WhiteCoat

Healthcare Update – 03-03-2010

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.

27 Responses to “Healthcare Update – 03-03-2010”

  1. Matt says:

    “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.”

    But these reports were PUBLISHED!! Why don’t you believe them? Why do you only critique them retrospectively? Why oh why?

    I’m glad Philip K. Howard is out there again. I think any time a tobacco industry’s (among others) defense lawyer and lobbyist has an opinion on protecting his clients’ interest (err. . . I mean an opinion on tort reform), we should listen closely. Bound to be unbiased information in there that will benefit all. So long as all includes insurance companies, chemical companies, and the rest of the Fortune 500 represented by that firm!

  2. VA Hopeful says:

    I thought tort reform was supposed to have many benefits aside from cost containment. We’ve all read the reports that high-risk specialists in states with unpleasant malpractice climates are getting harder and harder to find. I do seem to recall reading that after Texas did its thing that there was a fairly significant influx of physicians into the state.

    I believe there has also been talk, more from EPs than others, that a major source of concern for them has been seeing patients that have no intention of ever paying for their care but having those same patients turn around and sue them for a bad outcome. Most of us like the idea of doing charity work, few of us like the idea of getting sued if something bad happens.

    I haven’t read the IOM report, but I’ll do that and get back to you.

    • Matt says:

      If tort reform had any benefits beyond reducing insurer risk, California would be a healthcare Mecca as it’s had tort reform for decades. Assuming you believe companies that are in the risk business are entitled to legislative protection from risk, that is.

      • Carter says:

        Californian has pain and suffering caps. Caps are really one tiny irrelevent part of tort. It doesn’t prevent having to go through the junk lawsuit retard. Also california is the welfare dependency state of the Union. The populace is looking for their entitled payday.

      • Matt says:

        You need to look at the legislation. Caps are the centerpiece, “retard”. The “junk lawsuit” stuff is a canard, designed to make you get all excited and then support something that’s nonsense. There is no legislative proposal to stop people from actually filing claims – just ones that keep those with large claims from getting the full amount of their damages.

        But for that matter use any state which has had them for any length of time. You don’t have to use a large, at times, prosperous state with decades of using your proposal as your sample (although it makes sense). If you think California is the welfare dependency state of the Union, you must not get out much.

        You’ll find no difference in healthcare costs. Nor will you find that caps affect access. Access is a function of the wealth of the community, and caps can’t change costs because the only thing that changes costs are what the payors (the govt. and health insurers) are willing to pay. That’s it.

        The only reason to support tort reform is if you have some heartfelt sentiment that the insurance industry should have legislation reducing the very risk it insures. If you do, at least be honest about it.

      • VA Hopeful says:

        I actually would suggest that doctors who are required, by law, to see any and all patients deserve some legislative protection from risk.

        My primary point was basically physician coverage in states with some kind of tort reform vs. states that don’t. If CA is a good example, I’m OK with that as I’ve not heard of any shortages out there.

      • Matt says:

        You’ll not find much correlation between caps and access. Access is a function of the income of the population. You can check out the physician per capita numbers by state and see what I’m talking about. Poor rural states are low in physicians, wealthier urban do better. Caps don’t change that.

  3. Max Kennerly says:

    If anyone wants to gnash their teeth, I posted last week on Philip Howard’s TED Talk: http://bit.ly/9hDNxy

    Shorter version: his talk is too vague to mean much, but where specific, it’s flat-out wrong.

    As for Pittsburgh, I believe a lot of cities have fire departments act as medical first responders.

  4. Guiac says:

    Matt,

    Consider reading http://content.nejm.org/cgi/content/full/342/15/1123?ijkey=ffc7f1aea2deecc6599f630d9e4ac1aa52f4b3d8&keytype2=tf_ipsecsha

    Basically it is a criticism of the IOM report by Troyan Brennan who was the author of the two major papers used by the IOM to justify their claims regarding medical errors. It points out a number of serious flaws including the fact that their studies did not attempt to make inferences about errors, and that the “error rate” if one was to use 2 time points(as the IOM paper did) decreased from 92,000 deaths in ’84 to 25,000 in ’92 and who knows where we are today. There are a lot of critics of this IOM report based on their methods and assumptions and I think Brennan’s carries the most weight.

    • Matt says:

      I have read both the study and the criticism. I agree the paper is somewhat flawed, but no more so than many publications by the other side. There are better studies out there. I think we can all agree that most malpractice doesn’t result in a claim.

      Personally, this report doesn’t mean much to my position. I understand why people cite it, in the sense they’re saying why are we worried about a few cases when tens of thousands go unnoticed. But as to the merits of the “reform” legislation proposed, caps on damages on meritorious claims, I don’t see that this has much use.

