WhiteCoat

Healthcare Update Satellite — 8-21-2013

Look for more updates on my other blog at DrWhitecoat.com

Judge orders Colorado family to pay $340,000 in legal fees after losing the medical malpractice suit it brought against a hospital.
The family plans to declare bankruptcy. The family’s attorney, Stacy Warden, alleges that the hospital lacked compassion for “going after a family with a severely disabled child.” If attorneys file frivolous cases, perhaps the attorneys should be on the hook, not the families …

West Virginia couple is suing a physician for failing to diagnose an epidural abscess that later rendered the patient with permanent paralysis, in addition to other physical pain and suffering.
The details of the case aren’t provided, so the comments below are not necessarily related to this case.
However, just consider …
Spinal epidural abscesses present as either neck or back pain in 70-100% of cases. Fever and neurologic deficits accompany the pain in only 10-15% of initial presentations.
CT or MRI of the spine is the only way to diagnose this disease process and early diagnosis is important to a good outcome.
But the American Academy of Family Physicians and the Choosing Wisely campaign state that CT or MRI for acute low back pain is “often a waste of money” and probably not needed unless there is “a history of cancer, unexplained weight loss, fever, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.” Remember … these symptoms are present in only 15% of patients with spinal epidural abscesses.
Therefore, according to the AAFP and the Choosing Wisely campaign, it should be “unnecessary” to diagnose the 85% of spinal epidural abscesses that present with only acute back pain.
Yeah, that logic didn’t work too well with me, either.

Want a *brief* look into a day in the life of an emergency nurse … since certain other emergency nurses aren’t blogging any more? Here’s a local newspaper’s brief overview.

SAMHSA study (.pdf file) shows that emergency department visits due to nonmedical use of prescription stimulants and caffeine pills increased fourfold between 2005 and 2011.

Another hospital starts collecting payments at the time of a patient’s emergency department discharge. Wonder what happens if patients don’t pay …

Number of emergency department visits from magnetic foreign body ingestions increases fivefold between 2003 and 2011. The government already put buckyballs out of business due to safety concerns. The only logical conclusion is to criminalize the manufacture of any magnet smaller than the size of a child’s mouth. Come on, Joint Commission. You’re dropping the ball here. Our childrens’ safety is in jeopardy.
Next stop: Outlawing credit cards. Those magnetic stripes could KILL a person!

What happens when you pass laws to provide medical insurance to everyone? Emergency department visits increase. Massachusetts Medical Society President notes that when people have medical insurance and they don’t have a primary care physician, they “go to the emergency room.” Same thing can be said when people have medical insurance and their physicians won’t take their medical insurance because it pays less than the cost of care for the patients. Not that that would ever happen …

The rhetoric is getting old already. Your doctor is a worrywort, therfore you may end up getting “unnecessary” tests and paying for lots of expensive tests. But if your doctor misses a diagnosis because he didn’t order the “unnecessary” test, he’s a flaming idiot and should have his license revoked.
Harvard law professor Michelle Mello, who commented on the article, says that mediation in front of a judge would reduce defensive testing because it would reduce the stigma of being accused of malpractice and negligence. Just goes to show you that just because you’re a Harvard professor doesn’t mean that you know what you’re talking about. Doctors still have to report all claims – mediated or not – when applying for hospital privileges or state licensure, and any payments on a physician’s behalf get reported to the National Practitioner Databank – which is queried every time that a physician seeks licensure, insurance, or hospital privileges.
But thanks for spreading the misinformation, professor.

18 Responses to “Healthcare Update Satellite — 8-21-2013”

  1. SteveM says:

    … as opposed to the status quo where patients don’t have insurance,… and go to the Emergency Department. I have to say getting paid a little bit of nothing from these insured patients, sure beats getting absolutely nothing from the uninsured ones.

    • Cait says:

      Not everyone without health insurance is destitute, and therefore not everyone without health insurance who uses the emergency room is going to get away without paying for it.

      At the moment, there’s a huge incentive for the non-destitute uninsured to use urgent care centers or Doc-in-a-boxes (Walgreens, CVS, etc) or the like rather than ERs, because since if you have a job, any assets, or a credit rating you don’t want wrecked, you want to do everything in your power to avoid ending up at an ER and being socked with a super-sized ER bill which you WILL have to pay.

      At the moment, I’d say most of those who have no salaries to garnish, no assets to seize and no credit rating to wreck, are probably so poor that they’d be eligible for subsidized medical care even before Obamacare was invented. Lots of people are eligible for Medicare, Medicaid or CHIPS or the like but just can’t be arsed to sign up for it. They’ll still be eligible for those same programs under Obamacare, but somehow they’re now going to sign up for them?

