I felt like a med student who did his or her first suturing job that did not have to be redone by the attending who came to supervise! Now, I hope he will come in a little faster when I REALLY need him for that drunk guy with an open tib-fib fracture who will inevitably come in at 3am on a Friday night!
Tags: ERP
Posted in Patient Encounters | 10 Comments »
Monday, December 7th, 2009
 I was searching through a patient’s x-ray files for a comparison film and came across this aortogram.
Had never seen what an aortogram looks like prior to this exam.
Looked more like an emaciated picture of Gumby when I first saw it.
The head and body are the aorta.
The arms are the renal arteries (going to the kidneys).
The legs are the femoral arteries (going to the legs).
The white markings are calcium deposits within the vessel walls.
Posted in Random Thoughts | 13 Comments »
Saturday, December 5th, 2009
Obviously biased statistics published in the Metropolitan Corporate Counsel. “Four of ten medical malpractice lawsuits filed in America each year are groundless and overhead costs of malpractice litigation are exorbitant. These costs, of course, are imposed on doctors, hospitals and insurers, and then ultimately passed on to health care consumers.” In addition, “the overall shortage of doctors practicing both primary care and high-risk specialties may grow to nearly 125,000 by 2025.”
Most Americans want curbs on medical malpractice lawsuits. “In this country, there are just too many people who are just out for a quick buck,” said Christine Vasquez, 67, a retiree from Clarkston, Mich. “I think our insurance costs would go way down if (doctors) didn’t have to be so scared to be sued all the time.”
Connecticut fertility doctor loses NY license after using his own sperm to artificially inseminate a patient. How was he caught? Well, it just so happened that the physician was Caucasian and the intended father was African American. So the doctor’s a weirdo who doesn’t understand genetics. Not sure which would be worse … having his baby or shaking his hand after the office visit.
Walgreens error results in young girl being given amiodarone instead of tamiflu to treat influenza. Family not sure whether there will be heart damage.
A 2003 Auburn University study on pharmacy errors estimated they will occur four times a day at pharmacies filling more than 250 prescriptions daily and that in 1,000 of those errors are a threat to patients’ health. More than 3.6 billion prescriptions were filled in the US in 2008, which adds up to the potential for a lot of errors. This is another area in which humans are expected to behave perfectly.
In other news, as a result of this incident, JCAHO has recommended banning all pharmacies as a patient safety measure.
Eighty five percent of doctors surveyed reported that the threat of malpractice litigation is hampering their ability to practice medicine properly.
Ninety two percent of physicians want medical malpractice reform. The other 8% are plaintiff experts. Many physicians also supported ending coverage refusals based on pre-existing conditions. Sixty one percent recommended allowing patients to opt out of Medicare, “a government program that underpays doctors so badly in some cases that many Medicare patients have trouble finding doctors who will see them.” Hmmmm. Insurance doesn’t equal access. Wonder where I’ve heard that before. Another interesting statistic – 62% of physicians disagree with the American Medical Association’s endorsement of President Obama’s reform proposal.
Stuck with a hepatitis patient’s bloody needle. Would you take medicine with many side effects that might lessen the chance of you getting HIV or would you forget about it? A difficult decision explained by a new ED nurse who was put in the exact situation.
More emergency department closures in CANADA … not enough doctors are willing to work in Prince Edward Island. The Kings County Memorial emergency department closure during evening hours leaves the entire county without an emergency department during overnight hours. But at least everyone has health insurance, right?
Edwin Leap is spot on. “Healthcare reform that seeks to increase access will not help if physicians aren’t accessible. Right now, in a time in which increased work can in fact result in increased money, physicians are avoiding call in droves for lifestyle reasons. Guess what will happen when their pay is cut and they are salaried? When they make the same amount of money for lots of work or little work? Are we prepared to force physicians to work under threat of punishment?” The entire article is enlightening.
Got Propofol? Conrad Murray, the doctor implicated in Michael Jackson’s death, has started practicing medicine again — at the Conrad Murray Center for Sleep Pathology … er, um … the Armstrong Medical Clinic in Houston.
