WhiteCoat

Healthcare Update 03-18-2010

If you like these, check out the satellite edition of the Healthcare Update over at ERStories.

The only thing that changes is the names.” Canadian patients dying waiting for emergency department care. One patient’s family was told that the emergency department was short two doctors and four nurses and that “there was a 16-hour wait and that I just had to be patient” – as the patient died while sitting next to the nursing station. Nurses are forced to do overtime and then “the health system is not able to retain them.”
When you make the practice of medicine unattractive, not as many providers want to practice and this scenario will repeat itself.

It’s called job security. Survey shows that 61% of adults in the US drink “liquid stupidity,” only 31% of adults exercise regularly, and 20% smoke cigarettes. While 64% get 7-8 hours of sleep per day, 28% get 6 hours of sleep or less. The comments to the study were … interesting, including a post of the text of a now-dead Mississippi House Bill that purported to improve obesity in Mississippi by prohibiting food establishments from “serving food to any person who is obese”.

Think about this before your next one night stand. According to Bloomberg.com, one in six Americans has genital herpes. About half of all black women and 40% of black men have genital herpes. To treat the problem, GlaxoSmithKline sold $1.29 BILLION worth of Valtrex last year. Dang!

Georgia Supreme Court upholds liability protections for emergency medical services. The Georgia legislature passed tort reform in 2005, finding that health care providers in Georgia were having increasing difficulty in locating liability insurance and that when the insurance was able to be found, it was extremely costly, resulting in the potential for diminution in access to health care and an “adverse impact on the health and well-being of the citizens of this state.” Potential litigants must still prove “clear and convincing evidence that the physician or health care provider’s actions showed gross negligence.”
The dissent in the opinion (.pdf file) called the law “arbitrary” because it protected emergency health care providers, but did not afford the same protections to physicians who treat the same conditions in their offices or in the patient’s homes. The dissent forgot one thing – physicians can refuse to provide care to patients in their offices or at their homes. Emergency physicians provide care to all patients all the time. Protect the safety net.

More evidence that “insurance for all” isn’t the answer. This New York Times article describes the difficulty that Michigan Medicaid patients are having when trying to find medical care.
“With states squeezing payments to providers even as the economy fuels explosive growth in enrollment [now 47 million patients nationally], patients are finding it increasingly difficult to locate doctors and dentists who will accept their coverage.” One parent called 4 or 5 pediatricians to see her 2 year old son. None of them accepted Medicaid. She ended up having to go to a public clinic with a four month waiting list.
One obstetrician who stopped providing services “feared being sued by Medicaid patients because they might be at higher risk for problem pregnancies because of underlying health problems.” Only 2 of the 72 surgery residents who trained at one Michigan hospital decided to remain in Michigan.
Not only are states cutting reimbursements for care, but they are also cutting benefits — including dental, vision, podiatry, hearing and chiropractic services for adults.
Realize that, on a “dollars and cents” basis, lack of providers is beneficial to the bottom line. Less access means less provision of services, which means less payments for provision of services. Is this the kind of “insurance” that we’re seeking on a national level?

Kevin MD published a good Op-Ed piece in USA Today about patient satisfaction surveys – showing how the surveys have little correlation to quality of patient care. A couple of the editors at EP Monthly are working on publishing the results of the survey on patient satisfaction surveys taken on this blog a few months ago.

Same law firm obtains $9.7 million dollar judgment on behalf of patient whose cancer diagnosis was delayed and $38.7 million dollar judgment when obstetricians allegedly fail to perform a timely Caesarian section on child who was born with cerebral palsy.
Another firm obtains $22 million judgment against providers after patient ends up paralyzed from waist down when treated for leg fracture.

Is substance abuse a problem with our troops in Afghanistan? The number of narcotic prescriptions written by military physicians has quadrupled since 2001.

Answer: $400,000. Question: What was the median amount in damages awarded to successful medical malpractice plaintiffs in 2005? By the way, plaintiffs won less than 25% of the cases that went to trial. Using those numbers, if I were a radiology researcher, I’d be able to call all medical malpractice cases “inappropriate.”

