Archive for May, 2010
Saturday, May 29th, 2010
Now THIS is what I’m talking about!
From an article in ModernPhysician.com (registration required)…
Pricing transparency gaining renewed interest
Led by a physician lawmaker, members of Congress on both sides of the aisle have shown renewed interest in mandating a boost in healthcare pricing transparency, including charges for physician services.
Rep. Steve Kagen, M.D., (D-Wis.) sponsored one bill ( H.R. 4700) that would require all medical providers to openly disclose prices or face a financial penalty.”The “Transparency in All Health Care Pricing Act of 2010” would finally allow patients to see the price of a pill before they swallow it.”
Rep. Joe Barton (R-Tex.) sponsored H.R. 4803 which is a little more vague, but which still requires that all hospitals in each state report “the charges for inpatient and outpatient services typically performed by such hospital.” This bill has 11 co-sponsors.
Sources in the ModernPhysician.com article discussed whether the pricing scheme would be “too complex” and suggested that if competitors knew each others’ prices, they would raise prices in a given market. If hospitals have to list every little thing, I suppose it could be too complex. I don’t go along with the price fixing argument.
A few simple solutions:
1. If we’re worried about the complexity of pricing all hospital services, require that providers report pricing based upon CPT codes. That way, consumers can compare apples to apples (or codes to codes).
2. Any charges that do not correspond to a CPT code must be explicitly stated in simple English. No charges of $129 for a “mucous recovery device” when all they’re giving you is a box of tissues.
3. Require that any procedure or test or other charge whose price is not published must be provided free of charge to the patient. Patients have the option of accepting or rejecting items once they know the charges involved. You want to charge $129 for a box of tissues, you better tell me about it first. Then your charges will be out there for people like me to comment upon.
This whole pricing transparency thing is catching on. Just read a blog post about transparency from Paul Levy – the CEO of Beth Israel Deaconess Medical Center in Boston. In Massachusetts. You know, that state where they have insurance for everyone, but access for … well … not everyone.
“we should measure parties’ commitment to change by the degree to which they advocate and adopt the kind of transparency that exists in virtually every other segment of the economy”
Bingo.
Posted in Funding Crisis, Health care reform | 6 Comments »
Friday, May 28th, 2010
 During a shift a while back, I was having a bad day and became frustrated with a patient who appeared to be drug seeking.
A patient with chronic migraine headaches who happened to be visiting from out of town came in for “9.5 out of 10″ pain. Apparently she had been around enough to know that if she complained of the worst headache in her life, she’d be signing consent for a spinal tap.
I ordered an IV and some subcutaneous Imitrex.
The nurse came back after going in the patient’s room. “She can’t take Imitrex. It gives her palpitaions.”
“Fine. Giver her IV Toradol and IV Reglan.”
A few minutes later, the nurse returns. “Toradol doesn’t work for her headaches.”
“Give her IV Stadol instead.”
The nurse walked back out of the room. “She wants IV Demerol.”
“Tell her she’s not getting IV Demerol. She can have the Stadol or she can leave. This isn’t McDonalds – you don’t get things your way.”
The patient took the medications I prescribed, her symptoms resolved and she left.
I didn’t think much about the interaction until a week or two later when I overheard the following discussion between another staff member and a patient in the waiting room.
“This is bullsh**! I’ve been waiting here for three hours and I still haven’t seen the doctor.”
“He’s taking care of several very sick patients now. We’ll call you back as soon as possible.”
“Yeah? Well it’s still bulls**t! I have seen people get called back before me and I’ve been waiting longer.”
“You know what? This isn’t McDonalds. You don’t always get things your way.”
“You’re right about that! At McDonalds, they give you service … with a smile.”
“Yeah? Well at McDonalds, the customers pay for their food.”
[string of obscenities as the patient walked out the door]
After hearing that interaction, I never used the “McDonalds” comment again. The witty comebacks stuck in my head, but it also made me realize how my offhand comments could be taken to heart by others and used pejoratively.
More recently, one of our nurses did an excellent job managing a critically ill patient. As she wheeled the patient up to the ICU, I passed her in the hall, gave her a high five, and said “Strong work with Ms. Jones, here. You saved her life!” The patient looked up at her with a smile. The nurse blushed and smiled. The rest of her shift you could see that she was happier. Don’t know if it was my comment or not, but I like to think so.
So I started making a conscious effort to compliment people when they’re doing a good job.