See, America? Lawsuits improve patient safety. Attorney Michael Bryant, president of the Minnesota Association for Justice goes on record as saying “Right now the estimates are that 98,000 people die each year in this country due to medical errors. If you make it harder to bring those cases to court, I don’t see how you’re going to save more lives – you’re going to kill more people.”
In other news, JCAHO and Gerry Spence have both demanded that plaintiff attorneys begin running hospitals as a patient safety measure.
When emergency departments close, the delay in getting patients to the proper hospital may be fatal.
Posted in Healthcare Update | 21 Comments »
Thursday, December 3rd, 2009
I previously linked to the Providence Journal’s notes about the trial testimony from the Michael Woods case. Now comes word from the Providence Journal that the case has settled.
Faced with the possibility of a multimillion dollar judgment against the hospital, this week Kent Hospital president Sandra Coletta made a phone call to plaintiff James Woods one night. Then Mr. Woods “heard something he’d never heard from Kent Hospital before, someone saying she was sorry for his family’s loss.”
Ms. Coletta came up with an idea of creating an institute named for Michael Woods, who died in the hospital’s emergency department. She pledged that the hospital would “spend $1.25 million over the next five years to develop policies and procedures to promote patient safety and improve internal communication about patient care, beginning in the emergency room.” A Woods family member would be part of the institute’s board.
Actor James Woods agreed with Ms. Coletta’s plan and dropped the case.
The “undisclosed payments” that would leave Michael Woods’ family (and the attorney representing them) “financially secure” might have had something to do with it as well.
This case is another example of a defendant folding in the high-stakes game of medical malpractice litigation.
A bad outcome occurs. From the evidence presented, negligence is hardly clear cut and even “perfect” care may have resulted in the same outcome. In the lawsuit, a high profile plaintiff weeps during testimony. Jurors are naturally sympathetic. At risk for the defendant is millions of dollars and perhaps its very viability. At risk for the plaintiff … little or nothing except the time and diligence necessary to pursue the lawsuit.
If this was a game of high-stakes poker and you knew that you could win millions, but that your pot was never at risk, wouldn’t you bet the maximum on every hand every time?
We need a mandatory – not discretionary – loser pays rule in medical malpractice lawsuits.
Posted in Medical-Legal | 41 Comments »
Wednesday, December 2nd, 2009
… somebody’s WAtching meeeeee.
From one of my favorite magazines comes the story that we are being watched – a lot more than we know.
Wired Magazine reports that Federal law enforcement obtained telephone GPS data about Sprint customers more than 8 million times in a year. About 220,000 times per day. More than 9000 times per hour. About 3 times per second for every second of the whole year. These numbers don’t even include the data for the remainder of the cellular telephone market.
Must be a lot of criminals in this country.
I liked one of the comments to the article, though:
“Any society that would give up a little liberty to gain a little security will deserve neither and lose both.”
- Benjamin Franklin
Posted in Random Thoughts | 3 Comments »
Tuesday, December 1st, 2009
 A couple of news headlines paint a bleak picture about the future of healthcare in this country.
First are some comments made by US Republican Senator George LeMieux. During a news briefing (video here), LeMieux expressed a concern that Obama’s healthcare plan would amount to “Medicaid for the masses” and would put all Americans on a government run or government controlled health care.
The Palm Beach Post News also ran a story regarding a speech given by Senator LeMieux where he stated that the cost of the bill over the next 10 years was grossly understated due to “funny math”. He estimated the true cost of the bill to be more than $2.5 billion over 10 years rather than the projected $849 million.
LeMieux stated that in order to decrease costs, the bill intends to cut Medicare spending by more than $500 billion – through $400 billion in cuts to home health providers, hospitals, hospices and others while decreasing subsidies to Medicare recipients by more than $100 billion.
My favorite quote from the article is the following: “If we really want to provide health care for Americans, why shouldn’t we give them the tools to go out into the marketplace and be a consumer, which we know will end up driving down costs.”