21 Responses to “Healthcare Update 03-18-2010”

  1. Matt says:

    “Emergency physicians provide care to all patients all the time. Protect the safety net.”

    Government please save us. But government get out of our way. Mixed message?

  2. [...] } From White Coats Call Room “The only thing that changes is the names.” Canadian patients dying waiting for emergency [...]

  3. WhiteCoat says:

    “Government please save us. But government get out of our way. Mixed message?”

    Not at all.
    If government is going to create an unfunded mandate affecting only emergency medical providers [i.e. EMTALA], then why shouldn’t those same providers have protections not afforded to those to whom the mandate doesn’t apply?
    Don’t want to provide the extra protections? Fine. Then remove the unfunded mandate.
    Not too many attorneys were happy with my ELRALA post. Why do you think that was?

    • Matt says:

      “then why shouldn’t those same providers have protections not afforded to those to whom the mandate doesn’t apply?”

      Problem with your logic is that your “protection” (more accurately your insurer’s protection) applies to those patients who pay you as well.

      You keep calling it a “mandate” as if you have no choice. This is incorrect. You CONTRACT to take the government money, and this is a term of that contract. For some reason you continue to whine about the results of contracts YOU enter in to. Are you being tricked into signing them? Do you not read them before putting your name on the dotted line? Or are you just naturally adverse to taking any responsibility for your actions?

      As to your ELRALA post, I think it’s a great idea. Your reasoning behind it doesn’t make much sense, but that’s par for the course when you dabble in the law. However, if an attorney is subject to the same rules and makes the median $200K of an ED physician, then I bet you’ll have lots of them lining up. That’s twice the average attorney pay.

      • WhiteCoat says:

        “Problem with your logic is that your “protection” (more accurately your insurer’s protection) applies to those patients who pay you as well.”

        Yeah, and the average amount of rainfall in the African basin is 127 inches.
        You make no sense.
        The law applies equally to all patients, not just those that pay or those who don’t pay. What difference does ability to pay make? Unlike attorneys, we take care of everyone regardless of their ability to pay.

        We don’t have a choice. It’s like saying that you fly an airplane and you’re not going to abide by FAA rules. You don’t have to abide by them, but then they don’t have to let you fly, either. I’m venturing a guess that every hospital in the US accepts Medicare. Emergency departments are in hospitals. Emergency physicians work in emergency departments. Therefore emergency physicians must abide by hospital policies when working in emergency departments. Enlighten everyone on how an emergency physician can work in a hospital without abiding by Medicare rules.
        Oh, yeah. It’s the “free choice” argument. We’re free to choose whether or not to sign the contracts with the hospital. Hmmmm. Sign the contract or don’t work. Some free choice. It’s called a monopsony.

        If so many attorneys would jump at the chance to make “double the pay” (with three times the schooling and more than double the expenses), then why aren’t they “lining up” to go to medical school? I only know a handful of emergency physicians who are also lawyers. So what is it? Attorneys just haven’t figured out how to jump? Not smart enough to make it into medical school? If it’s such a great deal, where have you applied for medical school?

      • Matt says:

        “The law applies equally to all patients, not just those that pay or those who don’t pay. What difference does ability to pay make? Unlike attorneys, we take care of everyone regardless of their ability to pay.”

        You’re complaining that it’s not fair that you don’t get more protection for people who don’t pay. The heightened protection for your insurer applies to all ED patients, even if they do pay. Get it?

        “We don’t have a choice.”

        Ah, but you do. You had a choice every step of the way. It’s not like these regulations are new. And here’s the deal, you knew the game going in. You’re like a guy who all his life wants to join the FBI, and then when he gets there wants to complain that they won’t let you smoke pot on the job. And nothing stops you from leaving that area of medicine and doing something different. Nothing but YOUR choices.

        Sack up, man, and take some responsibility. You chose to play the game, stop whining about the rules or quit playing. At a minimum, quit running to the government for protection and then whining that the government wants something in return.

        “If so many attorneys would jump at the chance to make “double the pay” (with three times the schooling and more than double the expenses), then why aren’t they “lining up” to go to medical school.”