I say “strong work” a lot more. Now I hear other people saying it to each other.
I go into the rooms and tell patients things like “It’s lucky you have this nurse taking care of you. See how much better she’s making you feel?” The patients seem happier.
When secretaries are getting frazzled from all the work, I go up to them and say “I’m sure glad you’re working today. Otherwise we’d never be able to keep up with all the chaos. I don’t know how you do it.”
The funny thing? Even when the morale is low in the rest of the hospital, everyone is pretty happy in the emergency department. Sure, we complain about things like everyone else. But everyone likes working together.
While the rest of the hospital has been trying desperately to hire nurses to work on the floors (with a 20+ percent vacancy rate), in the past 5-6 years we’ve only had a few nurses leave our emergency department – a couple because they moved, and one because she got a significantly higher paying job at a hospital closer to her home. And there’s a waiting list for nurses in the hospital who want to work in the emergency department.
Amazing what a little recognition and teamwork can do.
Posted in Random Thoughts | 15 Comments »
Thursday, May 27th, 2010
Patient brought in by ambulance after allegedly drinking a bottle of Windex – making gruff statement about his previous history …
“Hey! This isn’t the first time I’ve committed suicide, you know.”
The nurse and I just looked at each other, made those faces where you raise your eyebrows and open your mouth but keep your lips pursed together, and nodded our heads.
What we felt like saying:
“OK, great. Can I get you anything to drink? Like some O-negative blood, maybe?” Then in a whisper “tell the secretary to get some garlic from the cafeteria – STAT.”
… or maybe …
“Very good, Mr. Christ, Social Services will be down here shortly to arrange for your transfer.”
Posted in Patient Encounters | 5 Comments »
Wednesday, May 26th, 2010
Also see the Satellite Edition of this week’s update over at ER Stories – with his new and improved website design and no more rogue ad plugins.
How does a patient break her foot badly enough to require surgery — using a Wii? Click here to find out. Clue: Alcohol was involved.
 California’s children not getting needed dental care. Half a million kids missed school in 2007 due to dental problems. Thousands of young children are put under general anesthesia or sedation (with their inherent risks) each year at just one residency program to fix chronic tooth problems. Denti-Cal, the state dental program for low-income children covers the extremely poor, but even those who are eligible for Denti-Cal have difficulty finding care. A survey found that “of 255 California-based pediatric dentists less than half participated in Medi-Cal’s Denti-Cal program, and of those, two-thirds limited the number of patients they accept because of low reimbursement fees and broken appointments. Some parents lucky enough to find a dentist who will see their child often wait months for an appointment.”
In case you were wondering, the new insurance-for-all health care plan doesn’t cover dental services, either.
Final legal challenge to fair payment of physicians in California is settled. Just another reason for doctors not to work in California. By they way, if you want a good explanation of what “balance billing” is all about, head on over to DinoDoc’s blog – and check out her new book while you’re at it.
Seventeen hour waits for care. President of the county medical society quoted as saying “If you want to think you’re in a war-torn third-world country, just [come here] on a Friday afternoon.” Ambulances have to wait in line just to drop off their patients, making them unavailable to respond to other emergencies. When three hospitals in your county close and the number of available beds decreases by one-third, the patients don’t just vanish. They crowd other hospitals. Jamaica Hospital was designed to see 60,000 patients per year. After surrounding hospitals closed, now Jamaica Hospital is seeing 135,000 patients per year.
Some patients are even traveling to different counties for care.
Now New York is considering additional budget cuts. Be interesting to see what happens when the next hospital closes.
This article shows that New York public hospitals are planning to cut 3,700 workers, including a 6% reduction in the physician workforce, over the next 5 years in order to trim a $1.2 billion deficit. As more and more insured patients enter the system, what effect will the cuts have on patients?
“They have to travel further. They have to wait a longer time for an appointment. They might end up in the emergency room for care. We keep hearing people are blamed for going to the emergency room, but if you don’t have other options, you go to the emergency room,” says one of the Public Health officials.
Speaking about books, Eileen Brenner, one of EP Monthly’s regular contributors has a new book out about how to survive a medical malpractice suit. Louise Andrew, a physician/attorney, calls the book a “GPS for Malpractice Litigation.”