      BUT, all the uninsured who actually do have assets to attach, wages to garnish, etc, who are currently careful about not over-using care because they’re paying for it out of pocket, will suddenly have insurance, and if going to the ER rather than a Doc-In-The-Box bears no financial penalty because the ER is “covered” under their new insurance, well of course they might start using the ER instead.

      Really I think the idea that the uncompensated care hospitals currently give away to the very poor who are already eligible for some program or another but just haven’t bothered to fill in the paperwork, is suddenly going to become compensated care because the same people who couldn’t be arsed to sign up for Medicare/Medicaid/CHIP //last// year are suddenly going to be diligent about signing up for Obamacare //next// year, is more than a little naive.

      The big change I *DO* see, is that people like I used to be, who made a decent salary and probably could have afforded insurance if they’d made it a priority, but they figured they were young and healthy enough to come out ahead by just paying out of pocket for occasional care as needed… well those people used to avoid the ER if at all possible because they knew it was hella expensive, and they wouldn’t be allowed to walk away from their bill. But once they have insurance, and “someone else” is picking up the tab, well why not? Plus, once you’re paying for insurance, you start feeling “entitled” to get whatever you can get out of it.

      Adding 30-50 million people to the insurance rolls **IS** going to create a huge base of newly insured who will now feel that they can use ERs without impunity.

    • WhiteCoat says:

      The study showed that the ED visits increased when patients had insurance. Not so much a commentary about payments as it is about how presence of “insurance” affects utilization of medical services.
      As for some payment for more patients being better than no payment for fewer patients, considering increased malpractice liability, increased charting, increased patient volumes, decreased patient satisfaction from increased wait times, and other intangibles, some people may disagree with you about the “something is better than nothing” sentiment.

      • SteveM says:

        You will see them one way or the other. I would rather be paid $10 for a level 3 now, than be stiffed for a level 5 a year down the road.

        Now to be fair, I suppose it depends on your practice location. I am in a rural area with a lot of old Germans who only allow themselves to be dragged in when they are missing a limb. If your patient mix is heavy on drug (narcotic and antibiotic) seekers and the like, then I will concede your point.

  2. JustADoc says:

    What are the odds of an epidural abscess in a pt with no history of recent infection or spinal procedures/injections or ‘a history of cancer, unexplained weight loss, fever, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.
    Your 10-15% only covers 2 of the above things. There are 9 things listed. Add recent spinal procedure and that is 10.
    If you have multiple case histories of epidural abscesses in patients without any of the above, I’d be interested in seeing them.
    In additon, I believe the ACR had a similar rec. That’s the radiologists BTW.

    • WhiteCoat says:

      First of all, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs can all be grouped into “neurologic deficits.”
      Cancer history and unexplained weight loss may be “red flags” for back pain, but are not predictors of epidural abscess.
      The only factor not mentioned in the Choosing Wisely criteria is “recent infection”. So the 10-15% covers almost all of them.

      The odds of an epidural abscess are small regardless of the presentation. Medscape quotes 1-2 cases per 10,000 hospitalizations – which is different from number of cases per patients with a chief complaint of back pain. That’s not the point I’m trying to make.

      Although rare, epidural abscesses exist, it is impossible to diagnose an epidural abscess without advanced imaging, and doctors get sued for missing the diagnosis. If we now pressure medical providers to avoid performing “unnecessary” tests in patients with back pain, then the disease is going to get missed even more often. You may be OK with that … until you’re the one in however many thousands of patients who complained of acute back pain and is now sitting in a wheelchair because the “unnecessary” lumbar spine MRI wasn’t done in a timely fashion — perhaps like the WV fellow in the article.

      BTW – the ACR recommendations for Choosing Wisely are here. They cover CTs of the head and chest, but not the back.

  3. JustADoc says:

    I notice you didn’t comment on the history of recent spinal procedures. And while you downplay all the other red flags(which I agree are more neurologic risks or metastatic risks) you don’t concede that recent infection is a pretty big player in risk for epidural abscess.

    Look, I agree that medical mal and defensive medicine plays a hige role in costs and ‘unnecessary’ tests. But, and this hurts me deeply to say this, if you are going to argue that any test that may show a disease that has a 0.01-0.02% rate of occurence(per the oddly useless rate quoted above), then maybe Matt is right that our arguments about defensive medicine are weak if one is willing to defend anything without actually seeing the case notes.