  5. [...] Whitecoat’s Call Room. His Healthcare update. Always a couple of interesting tidbits. Good news: Visits to Canadian hospital emergency [...]

  6. rlbates says:

    Interesting list. The first one derailed me from most of the others as I live in Arkansas and had missed this in local news.

  7. Sarah G says:

    Totally, 100% off topic (but funny!):

    Medical director of the UK Med Center’s ED does KISS karaoke after losing a bet:

    http://www.youtube.com/watch?v=JsCslccdaG4

    Naturally, he does “Dr. Love”.

  8. Fyrdoc says:

    “Now the city plans to have firefighters respond to some 911 calls … between fighting fires, of course.”

    Actually have to disagree with you here WC. Fire-based EMS is the predominant model in the U.S. today. With fire codes as they have been for years, the reality is that even in big cities, it is far more economically sound to use fire personnel to fill EMS roles.

  9. Tom, ms2 says:

    I’m surprised you didn’t mention that congress again band-aided the medicare payment cut until 3/20

  10. Ed says:

    You could just train personal injury lawyers as EMTs.

    They are going to show up anyway.

    ;)

  11. Dave says:

    As I’ve pointed out before, the malpractice system is flawed. Trying to be objective, the figures in the IOM report are often quoted but there are lots of problems with them. Most of the patients who die in hospitals are critically ill from an underlying disease or diseases. If you retrospectively look at the chart you can often find domething that could have been done differently, and MIGHT have changed the outcome, but probably wouldn’t. Regardless of the numbers, we can agree that some errors do occur. We can also agree that patients should be compensated for this. As you’ve pointed out, Matt, that often doesn’t happen. One flaw in the system.
    From a physician’s standpoint, though, a lot of errors are only errors in retrospect. Each disease presents differently in each individual and may mimic another condition- just yesterday a colleague saw a patient admitted with “pneumonia” – the admitting diagnosis from the ER, who had a fever, chills, cough, right lower lobe infiltrate on chest x-ray read as pneumonia, who really had a subdiaphragmatic abscess. She was astute enough to clinch the dx based on the patient complaining of shoulder pain, but a lot of people would have missed it.Half the people admitted to ICU’s to rule out an MI turn out not to have cardiac pain, and about 1-2% of people sent home from ER’s because the ER doctor is convinced the painis not cardiac from the tests we have available do have cardiac pain. Our tests often have a significant false positive and false negative rate, sometimes up to 20% as in the case of treadmills. The treatment is unpredictable – as I’ve alluded to before, if you give TPA for a stroke 30% of the time you help the patient, 6.4% of the time you cause an intracranial bleed that will hurt or kill the patient, and the rest don’t benefit. The current MKSAP audiotapes quote “just as many lawsuits are now filed for not giving TPA as for giving it”. It’s very easy in retrospect to say that “if you gave (or didn’t give) the medication the outcome would have been different.” Great, but you didnt know that going in.
    When I refer to defensive medicine I am refering to the mindset “If in the future such and such an outcome occurs, no matter how unlikely, will I be criticised for not ordering such and such a test or doing such and such a procedure”. This leads to testing and procedures with very low yield but oftentimes a larger risk of complications, radiation exposure, and further testing if you find something unexpected – an example being abdominal CT scans which pick up adrenal adenomas in about 1 in 20 people, of no clinical significance, but which then have to be followed serially, with each CT giving the radiation equivalent of a couple hundred chest x-rays. We do a lot of this – we wouldn’t do it in another liability climate.
    The current system doesn’t serve the patients well, makes the doctors paranoid, which is not good, and costs the system a lot of money. Finally, a patient can get hurt by the system wheneveryone’s done everything perfectly, and there’s no recompense for that in the current system (unless a suit is filed and a doctor is unjustly convicted of malpractice – there the patient wins but the MD loses.
    Did I mention caps in the above? Seriously, we need a better system. I don’t believe for a second though we’ll ever get one.

    • Matt says:

      Dave, you’re right, you didn’t mention caps. Which is why the discussion you want to have is a largely academic one. Without caps there is no legislation. You’re right, it doesn’t serve injured patients well. But I think you’ll agree with me that there will not, in our lifetimes, be a proposal that physicians and more importantly their insurers back, that pays more injured people faster. It’s totally against their interest.

      What I think physicians mainly don’t like is being brought into the system at all and having their actions questioned. After all, it’s not like they’re even remotely likely to PAY a judgment. But given that the fact the lawsuit is filed is their primary gripe, there’s no way to alleviate that complaint.

      There must be a dispute resolution system. There must be questioned answered under oath. There actions will be inevitably questioned by others in ANY system. No matter what we devise, they’re not going to like that part of it, and will complain it’s “broken”, “unfair”, etc.

      • Guiac says:

        Matt,

        I agree that caps are fairly poor solution. Personally I favor a separate system of health care courts. I understand that this has problems too, but in my mind is a better overall solution.