A peek at liability issues in government health care for people in custody. Illegal immigrant is arrested for possession of methamphetamine and sentenced to prison. He complains of a lesion on his penis as soon as he arrives in prison. Biopsy was recommended by several physicians, but was deemed “elective” by the US Public Health Service and was not approved. Instead, he was treated with Motrin and antibiotics. The ACLU had to intervene in the case and the patient was released from custody shortly before the procedure “because the government did not want to pay for his treatment.” The biopsy determined that the lesion was cancer and the patient required amputation of his penis. Unfortunately, the cancer had spread and the patient died. When his family tried to sue the federal health officials responsible for the patient’s care, the case was dismissed under the Federal Tort Claims Act which immunizes Public Health personnel who treat immigrants in custody. Hui v. Castaneda.
Will the liability pendulum swing too far in the other direction if a national public health system is implemented?
$36 million Florida judgment in medical malpractice case involving “seemingly erroneous” spinal steroid injection.
$18.5 million New Jersey verdict against Newark Beth Israel Medical Center and obstetrician in medical malpractice case alleging delayed Caesarian section as a cause of patient’s cerebral palsy.
Family of patient who dies from swine flu files lawsuit against hospitals that treated him. “Had he gotten aggressive intravenous treatment for H1N1 early on, he’d be alive today,” the family’s attorney said. Even though the patient had “always been healthy,” and even though CDC guidelines (patient fell ill in September 2009 and link is to December 2009 guidelines – I wasn’t able to find earlier versions, although the recommendations were similar) recommended against treating patients for H1N1 unless they were in one of the “high risk” categories, they required hospitalization, or they had “progressive, severe, or complicated illness,” that “aggressive IV treatment” would definitely have cured him.
When someone dies from an illness, the medical providers must have done something wrong.
I can’t help wondering whether this man got a H1N1 vaccination – if they were available in his area. If he didn’t get an available vaccination, I would absolutely use his failure to vaccinate as a defense in the case.
An act of kindness or a precedent with unintended consequences? StoryTellER Jim describes an interesting dilemma about a patient who feigns a medical problem to get some food in the emergency department. It’s great to be able to help people who are hungry, but at the same time, the patient had unnecessary lab testing performed and she took up a bed in the emergency department for several hours. Obviously not the best use of resources.
Do emergency departments become soup kitchens in addition to trying to provide medical care or do we adopt a “don’t feed the bears” approach? The thinner that we stretch our resources, the less resources we have to offer. I think we need to take the latter approach.
Neat news story on educating kids about emergency medicine. Take them on a tour of the ambulances and emergency department to show them what it’s like to be a patient. I bring blown up pictures of medical items, splints, and fetal monitors (to listen to heartbeats) classes in our kids’ schools. In this story, they strap a kid to a backboard and they put EKG leads on another kid. Everyone looks like they’re having fun.
Of course, to simulate the realism, the kids have to wait 17 hours in a room full of coughing and vomiting people for the tour to start, then they get left alone in the radiology department for three hours, and finally they get poked twelve times with a needle to find a vein. Then when they get back to school they get a student satisfaction survey so they can get the teacher fired. Yep, that about covers it.
Posted in Healthcare Update | 7 Comments »
Monday, May 24th, 2010
Ambulance call goes out for a patient who is in “excruciating pain all over.” She has a history of fibromyalgia and ran out of her pain medications at home. Time of call: 18:35 on a Friday night. Being out of pain medications after office hours on a weekend is a red flag. When she arrives, she happens to just have moved into town this week. Another red flag. The emergency physician working at the time looks her up on the state database. She has received medications from 13 previous physicians. Red flag #3. She gets a shot of Toradol, is informed that we do not refill prescriptions for chronic pain medications in the emergency department, and is sent on her way.
About 2 hours later, another ambulance call goes out. A 36 year old woman fell while walking up steps, hit her forehead on the edge of a step, sustained a deep laceration, and passed out. Now she has an excruciating headache.
As the ambulance rolls in … it’s the same woman.
We remove the bandages and there is a scratch across her forehead. Said scratch looks very much like the patient took her fingernail and scraped herself across the forehead. Patient swears the “laceration” is from the impact. The laceration is too superficial to suture, so instead the patient gets some nice “Hello Kitty” band-aids applied to her wound. The defensive medicine clinically indicated CT scan of the head is normal. Because she was just discharged from our emergency department only a few hours ago, it is too soon for another dose of Toradol. Fortunately, there is some Tylenol … Number Three waiting at the desk along with her discharge papers.
