WhiteCoat

Healthcare Update — 11-11-2010

Some people think that there is a trick to getting seen in emergency departments more quickly by arriving in an ambulance. Not necessarily so. When the emergency department is full, ambulance runs are routinely triaged to the waiting room if the patients do not have an urgent complaint. In Canada, paramedics share the pain. They get stuck waiting along with the patients until a bed opens up. Edmonton paramedics are forced to wait an average of an hour and 22 minutes with a patient in the emergency department waiting room every time they bring a patient to the hospital. What happens when all the paramedics are sitting in the hospital and they get another 911 call?

The “Kind of an Emergency” Department: Fountain Valley Regional Hospital in California and two Memphis, TN hospitals jump on the growing bandwagon allowing patients to reserve an appointment in the emergency department so they don’t have to wait. The catch is that patients have to pay $14.99 for the privilege. The fee is refunded if you aren’t seen within 15 minutes of your arrival. I think that the idea has good and bad points. Patients need to realize that medicine is a business that costs money. When you think of the old idea about “fast care, quality care, free care — pick any two”, the idea of patients paying extra money to receive an added benefit makes sense – like paying more to fly “business class” as opposed to “coach.” On the other hand, a requirement that people have some type of credit or debit card and then use it to pay a $14.99 fee online for an appointment makes it more likely that indigent patients or those on fixed incomes won’t be able to use the service. Acceptable?

Taking “trick or treat” way too far. Four year old in Lubbock, TX begins acting strange and then seizing after eating Halloween candy. A trip to the emergency department showed that he had methamphetamines in his system. Police suspect that someone may have laced his candy with meth. Yes, I asked the same question, too. Police investigated the child’s home and didn’t find a meth lab there.

It will adversely affect doctors, patients, taxpayers, attorneys, farmers, college students, people living in rural communities, retirees, the military and federal employees. Yup, the latest deficit reduction plan will officially piss off just about everyone.

Very thought provoking blog post about judging others written by a social worker working in an emergency department when a drunk driver causes a five car accident that killed four of five family members in another vehicle.

Man wins $4 million in medical malpractice case against hospital but surgeon gets a defense verdict. It appears that the patient had surgery for a gall bladder removal. He was later rushed to the emergency department for pain and fever. A CT scan showed that his gallbladder was still there … and that a surgical sponge had been left inside the patient. The surgeon was cleared of negligence by blaming the nurses for not counting the sponges correctly. The article doesn’t explain all the facts in the case, but I found myself needing to know: Did the jury just think the gall badder regenerated like some freaky salamander tail after the surgeon allegedly removed it?

Canadian police are launching a full criminal investigation into the death of Brian Sinclair, a double amputee who died after sitting in an emergency department waiting room for 34 hours. Criminal prosecution of medical care is a very bad idea. Starting a precedent where medical staff can be sent to jail for making patients wait will have one and only one effect: A lot of providers will leave the profession fairly rapidly. Then the waits will go up. Then more medical staff will go to jail. Oh well. At least the inmates will have good medical care. Hey … wait a minute … if the police are investigating … and the prisons need doctors and nurses … maybe … naaaahhh.

Texas considering whether or not to drop Medicaid. “This system is bankrupting our state. We need to get out of it.” The state figures that it can save $60 billion from 2013 to 2019 by leaving Medicare and CHIP patients to fend for themselves.
Meanwhile, South Carolina plans to stop paying doctors for treatment of Medicaid patients effective March 4. Oh, they still expect the doctors to see Medicaid patients “in hopes that they will eventually be paid.” The state’s Medicaid population has grown from 100,000 to 975,000 since 2007 – which means that more than 20% of the state’s population now has Medicaid as their primary insurance.
With 30 million patients getting brand new insurance cards in the next few years, a whole lot of people are going to learn the difference between “insurance” and “access”.

That’s it. Your satisfaction scores are TOAST! Interesting court battle brewing in Chicago. Northwestern Memorial Hospital has been trying to discharge an 86 year old patient with inoperable pancreatic cancer who has been stable for discharge for almost a month. The patient doesn’t want to go home from the hospital and her daughter is worried that “she is unable to adequately care for her frail, terminally ill mother at home.” Medicare deemed the extended stay medically unnecessary and won’t pay for her inpatient bills any more. The patient’s daughter, a who is power of attorney, states that Northwestern should make special accommodations for her mother since Northwestern allegedly delayed diagnosis of the pancreatic cancer. Now Northwestern is going to court to have the daughter’s power of attorney revoked.
Three simple letters would probably go a long way toward resolving this problem: ABN.