        Now you’ve changed your argument, haven’t you? Maybe they have the same pathological aversion to blood that you do to a courtroom. Maybe they really enjoy litigating constitutional issues. Hell, who knows why people choose to do the things they do. You bitch constantly about “unfunded” mandates. No one MADE you go into this area of medicine. You CHOSE it, however much you want to blame others for your choices. So those attorneys chose to do something different.

        The point remains the same, though. Your half-witted ELRALA post actually might work – but you’re going to have to pay people to do it. Just like – wait for it – YOU GET PAID when you sign on for this deal.

        Again, you run to the government for protection, and then you bitch about the government rules. That’s a mixed message.

      • WhiteCoat says:

        Please link to anywhere that I’ve said “it’s not fair that you don’t get more protection for people who don’t pay”. You’re FOS and you know it.
        I have always maintained that we deserve added protection because we take anyone anywhere and any time. Unlike attorneys and almost any other profession in this country, we can’t and won’t cherry pick healthy people, cleanly people, rich people, people who speak English, or people who don’t threaten to kill us as we try to help them. We take them all. In current day dollars, an average emergency physician provides probably close to $200,000 in charity care. Funding is an issue only because without it, hospitals can’t keep the doors open. We deserve protection because we’re the safety net and it the safety net fails, a hell of a lot more people will die in this country.
        Maybe we can just start sending them to Gerry Spence instead.

        If you really want to analyze the “deal” that our predecessor physicians entered into, the current state of Medicare is nothing like the “deal” that was entered into in the beginning, but that’s how a monopsony operates. Adjusted payments have been cut dramatically (and I don’t have time to look up numbers right now) and expenses (including malpractice insurance premiums and costs of complying with hundreds of new federal regulations) have gone up significantly. The “deal” isn’t the same, but now that there is a monopsony, the choice whether or not to take Medicare is a Hobson’s Choice, which really isn’t a choice at all.

        Your argument against attorneys going into medicine kind of undercuts that lame argument you use about tort reform in California, doesn’t it? Why not go to California? They have tort reform there for 30 years!
        Why don’t poor underpaid lawyers go into medicine? They can make so much money [cough] doing it!

        Just like your previous comment, your mixed message assertion still makes no sense.

    • Matt says:

      “If government is going to create an unfunded mandate affecting only emergency medical providers ”

      Right there. Your bitch is that you don’t get paid for treating people but still face the liability. Except you’ve limited your insurer’s liability to those who DID PAY YOU. Good for your insurer, I guess. If only the rest of the insurance industry had physicians as their spokesmen!

      “In current day dollars, an average emergency physician provides probably close to $200,000 in charity care”

      You don’t understand “charity”. YOU GET PAID. YOU NEGOTIATE A CONTRACT TO TREAT THESE PEOPLE FOR THE MONEY.

      “If you really want to analyze the “deal” that our predecessor physicians entered into, the current state of Medicare is nothing like the “deal” that was entered into in the beginning, but that’s how a monopsony operates.”

      Learned a new word and you can’t quit using it huh? You guys are the highest paid profession in the world by a significant amount, thanks to that deal. You were fools if you thought that in good times and bad your salaries would keep increasing on the taxpayer’s backs. It’s renegotiated every year. But here’s the thing – YOU STILL HAVE A CHOICE. You don’t have to sign that deal. You can do something different, even in medicine.

      ” We deserve protection because we’re the safety net and it the safety net fails, a hell of a lot more people will die in this country.”

      I love this statement. Guess what – we’re all going to die anyway. And if we die in your ED, you just say “well, we did all we could” and move on. You’re not the safety net – you’ve said as much yourself whenever you’re looking to avoid liability. But when you WANT something, well, you’re the last line of defense.

      Tell me, how do you make dramatic statements like that and yet still cry for the free market with a straight face. The free market doesn’t include safety nets. If you want to be a safety net, and get all the protections, then yes, your services will be funded by the government fully and you’ll play by their rules. But you want it both ways. You want all the upside of the free market, and none of the downside, just like you want all the upside of government protection, but none of the downside of government rules.

      “Why don’t poor underpaid lawyers go into medicine? They can make so much money [cough] doing it!”