About 6 hours later, a police call goes out on the scanner. On the main highway through town, there is an erratic driver. Two truck drivers saw a car swerving back and forth on the road. They assumed the driver was intoxicated, so they blocked the lanes of traffic with their rigs, slowed down, and forced the car to come to a stop. Then they called police.
The driver of the car told police that she was on her way back home from an out of town emergency department where she was seen for back pain and given an injection of narcotics. The patient was slurring her words, so police called an ambulance and the driver was transported to our ED.
You guessed it. Same patient.
Alcohol was not detected, but she did seem to respond nicely to naloxone.
Well, ma’am, given that you have been present in our emergency department more than the staff has been present in our emergency department over the past 24 hours, we have taken the liberty of completing a change of address form for you at the post office and we will start holding your mail in the doctor’s lounge so that you can pick it up on your subsequent visits.
Please remember the excellent service you received when filling out your patient satisfaction survey(s).
Posted in Patient Encounters | 8 Comments »
Saturday, May 22nd, 2010
This is a repost from a couple of years ago.
I actually had a new post planned, but had to reference something on this post. When I moved from my old blog to EP Monthly, this post apparently didn’t get transferred.
Some fond memories below.
—–
The effect of a placebo is based on someone’s belief that an inactive substance is going to help them. This belief can actually cause the brain to release chemicals that mimic the effect of antidepressant medications and/or analgesia.
Some placebos are not just “sugar pills.” For example, some people with viral upper respiratory infections must have antibiotics to make them feel better. Physicians know (or at least they should know) that using antibiotics for viral infections is a useless proposition. Like spraying Raid on dandelions. But some patients swear that the antibiotics make them feel better and will seek out physicians who inappropriately prescribe antibiotics for their head colds and bronchitis. By the way, this placebo effect wouldn’t be a big deal except that now we have made many antibiotics less effective because we prescribe them so much. MRSA is proof that single cellular organisms evolve faster than the prescribing practices of some physicians.
Vitamins. Supplements. Energy drinks. They all may help cure what ails ya, but is there a scientific basis for the improvement? Or is it the placebo effect? Who knows? Who cares? If you feel better, it doesn’t matter whether you’re popping a couple of M&Ms or chugging quart of snake oil. Go for it.
Lately a lot of patients have shown dramatic improvement in their pain symptoms with the placebo effect in our ED.
An issue some of our nurses have is that they have to get the patient to believe in the effectiveness of the placebo in order for it to work. If you give someone a shot and tell them that it is just some “saline,” you probably won’t get much of a response. If you give someone a shot of “obecalp” (which is “placebo” spelled backwards), and tell them that this is a medication for their pain that may make them sleepy, it might work. Therein lies the problem. How to you get the patient to buy into the placebo effect without lying to them? OK ….. shhhhhh. Can you keep a secret?
If a patient is looking for pain pills, hand them three regular Tylenol pills. If the patients ask what they are getting, they are told they are getting “Tylenol …. number three.” Not a lie. They really are getting three Tylenol pills. Good placebo effect. Probably half of the patients who get “Tylenol … number three” get significant relief with three plain ol’ acetaminophen pills.
One 19 year old kid with chronic back pain (how does pain become chronic at age 19?) came in the other day after running out of his pain pills. The ED doc gave him a shot of Toradol. When that didn’t help, she had the nurse give the kid a couple of Tylenol tablets. He asked what medication he was receiving. The doctor told him it was “acetaminophen.” He asked her “is that like the pain medication in Vicodin?” She replied “Of course. Acetaminophen is one of the active ingredients in Vicodin.” He was happy and pain-free 30 minutes later.
The most profound placebo effect I have ever seen actually occurred in a little old lady that I saw about 6 months ago. She was dancing around the waiting room complaining of severe pain in her hip. Howling (literally) in pain. Like if she kept it up, a rain cloud was going to form in the waiting room. We got her back to a room and she was screaming and rolling around on the bed. She had a medication “allergy” list that was extensive, but that did not contain Demerol. And she needed a pain shot … NOW. I was busy admitting someone and told the nurse just to give her a shot of saline in the butt then I would go in to see her. The nurse wouldn’t do it because she knew the patient would ask her what she was giving her and didn’t want to lie to her.
I looked at her and raised my eyebrow. Then I heard her heel spurs jingle. The theme from “The Good The Bad, and The Ugly” echoed in the distance.
“Feelin’ lucky … punk??”
“Give me that syringe of saline.”
She tossed it at me and I caught it in mid air as I walked toward the patient’s room.