        As for the IOM reports I think the big issue in my mind is somewhat akin to the idea of “never events” Certain events such as wrong site surgery obviously should never happen. But others such as delirium in the elderly would be nice to avoid but I don’t know how. In fact I’m unaware of anyone that knows how to prevent it 100% of the time. Similarly some of the “errors” are really just bad outcomes with no clear evidence that they could have been prevented.

        The real goal of these reports should be to identify systemic errors that can be addressed and corrected, similar to what the FAA does for aviation issues. Unfortunately the discoverability peer review processes that can be used to identify these errors is not protected – which silences those who would seek to fix many of these underlying problems.

  12. Chelsea says:

    WC – it would be much easier to research which hospitals to go to if we had that price transparency – which we don’t. And people cannot always predict what health or trauma condition is going to cause them to wind up in the hospital, so how do they research that?

  13. Dave says:

    Matt, I agree the discussion is academic. I don’t think lawyers want another system either, though.
    To use my example of TPA for strokes, though, I would like to know that if a patient comes to the ER in the proper time frame, has the requisite studies, has no contraindication to the therapy, is informed fully of the risks and benefits, and is given TPA (which is currently the standard of care) that I will not wind up in court if he’s one of the 6.4% who have a bad outcome from the medication. I don’t have that assurance now – just the opposite.
    One major problem with our system is that bad outcomes have only one recourse. If the patient above gets an intracranial bleed and winds up hemiparetic and aphasic, the susbsequent cost of his care will be so astronomical that a lot of families would be tempted to sue to try to avoid bancruptcy (the odds of winding up like this are much less if you give TPA than if you dont, but odds only apply to populations). It truly sucks that families are devastated financially by the cost of care. Unfortunately, health care reform is going nowhere. And there’s plenty of blame to go all around for that.
    As for the comment by Guiac, another “never” event is a patient falling in a hospital, even though every month I get patients admitted because they are falling right and left at home. This is crazy – no contact with the real world.
    As far as being angry about being questioned on our decisions, most doctors worry incessently about whether they’ve made the right decisions because we know how easy it is to make wrong ones. I recently told a young graduate before entering practice that she had just had her last good night’s sleep. I think it’s a stereotype that we’re arrogant. Maybe some doctors are, but a lot of us are full of self-doubt, and it’s better for our patients that way. I grant that we have to look confident in front of the patient but that may be a facade.

    • Matt says:

      “I will not wind up in court if he’s one of the 6.4% who have a bad outcome from the medication. I don’t have that assurance now – just the opposite.”

      Again, you want an assurance that you will never be sued. But NO dispute resolution system has that ability to stop claims BEFORE they are filed. That would require knowing the future. How do you propose to accomplish this.

      As to what lawyers want, I think you assume a unanimity of opinion among those with a law degree that doesn’t exist.

      “I think it’s a stereotype that we’re arrogant. ”

      My stereotype wasn’t to do with arrogance so much as for some reason physicians are more afraid of a negligence lawsuit than anything else it seems. And it’s those that they are asking for legislative protection from. It’s from that I derived the conclusion that you despise being questioned about your medical decisions. After all, you’re not trying to get legislation to keep you from being able to be sued in contract disputes.

  14. Big Bob says:

    Matt,

    In school we are taught that tests do not tell us yes or no, they just change the shade of grey a bit. There is no such thing as a fool-proof test. Trials attempt to make the outcome an absolute term – ie you were right or you were wrong. There are times when the doctor is clearly negligent, but I think the frustration that many doctors have with the legal system is that it tries to change the rules and make something that was never concrete and never absolute into something that is a yes/no. No doctor in his/her right mind ever orders a treatment and says “this is 100%. The human body has 100,000 proteins (we only know the function of a few thousand), and an MI looks like one thing in one patient and a different beast in another. Often times we must play the odds – vascular surgery may save their leg but increases their risk of heart attack enormously. You are wrong if you do and wrong if you don’t.

    It doesn’t help that we have all seen the physician do right by the patient but have a bad outcome and get sued. You may think that is the price of doing business, but for doctors it is personal – it damages the self-esteem and makes it hard to make tough decisions, it takes away family time for years, it damages reputations, and it can threaten our ability to get malpractice insurance and continue to make a living. You may disagree with it, but if you can’t understand why doctors don’t like malpractice then you apparently are missing something upstairs

    • Matt says:

      Bob I don’t quite understand your first paragraph. The test is not 100% right or wrong with each action. Obviously every trial involves a bad outcome because negligence with no damages is not actionable but a physician is not required to be perfect to prevail. If you think that you’ve been misled.