    BTW, here is a link to ACR’s LBP imaging recs: http://www.guideline.gov/content.aspx?id=35145#Section420

    Of note, for acute LBP with no red flags any imaging is ‘usually not appropriate’. later on they talk about recs when infection is a concern along with other conditions.

    • WhiteCoat says:

      I’m sure that recent infection increases the risk for epidural abscesses. I don’t know how much, but I know that the correlation isn’t 100%. You’re still missing the point.
      We as a profession and a society have to decide what is and isn’t appropriate regarding testing, but we also have to match the ends with the means. Maybe it isn’t appropriate to go chasing a rare medical diagnosis like a spinal epidural abscess – using whatever definition we want to use for “rare”. But if that is the case, then there should be complete professional/civil/criminal immunity if the same rare diagnosis is missed.
      The problem is the disconnect: You’re a bad doctor if you order the “unnecessary” test, but you’re also a bad doctor if you miss the diagnosis because you didn’t order the test. Until we change that mindset, defensive medicine will persist.
      Many doctors fear the bad outcome and won’t risk a miss when patients expect the testing and will sue them for millions if the diagnosis is missed – even if the chance of such a miss is small.
      All the recommendations and Choosing Wisely bullet points in the world aren’t going to change that fear.
      In fact, that gives me an idea for another poll.

      • Matt says:

        “But if that is the case, then there should be complete professional/civil/criminal immunity if the same rare diagnosis is missed.”

        Well, will you give the opposite then? If those guidelines are ignored or not followed, you admit liability and the only argument is the amount of damages?

        Everyone fears a bad outcome in everything they do. The defensive testing argument remains a canard, though, simply because all of the “cures” proposed for it never work. I don’t know why we still talk about it as if there is some mythical key to billions in savings if we just change this or that in the legal system.

        Being sued, even successfully, doesn’t mean you’re a “bad doctor”. It means there is a disagreement about whether you made a mistake and/or the damages flowing from it. I realize that’s a fine point, but it’s one you intellectually ought to be able to grasp, even if it’s emotionally difficult when the process server shows up.

  4. VA Hopeful says:

    I thought the Choosing Wisely campaign was more geared at getting patients to stop asking for things that don’t help – antibiotics for colds and what not.

  5. Matt says:

    ” If attorneys file frivolous cases, perhaps the attorneys should be on the hook, not the families …”

    Was the case frivolous? So if the defense spent $340,000, and it’s a lot easier to find defense experts than plaintiff’s, that must have been quite a “lottery” the plaintiff’s were playing.

    • WhiteCoat says:

      I never said the case was frivolous. You need to read closer. And perhaps look up the meaning of the words you use. I’m not sure that you know what “lottery” means.

      • Matt says:

        Note the question mark at the end of the sentence. I was asking. It appears it is you who needs to read closer.

        I’ve never played a lottery that cost $340,000 to play and had an average payout of around $300,000. Have you?

  6. SteveM says:

    Did their attorney provide “informed consent” that they would be liable for any plaintiff fees and inform them ahead of time of the exact amount that they would be liable for? If not, it seems to me that Warden committed malpractice.

    • Matt says:

      Just in case, let’s get them some “reform” to save the malpractice carrier from the excesses of a crazed jury ready to hand out billions to a sympathetic plaintiff.

  7. Ian Random says:

    I actually agree with the verdict in the malpractice case. Hopefully, the family will bring suit against the manufacturer of the faulty reproductive track and all the subcontractors. Technically, you don’t start to rot until 4 hours after death. It is the disruption of oxygen that causes cells to think they are cancerous and commit suicide which causes the damage. That is why they are researching reperfusion. Also the brain appears to lack the clean-up antibodies to allow recovery from injuries which is lost in the stem cell funding debate.

  8. SeaSpray says:

    Do they mean the smaller copay for using the ED or the actual balance of the large ED bill?

    I know you can’t ask for payment before a patient is to be seen, but we were allowed to ask for the smaller co-pays on insured patients when registered. Most patients didn’t have money on them. But some agreed to pay up front. I’m guessing that since it was after treatment they were already looking to get paid for treatment.

    Our hospital did get aggressive with trying to collect money from inpatients. I felt sorry for the elderly patients who were scared and worried about the bill while STILL an inpatient. And it also happened to an elderly aunt of ours. All she had was MDCR and that was not covering the costs she had accrued at that point. Fortunately, she did qualify for the state financial assistance.

    I think it was wrong to lay that on inpatients. For ED – worth a try. I can appreciate it is a business and hospitals have difficulty in getting paid.

    But hey ..with the AFFORDABLE CARE ACT …everyone will be happy now. Right?

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