“I’m Dr. WhiteCoat. I was just taking care of another patient, but the nurse told me that you’re in such bad pain that I wanted to give you some pain medication right away. I asked her to give you some strong medicine, but she felt uncomfortable giving this much to someone all at one time, so she asked me to give it to you.”
“Oh, good. My hip is killing me.”
“You aren’t driving, are you?”
“No.”
“And you don’t have anything important to do today, do you? It might cause you to be groggy for most of the day.”
“No. No. Not at all. What is it that you’re giving me?”
“The chemical name is norMAL SAHline.”
“I’ve never heard of that one.”
“It’s kind of experimental. Oh, I almost forgot. You don’t eat a lot of red beets, do you?”
“No.”
“Good. Where do you want me to give you your shot?”
I walked out of the room and squinted at the nurse in an “I’ll show YOU” kind of way, then went to see another patient.
When I returned to the desk, one of the other nurses was waiting for me with her hip cocked to the side and a smirk on her face. I was getting ready to tell her to “give it some time” when the patient’s nurse came up and squinted back at me.
“You’re a son of a beeyoch. Her pain is gone.”
I smirked along with Nurse #2, now.
“Go on, tell him the rest,” Nurse #2 said.
Nurse Nonbeliever shot her a scowl and then continued. “Not only is her pain gone, but she wants you to call her doctor to see if he can get home health to bring the medication to her home so she can have some on hand if her pain gets really bad again.”
At that point, I scowled, stopped, turned around, and walked briskly toward the lounge. I motioned for them to come along. The nurses looked at each other and then followed me.
I closed the door behind them.
They were both then treated to a WhiteCoat version of the Humpty Dance.
Posted in Funny, Patient Encounters | 7 Comments »
Friday, May 21st, 2010
 Ambulance service held liable for failing to “do what was necessary” before accepting emergency transport of pregnant patient.
I mentioned this case in a previous Healthcare Update.
A child was born at 25 weeks gestation – 15 weeks premature – and was not breathing. Babies born at this age have a viability of 50-70%. In other words, up to half of children born at this age of gestation die. The family called 911. The paramedics arrived, performed CPR on the child, and brought the child back to life. I know a lot of physicians who would have difficulty resuscitating such a premature infant.
These paramedics should have been commended as heroes for saving this child’s life.
Instead, they were sued and found liable for $10 million.
The plaintiff attorney stated that “the paramedic should have evaluated her before they transported her.”
In its verdict, the jury found that the ambulance company “was negligent by accepting the transport task” and the company showed “reckless disregard” in rendering its services.
So instead of getting to the mother as soon as possible, getting the baby out, performing CPR, and saving his life, the attorney apparently believes that the paramedics were supposed to diddle around arguing about whether or not to transport the mother to a hospital. Good idea. Let’s write that requirement into all future Florida EMS protocols. We can call it the “Kelley Amendment” – named after Bob Kelley, the plaintiff’s attorney in the case.
After the verdict, the ambulance company may soon have to determine whether it can stay in business.
A past-president of the American Ambulance Association is quoted as saying “EMTs and paramedics will go on the call until lawsuits like this break the bank and they can’t go anymore. That is $10 million that comes out of the ability to provide care, and the community will suffer because of that cost.”
As I’ve asked in the past … which is more important – perfect care or available care?
Jurors in Florida’s Volusia County seem to have made their decision.
It will be interesting to see whether the jurors’ decision to award an additional $10 million to someone who had the benefit of excellent care yet who experienced a bad outcome will affect the future availability of emergency transport in Volusia County and other Florida counties.
My guess is that few EMTs will want to work in Volusia County any more.
Regardless of the verdict, you EMTs are still heroes in my book.
UPDATE May 23, 2010
Additional facts about the case (and commentary) from the Editor in Chief of JEMS
Posted in Access to Care, Medical-Legal | 128 Comments »
Thursday, May 20th, 2010
 Sorry about the sparse posting lately – have been away in Washington at an ACEP conference
Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference.
I attended some excellent lectures about leadership.
- Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions.
- I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional.
- I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for.
There were other lectures about how health care reform fell short and some possible options for the future.
One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference.
And I went to legislators’ offices.
The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff.
I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input.
I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer for him. We sat there for 45 minutes talking. Below are some of the things we discussed.
“What do you think about the SGR?” He asked.