Another free market advocate. I love it.
As our legislatures plans to significantly cut spending on the Medicare program, today several Massachusetts hospitals are filing a lawsuit against the state of Massachusetts because the current reimbursements from Medicare and Medicaid are already too low. According to this article in the Boston Herald, Massachusetts currently reimburses hospitals for only 40% to 86% of the costs of providing care. Because at least 63% of patients going to these hospitals have Medicare or Medicaid, the low payments are pushing many hospitals “to the brink of financial ruin.” The state countered by stating that it recently increased payment to the hospitals by 10 percent. Unfortunately even a 10% increase still leaves hospital payments at 44% to 95% of the cost of providing care – still below the break even point.
No business can stay afloat when the costs of doing business exceed revenues.
Recall that in 2006, Massachusetts was the same state that established a mandate that every person in the state have health insurance … similar to the mandate proposed in the current US health care bill.
Also recall how, since this Massachusetts mandate was created, the number of visits to Massachusetts emergency departments increased 7 percent and how the cost of caring for patients in Massachusetts emergency departments increased 17 percent – due to the lack of primary care providers in the state.
Oh yeah, and in a survey last year, only 2% of graduating medical students in the country plan to go into primary care internal medicine.
So the plan in Massachusetts to insure all of its state residents has resulted in almost every state resident having insurance … and in more people having trouble finding care.
The greater number of insured patients increases the costs of providing care to those patients.
Then, to control costs, the government cuts or maintains ridiculously low payment schedules to providers – to the point that the providers are having difficulty staying in business.
Welcome, ladies and gentlemen, to your new national health care system.
The current health care bill plans to cut Medicare spending by $500 billion.
Medicare plans to cut physician reimbursement by 21% next month.
What good will your new health insurance be few providers are willing or able to provide care for you?
The biggest myth of this health care debate is that having “insurance” is equivalent to having “health care.” The two are not the same, nor will they ever be the same. Just ask people who have Medicaid “insurance.”
If the hospitals in Massachusetts want to get more reimbursements, suing the state is the wrong way to go about doing so. In this case, lawsuits are a costly lose-lose situation. All the money the hospitals spend in attorneys’ fees and court costs could be put to better use. Boston Medical Center already tried suing the state for the same reason and the litigation is still dragging out in court.
A lobbyist once told me that the quickest way to enact change is to cause a public outcry.
You hospitals want an increase in funding? Drop the lawsuits and just shut your doors. Take your ball and go home. Too many patients and almost every legislator in our government take their access to health care for granted. Let patients walk up to your facility with their insurance card in hand and let them jiggle the handle on on the door a few times before realizing that they cannot get inside. Stop providing care until the state and federal government provide better reimbursement.
If it costs these hospitals more to provide care than the hospitals are being paid, closing the doors would save the hospitals money each day that the doors are closed. Divert ambulances. Transfer admitted patients to other facilities. The 1.5 million patients each year, including more than 300,000 emergency department patients each year that are being treated at the near-bankrupt Massachusetts hospitals will have to be redirected to another facility to find their care – if care is available.
At the entrances of each closed hospital, post giant pictures of the state and national legislators and an explanation of how their actions or failures to act have caused the hospital to close. Make sure to include the date that the legislators are up for re-election.
Then give the local news stations a call to let them know what’s happening.
They’d have funding within a week.
Posted in Access to Care, Funding Crisis | 46 Comments »
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ERP Makes the News
Wednesday, December 2nd, 2009ERP, who guest posts on this very blog, got interviewed for an article about how to get treated “better” and “faster” in the emergency department published on AOL today. Congrats!
The comment section to the article has some er, um … interesting reactions … and misperceptions about patients using emergency departments.
All in all, the article isn’t bad and gives some decent suggestions like bringing a list of medications and recent tests with you and also bringing along an advocate.
But the reporter calls us emergency “room” docs.
Grrrr.
Posted in News Commentary, Random Thoughts | 5 Comments »