      I never said we were underpaid. I just said that if you like your silly idea, which you compare to EMTALA, offer to pay what those subject to EMTALA get, and you’ll have plenty of takers for it.

      There is no profession that makes as much or cries as much as physicians. Again, take responsibility for yourself and your actions. You’ll be amazed how empowering it is.

      • hawk says:

        Matt

        You show once again that you are shortsighted and dont understand medicine at all.

        ‘You don’t understand “charity”. YOU GET PAID. YOU NEGOTIATE A CONTRACT TO TREAT THESE PEOPLE FOR THE MONEY.’

        Actually, there are many patient that er docs and hospitals dont get paid to treat at all. these are people without insurance, who have no intentions or means of paying. yet unlike any other profession or specialty, we are federally mandated to treat them, regardless of their ability to pay.

        ‘But here’s the thing – YOU STILL HAVE A CHOICE. You don’t have to sign that deal. You can do something different, even in medicine.’

        I would really love to know how you think we can do this? once you are residency trained, you really cant practice outside your field of specialization. imagine if something went wrong with a patient you were treating in a for something you were not specialized in, the jackals, er lawyers, would have a field day.

        ‘ Guess what – we’re all going to die anyway. And if we die in your ED, you just say “well, we did all we could” and move on. You’re not the safety net – you’ve said as much yourself whenever you’re looking to avoid liability. But when you WANT something, well, you’re the last line of defense.’

        if only that were true. unfortunately, nobody wants to accept that they are going to die, be it from old age, neglect of their body, stupid choices, etc. that is why lawyers have a filed day with medical malpractice. we are sued because we are not gods who can reach down and save the unsavable with a glance and a touch of our fingers.

      • Matt says:

        “yet unlike any other profession or specialty, we are federally mandated to treat them, regardless of their ability to pay.”

        Nonsense on two counts. One, what do you think a public defender does? Same as you – he enters into a contract, knowing full well the details, and he gets paid. Same as you. You’re not federally mandated to treat them – you sign a contract in which you agree to abide by those mandates. The feds don’t make you sign the contract.

        ” once you are residency trained, you really cant practice outside your field of specialization.”

        Were you unaware of the fact that if you entered into this fields you would have this requirement to get paid pursuant to these contracts? Really?

        “we are sued because we are not gods who can reach down and save the unsavable with a glance and a touch of our fingers.”

        You’re also sued because some of you have drug addictions and still treat patients. You’re sued because sometimes you’re alcoholics and treat patients and screw up. And sometimes you just plain old screw up, like we all do once in awhile. Getting the medical degree doesn’t make you infallible.

  4. Wow. I noticed someone in a previous post had commented that he couldn’t follow ERP’s blog because of a virus – and when I followed your link to erstories above I can see what he’s talking about.

    It’s no virus, but Satan Incarnate, erstories.net has obnoxious ads. I won’t be going back there. Multiple flashing pink banners and it *Yells* at you.

  5. Ed says:

    I had never really read the contents of the EMTALA. WOW! What a bone-job.

    I particularly like the section that states that a hospital cannot perform a credit check “before, during, or after” care is given. And cannot report non-payment to the credit companies.

    I think Matt is right. All hospitals should dump Medicare/Medicaid and get out from under this stupid law.

    Of course it will be a very short period of time before the law is passed that takes that option away.

  6. bb says:

    Matt, where is that contract to treat nonpayers????

    Guess it won’t matter anyway with Obamacare….medical providers are all going to become defacto employees and everyone is going to get medicaid/DMV type of care.

    Maybe We should just become federal employees. I wan’t to retire at 55, work 9-5, have paid holidays and vacations