Last but not least is the WTF story of the week: Woman charged with aggravated assault for threatening to batter a police officer with a “rigid female pleasure device.” Whaaaat? First, I can’t believe that an officer wrote that in a report. Bet it will make for some interesting looks in the evidence room. Second, if someone busts into your house, it a “pleasure device” the first thing you’d grab to defend yourself? Third …. ah nevermind. This is a family blog run by medical professionals.

26 Responses to “Healthcare Update — 11-11-2010”

  1. NurseBeth says:

    WC, check out the USA Today article today about Blue Cross vs. the Physical Therapy company. I’d really like to see your comments and insight.

  2. Anonymous says:

    “makes it more likely that indigent patients or those on fixed incomes won’t be able to use the service. Acceptable?”

    Of course that’s acceptable. I work hard for my income, so why shouldn’t I be entitled to using it to receive additional privileges over someone who doesn’t? However, you’re missing the point entirely. How can it be possible that you can schedule an *emergency* in advance? Something like what you described is tantamount to encouraging use of the ED as a primary care facility; a role for which it was never intended.

    “Did the jury just think the gall badder regenerated like some freaky salamander tail after the surgeon allegedly removed it?”

    I’m wondering what the F he was doing in the OR for that amount of time. Yes leaving a sponge is bad enough…but he didn’t even remove the organ he was supposed to remove! Essentially he performed the exact same job that I could have performed with no medical degree…and somehow he didn’t get sued into the ground?

    • DensityDuck says:

      “…what you described is tantamount to encouraging use of the ED as a primary care facility; a role for which it was never intended.”

      Or maybe there need to be 24-hour “non-emergent” outpatient facilities, where people who DON’T have an emergency situation could receive unscheduled medical care. When my four-year-old puts beans up her nose, it’s not an EMERGENCY, but that doesn’t mean I want to wait two weeks for my GP’s first available office visit!

      • VA Hopeful says:

        If its not an emergency, you don’t need 24 hour access to care. Urgent Care places routinely stay open til 8-10pm, if its not an emergency at 1am than it can wait til morning.

  3. Matt says:

    It will be interesting to see how many physicians survive in Texas if $60 billion is removed from the total medical expenditures.

    • DensityDuck says:

      @Matt: Considering that that $60bn income is associated with MORE THAN $60bn in expenditures, I’d say that the physicians will do just fine. Better, even.

      But then, you’re a lawyer, not a mathematician.

      • Matt says:

        Not sure what you’re saying exactly but I guess we’ll see. I just have a hard time seeing how a quarter of Texas health care spending can be removed and there not be an adverse impact on the providers.

        But like you said, I’m not a mathematician.

      • Matt says:

        Check that – it’s $60bn over 6 years. It’s still 1/4 of total Texas healthcare expenditures though, so the point remains.

      • JustADoc says:

        $60 billion revenue
        -$62 billion overhead to get that revenue
        ——————–
        ($2 billion profit)

        Does it need to be simpler?

      • Matt says:

        Oh I get that. But here’s the thing you’re forgetting. I may take a 3% loss on certain things simply for the consistent revenue stream, knowing it allows me to service the costs of equipment or personnel which can make me more money elsewhere.

        But if you remove that revenue stream, my profit margin has to be VERY high elsewhere to maintain the current levels of debt service, payroll, etc. For example, I have clients who do work for Wal-Mart. Trying to make a profit off Wal-Mart is nearly impossible – at best it’s break even. However, they take it because it’s consistent and assures they’ll always meet payroll because even if Wal-Mart slow pays (and they do), once the revenue stream starts it’s solid. Wal-Mart’s not going under, and they’re not going to stiff them (much). This allows them to keep crews going even when more profitable work isn’t available.

        Even if they’re losing 3% on that $60 billion – that’s still a significant amount of revenue in the system that has to be removed. That’s revenue that is being used for SOMETHING right now. That SOMETHING now becomes more difficult to pay for.

        Since we’re dealing with Medicaid patients, it’s unlikely they have the revenue to make up the difference out of pocket. There simply isn’t enough REVENUE to support current provider (not just physicians) income at current levels if you take out 1/4 of the healthcare spending.

    • Anonymous says:

      I’ve seen similar things happen in video games…yes I learn things from everywhere. Sometimes you sacrifice one resource and you initially get pinched from the vacuum created, but eventually it makes you light enough that you can re-adapt and keep growing. I don’t see why this video game logic can’t apply as well to dead-weight healthcare programs like Medicaid. Personally I don’t see the big deal: just by the fact that you can’t afford your own healthcare tells me you’re not even worth keeping alive/healthy.