- Honestly, I don’t think they should fix it. Nobody cares about it right now. All they know is that they can keep kicking it down the road until it becomes a big enough problem that someone is forced to fix it. The only way to deal with the issue right now is not to fix it. Cut payments to physicians. Let most of them drop out of the system. Let the patients who depend on Medicare be stuck without medical care. Almost immediately, the AARP will pay for a bunch of buses for all the grandmas and grandpas with their pink hair and canes with the tennis balls on them (probably my own mother included) to go to Washington and demand a fix. Only then will legislators realize that the current system is unsustainable and unfixable. We can’t patch this system and expect that it will continue to work. We must focus on starting over and creating an entirely new system that will be sustainable in the future. And a side note – if you try to create another system without extensive input from physicians, it will fail in the same manner that the current system is failing.
“Do you think that the AMA represents the views of physicians across the country?”
- Not really. I believe there is a lot of attrition from the AMA and know of many physicians who have dropped their membership. At the same time, membership in specialty societies is growing. ACEP is a perfect example. ACEP’s membership is going up, not down.
“How would you make the health care system better?”
- Patients must have more skin in the game. Right now many people think that the value of the health care they receive is their $20 copay. You can’t get work done on your car for that much. A plumber would laugh at you if you told him that was all you would pay him. But, in practical terms, all a physician visit is worth is $20. That mindset has to change. $20 per visit won’t even keep the lights on.
There is a tremendous demand for high technology and for extensive testing that is often low yield. That is because a majority of patients have no direct responsibility for paying the cost of the testing. There is no incentive for patients not to want a test and there is no incentive for a physician not to order the test. In fact, with the push toward “patient satisfaction” as a basis for reimbursement, the incentive for physicians to order extensive testing will only increase. If patients don’t have skin in the game, costs will continue to rise no matter what regulations are put in place. I guarantee it.
- The only instance in which patients and physicians work together to decrease costs is when patients have to pay out of pocket for their medical care. If a patient’s medication goes off formulary for their health plan, the patient goes to the physician to find an alternative or to get the physician to request an exception from the insurance company. If a physician would like an MRI on an patient’s back after the patient was injured at work, the patient will not get the exam done until worker’s compensation agrees to pay for the test. This is what we need – patients need to be responsible for the costs and physicians need to help them determine what they really need and don’t really need. If patients want a low yield test, no problem – but they have to pay for it out of their pocket. Let them have ten low yield tests if they want. The only one who bears the cost of the testing is the patient.
Homeowner’s insurance doesn’t cover the cost of someone mowing your lawn and it doesn’t cover the cost of your kid breaking a window.
Auto insurance doesn’t cover the cost of oil changes or fixing your tire.
Why should health insurance cover routine medications and routine medical care? It shouldn’t.
- Health savings accounts have to become an integral part of our culture. Use the money in those accounts to pay for routine health care costs. Make money in the accounts tax-free to encourage people to use them. Allow patients to carry some of the money in the accounts over to future years, but require that they spend at least some of the money in the account each year to encourage people to engage in preventative health care practices. Family practitioners could drop all their insurance plans and could all go “cash only.” No insurance hassles. Money at time of services. They’re happier and more productive. More people go into family medicine. Patients get seen quicker. What a concept.
- Mandatory insurance isn’t fair and it probably isn’t Constitutional. You want everyone to pay into the system, increase taxes in an amount proportionate to the amount you’ll need to provide for medical care and provide the care at government-run hospitals for free. You don’t have to pay for an insurance policy, you have to pay 5% more in taxes. In return, you have access to health care at any VA hospital. Include county hospitals if you need more access. Will the care be the best available? Probably not. Will everyone get a same-day appointment? Not likely. Will everyone have access? Absolutely. Do this and you could eliminate much of the costs that are currently wasted on insurance companies.
“What do you think still needs to be included in the health care bill?”
- Malpractice reform. The AAJ has talking points stating how direct medical malpractice costs are an infinitesimal amount of total medical expenditures in this country. The statistics are true, but are only half of the story. The AAJ states that instilling fear in medical practitioners is good for medical quality of care. That fear drives defensive medicine. Defensive medicine accounts for hundreds of billions of dollars in indirect medical costs – at little gain to the system. If lawsuits improve quality of care, then the trial lawyers have failed. They’ve been suing doctors for decades and mistakes are still being made. The only thing that seems to go up is the size of the judgments. We can’t sue our way to better health care. Yes, I said that and yes the assistant laughed. I think he even wrote it down on his pad.