  7. Dave says:

    How has the insurer’s liability been limited to those who pay? Anyone coming into an ER can sue.
    Constitutional right, correct? Unless it’s a good Samaritan case outside an ER, which our current legal climate has forced most states to pass laws about.
    Matt, you get a lot of kicks out of insulting doctors, which I think is pretty sick, especially given your own profession. Some doctors have decided to forego taking care of people whom it is not economically profitable to see. They have gone into concierge medicine, cosmetic surgery, dermatology, etc. Most doctors continue to see medicare and medicaid patients even though good business sense would dictate that they limit their practice to more lucrative patients. It really seems to piss you off that they do so, by “accepting government money”, but if all physicians did what you seem to want (ie refuse to participate in these programs) a hell of a lot of people would not get care.
    The infectious disease doc I referred to in an earlier post was up all night in an ICU taking care of an indigent septic patient, and somewhat irritable about it. One of the ICU nurses heard him grousing a bit and told him she wished she made what he did. His response was to tell her that if that was the case to request she not get paid for that shift, because his income for that patient was going to be zero. He was not contracted by any hospital, he was there because he felt it was his professional responsibility. Sure, he made a decent salary, about the same hourly wage as the nurse if you factor in his 100 hour weeks. Before you insult doctors once again for taking care of indigent people, or for taking care of people where the payment is less than the overhead, please respond how many clients you saw last year who did not pay you, how much work did you do that you were not reimbursed for adequately but people would be left in the lurch if you did not do it. Also, please tell us if the medical profession as a whole opted out of medicare and medicaid, where are these people to get care? Answer – emergency rooms. All you do is snipe, but you have no solutions to the problem of indigent care other than to pass laws mandating they be taken care of. And I dont think emergency departments have the option of opting out of EMTALA regulations ANY step of the way, do they? I thought it was a law.
    I’m wasting my breath. I’m sure this will be answered with more insults.
    Finally, a lot of docs DONT think the free market system is the way to go (we dont have this anyway now).

    • Matt says:

      “How has the insurer’s liability been limited to those who pay?”

      It hasn’t, that’s the point. You guys are crying that because some of your patients can’t pay, you should get limited liability. As if people being poor means they shouldn’t be entitled to rely on your actions meeting the standard of care.

      “Matt, you get a lot of kicks out of insulting doctors”

      I get no kicks out of it. It sickens me that you guys are the PR front for liability carriers, at the expense of injured patients. It’s not fun for me to fight that.

      “. It really seems to piss you off that they do so, by “accepting government money”, but if all physicians did what you seem to want (ie refuse to participate in these programs) a hell of a lot of people would not get care.”

      It doesn’t piss me off in the least. What is annoying though, is so many physicians’ rank hypocrisy, calling for less government in medicine, but then trying to get the government to protect them from the cost of their negligence. I’m not angry you help poor people – I’m angry that you try and make it harder for them to hold you accountable if your treatment is subpar.

      “Before you insult doctors once again for taking care of indigent people, or for taking care of people where the payment is less than the overhead,”

      Perhaps I was unclear, and if so, I apologize. I am not insulting you for taking care of poor people. I’m annoyed that you’re trying to say that because they’re poor you don’t have to treat them up to the standard of care.

      “Finally, a lot of docs DONT think the free market system is the way to go (we dont have this anyway now).”

      It’s a moot point as of yesterday. While you guys have been fighting for your insurers to save a dollar and maybe pass a penny on to you on the backs of the injured, your profession just took a giant leap toward being nationalized.

      Oh well, at least you’ll get to join a union.

  8. Fyrdoc says:

    “You don’t understand “charity”. YOU GET PAID. YOU NEGOTIATE A CONTRACT TO TREAT THESE PEOPLE FOR THE MONEY.”

    Really?!? Paid by whom? Let’s see, according to you, the fact that in order to have the durable equipment to practice my trade I must agree to take MC/MA patients equals a “contract”. O.k., fine. I take MC/MA patients. And I am paid for them (usually in the neighborhood of $0.80 on the dollar against cost). For the “privilege” of being able to bill MC/MA for those patients who are part of that program, I am forced to treat anyone who walks in the door. I am allowed to bill them, but if they don’t pay – oh well. The amount of people who do not pay their ED bills equals an average of $200,000 per year for every full time emergency physician in this country. I do work, I do not get paid for that patient. No one, not the hospital, nor I can force collection. That is charity care. There is no “contract” – my “contract” if we accept that I have the freedom of choice in the matter pertains to the payment for services rendered to those patients enrolled in MC/MA. No one is including the fact that we are hopelessly underpaid by these programs in the $200K/yr/ED physician estimates (although we should). That figure is merely the amount of unpaid bills generated annually, for patients to whom we have provided care. How is that not charity care?