      • Necandum says:

        ” just by the fact that you can’t afford your own healthcare tells me you’re not even worth keeping alive/healthy.”

        If you really believe that, then you have lost your humanity.

    • WhiteCoat says:

      I’m more worried about how many patients will survive in Texas if $60 billion is removed from total medical expenditures.
      Who cares about the physicians? Texas has tort reform, right Matt? That’s all that should matter for them.

      • Matt says:

        You’re not making much sense. But honestly, I understand why. But a tort reform advocate lamenting the plight of poor patients? Does your hypocrisy know no bounds?

        It’s all a bluff anyway. Single payer just makes another leap forward.

      • ERP says:

        Right. I worry these patients will be royally screwed. But then again, that’s the Texas mantra in about everything- every man for himself and f-u if you fall by the way side. Honestly, they may as well secede and see how they maintain themselves.

    • JustADoc says:

      Yeah, it is being used to pay for the costs of seeing those patients and complying with requirements and prior auths of Medicaid. Tons, heck even most, doctors don’t take Medicaid and do fine. The docs who take it do it because either they feel it is the right thing to do or they are trying to build a practice. A practice that is full could drop Medicaid and not even blink. How do I know this? Because it’s been done thousands of times.

  4. Nurse K says:

    I just want to point out that Canada has universal health care. So everyone has equal access to 34-hour waits in the ER lobby and 1 hr 22 min waits on an ambulance stretcher in the ER lobby.

    Re: Gallbladder removal. Lay juries suck.

    • Necandum says:

      Just wondering, do you think this is because the government pays for their healthcare, or because there aren’t enough doctors/nurses?

      I think its a good idea to consider the issues of paying and providing healthcare as completely different. As I see it, the former would be best done by the government as they are not profit driven and the latter by private organisations acting under close scrutiny, to prevent politicians from making decisions instead of the people who actually know what they’re doing, while still allowing for regulation.

      • igloodoc says:

        It is multifactorial. My information may be a little old, so perhaps a Canadian can correct it. As I understand it, the hospitals are all owned by the government. If government budgets get tight, nurses and staff are laid off and beds are closed, until budgets are restored.
        In addition, there is a real problem with system throughput. Nursing homes, for example, rarely accept people with IV’s. So, people with potentially treatable outpatient problems (ie MRSA ulcers) linger in acute beds until their IV’s come out. Then, like acute care beds, there are much fewer nursing home beds available, so healthy people wait in an acute care bed until a nursing home bed comes up.
        Psych beds, like here, are also hard to come by. In the hospital I toured, there was a 3-7 day wait for a psych bed, and the patients were held in the ED hallway.
        The culture is a little different too. People seem to be just programmed to go to the ED after hours, as many city Docs do not take patient phone calls after hours. (Some still do, though). And, of course, the ED is where the tests are done relatively rapidly, and you get seen faster than the wait for the appointment (even 12hr waits are better than the alternative).

        The factors add up and create the perfect storm….ED style.

      • Necandum says:

        *shudder* Lovely. Thanks for the info.

        Then again, there’s no reason that every healthcare system run by the government has to be the same. I wonder what kind of difference a few checks, minimum standards and a guaranteed source of founding would make.

        One possibility I see is to make the system directly funded by the population. That is, split up the previous year’s cost by tax bracket and portion out accordingly. As far as I can tell, that’s sort of what’s happening in America in a round-about and very inefficient fashion, with the insured subsidising the care of the uninsured. Plus, that way the budget situation of the state won’t influence whether hospitals stay running or not. At the very least, it’d make an interesting social experiment.

    • Matt says:

      “Re: Gallbladder removal. Lay juries suck.”

      Because they reached a verdict in a case you know nothing about?

      • Nurse K says:

        If there were 34-hour waits around here for paying customers, hospital-building types would go nuts with building hospitals, additions to existing ERs, 24-hour urgent cares, and anything else. The trend around here is to build to make the waits nonexistent or very short.

        Matt: They said he supposedly removed a “mass”, thinking it was the gallbladder. Um, okay. “Masses” connected to bile ducts?

      • ERP says:

        I wonder how this was posed to the jury. Also was the sponge misidentified as the gallbladder?

  5. Joe says:

    I’m a little surprised that nurses are still *counting* sponges. That seems extremely prone to error.

    One solution: package sponges in trays of, say, 6 sponges per tray. (Think ice-cube trays, with 6 individual cups per tray.) Used sponges get put back in the trays they came from; nobody is allowed to put sponges directly into the trash. Nurses are only allowed to throw away full trays. A missing sponge will be glaringly obvious, because there will be an empty cup in the tray.

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