- Damage caps are a tricky subject. Capping a patient’s damages at $250,000 isn’t fair to the patient, but neither is making a doctor liable for a $60 million judgment. There has to be some reasonable limit to damages, but even those limits won’t decrease the physician fear of being sued. [I actually agree with Matt on this point - in almost all cases, caps don't save physicians money, they save insurance companies money - but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won't be able to practice. There has to be a happy medium].
- Like it or not, we will likely need to provide some type of limited liability protection to certain providers if we want to increase the numbers of those providers. Few physicians like being on call at hospitals because they know that they probably won’t be paid for the care and that they are highly likely to be sued if anything goes wrong. We have to ask ourselves whether we value the ability to find a physician to care for us in an emergency more than we value the right to sue that physician if anything goes wrong. Which is more important to us: Perfect care or available care?
We had other discussions, but this post is already getting too long.
You naysayers want my ideas? Here they are.
Now try to show me how they won’t work and come up with some better ideas.
Posted in Access to Care, Defensive Medicine, Funding Crisis, Health care reform, Medicare, Policy | 43 Comments »
Tuesday, May 18th, 2010
Lather, rinse, repeat. Difficulty in accessing psychiatric care and lack of follow up blamed for a mentally ill Louisiana patient stabbing her grandmother to death. Sketchy episodic care doesn’t address underlying psychiatric problems. Patients go from emergency department to psych hospital to emergency department. Because only 145 psychiatric beds are available in the entire state of Louisiana, patients who are a risk to themselves or others are sedated and wait in emergency department beds for days to weeks until inpatient beds open up. Effective July, the state is dropping funding for 35 more inpatient psychiatric beds, which will make definitive care for seriously mentally ill patients that much harder. As the emergency nurses complete the every 15 minute checks on sedated patients as required by JCAHO (and complete the requisite paperwork each 15 minutes), there will be even less care available for other patients with emergencies.
What are we whining about? The best paying jobs belong to doctors. I saw a graph on a message board somewhere showing that upon graduation from college, it took doctors 19 years to catch up to the salaries made by a UPS driver. While attending physicians are paid well, don’t forget that doctors have to spend hundreds of thousands of dollars on college and medical school – while at the same time their peers are earning money working. Residency positions pay much less than attending positions while interest accrues on the educational loans.
When you think about the $105/hour that surgeons are quoted as earning, take away $25/hour in taxes, then deduct $25 to $50/hour each year for medical malpractice premiums, then deduct another $15/hour for student loan payments, then factor in that few surgeons work only 40 hours per week. I’d venture a guess that an average surgeon works more like 60 hours per week.
When you hear about how good all the greedy doctors have it, keep in mind that many times there’s more than meets the eye.
Eat your veggies, dear, they’re good for you. Woman sentenced to 4.5 years in prison after putting foxglove plants in her husband’s salad. Foxglove is what digoxin – a heart medicine – is derived from. Oh, and if that didn’t work, she also stockpiled the poison ricin.
Not sure why they needed a poll to figure this out … When you increase the number of patients with “insurance”, then decrease the number of emergency departments and decrease the number of family practitioners so that the “insured” patients can’t find routine medical care, what do you expect will happen? Emergency department visits will increase and the strain on the safety net will get worse.
Hey! Who keeps messing with the nitro drip and why do the monitors keep blinking on and off? Israeli officials dig up grave site and remove Pagan bones to make way for new “fortified” emergency department. The citizens are pissed off. The graves have been desecrated. Can you say Poltergeist 4?
Liar liar. Healthcare worker files complaint after waiting 8 hours with abdominal pain at LA County Hospital. She stated that her vital signs were never taken and that she was told the average wait time to be seen was 35 hours, so she left and went to another hospital.
After an investigation, it was discovered that the staff took her vital signs 4 minutes after she arrived and that her name was called after only 4 hours. With patient volumes up by 15%, expect wait times at LA County/USC to increase.
Do you want me to fill out the JCAHO forms before or after I write admission orders, transfer the patient in Room 2, intubate the trauma patient and sew up the laceration? Emergency physicians in this study from Australia were interrupted an average of 6.6 times per hour. Eleven percent of all tasks were interrupted and 3.3 percent of tasks were interrupted more than once. It took doctors less time to finish interrupted tasks, leading researchers to believe that doctors “cut corners” when finishing an interrupted task.
Posted in Healthcare Update | 25 Comments »
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