    Then you want change the terms again, with a poor example. “You’re like a guy who all his life wants to join the FBI, and then when he gets there wants to complain that they won’t let you smoke pot on the job. And nothing stops you from leaving that area of medicine and doing something different. Nothing but YOUR choices.” So you agree, there is no way to practice emergency medicine without accepting MC/MA. O.k. So now the tactic is that we should just go into a different area of medicine… Yeah, that would be a sustainable system, and such a better societal choice than making the needed proof to be willful and wonton misconduct for EMTALA cases (all ED cases and those cases seen by “on-call” specialists). Beggars can’t be choosers after all. But I am glad to see you have finally accepted that an emergency physician must, for all practical purposes, accept MC/MA. It shows you can be taught. Now if we could only get you to understand the interplay of practices and costs, we’d be cooking with gas. Might I suggest you read “Hippocrate’s Shadow”? You may find it enlightening.

  9. Fyrdoc says:

    Here is a link to the book I referenced above. BTW – I do not know the author and have no financial interest in the book:

    http://www.amazon.com/Hippocrates-Shadow-David-H-Newman/dp/1416551549/ref=sr_1_1?ie=UTF8&s=books&qid=1269098119&sr=8-1

  10. Matt says:

    It’s a little ironic that all of you can write treatises on this subject, which in reality affects your income in a tiny, tiny amount, and even using the most draconian “reforms” you’ve backed changes your practice maybe 5%. Yet let the government literally take over your practice, and the public barely hears a peep from you, let alone legislative alternatives.

  11. Dave says:

    There is NO doctor who feels that poor people should be treated with any less standard of care that anyone else. Again you insult the people who are actually caring for poor people (as I predicted). As far as taking resposibility, the docs, nurses and other personnel in an ER shoulder a lot of real responsibility – I’m talking about responsibility for people’s lives and health, not the legal dog and pony shows you’re referring to, and believe me they feel the responsibilty when they’re handing a crisis. There are other professions that do so, including the law enforcement personnel and the military, and isn’t it interesting that they have the same kind of retrospective quarterbacking that doctors do?

    I’m not an ER doc, but I think the gripe is that the government is forcing ER personnel to see these patients. Therefore the doctor is acting as an agent of the government in these cases. I think maybe the government SHOULD assume the liability in these cases.

    • Matt says:

      “There is NO doctor who feels that poor people should be treated with any less standard of care that anyone else.”

      Really? What does this mean then:

      “If government is going to create an unfunded mandate affecting only emergency medical providers [i.e. EMTALA], then why shouldn’t those same providers have protections not afforded to those to whom the mandate doesn’t apply?”

      Why does the funding of the mandate matter? Clearly, because WC isn’t getting paid he feels like he shouldn’t have to meet the standard of care.

      “not the legal dog and pony shows you’re referring to, and believe me they feel the responsibilty when they’re handing a crisis”

      What do you call a person dealing with mountains of medical bills, unable to work so unable to pay for their car or their house or their family’s food? Not to mention perhaps a lifetime of pain because of a physician’s malpractice? That not a “crisis” in your book? You think the lawyer handling their case doesn’t feel a responsibility?

      ” isn’t it interesting that they have the same kind of retrospective quarterbacking that doctors do?”

      This complaint about retrospective quarterbacking is dumb. We don’t have the ability to go back in time, so every examination of past events if retrospective. We can certainly judge them by the information known at the time, and indeed we do, but they are by the laws of nature retrospective.

      ” but I think the gripe is that the government is forcing ER personnel to see these patients. Therefore the doctor is acting as an agent of the government in these cases. I think maybe the government SHOULD assume the liability in these cases.”

      You physicians have redefined “forced” to mean “anything I contract to do but don’t like in the contract”. If you want to take the position that they are agents of the government, fine. Problem with your theory is that I don’t think ER docs like WC want to be considered government agents. In fact, he’s specifically said he wants more “free market” and that healthcare is not a right. If my tax dollars are solely responsible for his salary, then I’ll expect him to be more available, and the government to pick up the tab on his mistakes.

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