      I didn’t say I don’t understand why you dislied being sued in fact quite the opposite. I have been sued myself, for something not covered by insurance in fact, and it’s zero fun. However the point of the suit is to get the facts out there with regard to a dispute and get it resolved. You say you’ve seen physicians sued having done nothing wrong but that’s an opinion based on full knowledge of the facts, something the plaintiff may not have had at the time of filing.

      I’ve been involved in a medical practice splitting up and the litigation as the partners all sued each other. To a man, every party thought the other side’s case was patently frivolous. Without a doubt. Defendants always say and many believe the other side has no case. Even when physicians sue health insurers, which they do often and for large sums, the health insurers claim they’ve done nothing wrong. Believing ones side is in the right is why we have lawsuits. If both sides agreed one was wrong why would you need to file unless you were just arguing over damages?

  15. Big Bob says:

    Matt,

    Now it is my turn not to understand your first paragraph.

    I was simply stating one of the fundamental tenants of clinical epidemiology that tests must be interpretted in the clinical setting. All tests have sensitivity, specificity, positive predictive value, etc. The skilled clinician therefore looks at test results not as yes/no but as a variable that adjusts the pre-test liklihood. The thing that many in the public do not realize is that there are many many clinical situations where the pretest probability is so low or high that the test becomes absolutely 100% useless. A good example is that if the patient has classic symptoms of appendicitis, then a CT of the abdomen is fairly useless (as demonstrated by several studies). If that patient has classic symptoms of appendicitis and you do get a CT scan and it is negative, you still think they have appendicitis and the test has told you nothing. Conversly, if the disease is very rare and the symptoms are not classic (ie atypical chest pain in a 25 year-old female), then any test you order is much more likely to be a false positive than a true positive and the patient is more likely to be damaged due to treatment because of the false positive result than they are to be damaged by the small chance that they have the disease. The problem is that the public and I dare say many lawyers tend to think that you should always order the test and just see if it is positive or not. Good physicians know that there are times when it is better not to order the test even though there is a chance they may have the disease, but most of the public and lawyers do not accept that. The frustration I sense that many physicians have is that the rules for interpretting tests are different in court than they are in clinical practice. So you say trial is just getting the facts out in the open to settle a difference in opinion, but that is precisely the problem – that there are different ways of looking at tests in court than in the clinic. The way that many of the public and lawyers look at tests is different but is fundamentally not the correct way to look at it.

  16. Dave says:

    Matt,
    If, to use the example I gave above, I gave TPA to a patient with a contraindication (blood pressure unacceptably high, for example, or recent surgery), and the patient had a bad outcome as a result, I would deserve to be sued. There are clear instances where a doctor has screwed up. But if I follow the accepted guidelines and have a bad outcome, I should not be sued. We should have a system that distinguishes the 2 scenarios. We do not have such a system now.
    To follow up on what Big Bob has said, Dr Donald Snead, former director of the internal medicine program at Duke university, once made a comment that in Internal Medicine 85% of the time the diagnosis was an educated guess. It might surprise you to find that up to 50% of patients with a myocardial infarction present with a normal EKG. Actually 10% of patients who have a myocardial infarction do not even present with chest pain. Consequently, we use our judgement a lot. To give another example, if a patient doesn’t have the renal function for a CT angio to rule out pulmonary emboli, a lung scan is done. We get one of three readings:
    “Low probability” – the chances are about 90% that a clot is not present
    “Intermediate probability” – about a 50 % chance that a clot is present.
    “High probability” – about a 90% chance that a clot IS present. Still 10% chance that it’s not.
    Based on this test and the clinical picture we have to “guess” whether the patient had an embolus. If we’re wrong, which we’re bound to be some of the time, the consequences can be serious. Through the “retrospectoscope” everything is always crystal clear and we’re held up to a 100% accuracy expectation – this just isn’t possible. We then have to depend on a lay jury to determine whether we practiced according to a reasonable standard of care. Just as I would not have the expertise to say whether an engineering error was made if a building structure failed, so I don’t feel medically untrained jurors are the best people to determine when a doctor’s clinical judgement is outside a reasonable standard in a nebulous situation. So sure, we’re extremely touchy about this issue, and I think most doctors would prefer health courts as being more objective that the current system. Some states have a panel to determine whether a case has any merit before it proceeds, which I think is a good idea.
    I read yesterday a movie star is suing for 100 million because she thinks some ad was a spin-off on her. Where does that come from?

  17. Carter says:

    Matt, or other lawyers, don’t or can’t understand because they don’t really need to ever make a snap judgement based on incomplete information and competing interruptions. An ER doc might make 20 or so important best judgements a day. A lawyer has years to research a case….and then they don’t have to claim ultimate responsibility….they get to pawn it off those hard decisions to what 12 jurors decide.

    When I have to make a judgement on whether to give tpa or not I wish a had the luxury or years, and experts, and a twelve person jury to decide….because after all know a jury is a collection of our “peers”

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