WhiteCoat

Healthcare Update Satellite — 10-09-2013

Government getting pissed because providers are beating it at its own game? When feds started pushing electronic medical records and threatening to penalize patient, a funny thing happened … the amount of money the feds spent on healthcare increased by billions of dollars. Now Kathleen Sebelius and Eric “Fast N Furious” Holder are warning that doctors that copying and pasting patient data between patient medical record entries should not occur because it risks medical errors and overpayments. They promise to “prosecute health care fraud” and will “consider future payment reductions as warranted.”
In other words, if you type or write the same thing over and over again, you’re fine, but if you cut and paste you are a prima facie criminal.
When people with no clue about the inner workings of the health care system attempt to create laws regulating the system, increased costs will result.
Medicare recently implemented a rule requiring that full hospital admissions must be reasonably expected to require a “two midnight” stay in the hospital, requiring physicians to certify the medical necessity of such care, and imposing more costs on patients if they do not stay two midnights. Do they really think that there will be less admits? All that is going to happen (and that is already happening) is more thorough documentation of a patient’s condition and comorbidities – which will increase billing levels further and will increase costs. Oh, and look for an increase in the number of new symptoms requiring extended hospital stays if a patient is stable to go home before the second midnight. What’s that, the patient’s pulse oximeter reading suddenly dropped? Let’s keep the patient on telemetry and do pulmonary function testing tomorrow? Whats that? The patient developed chest pain on the second night? Now they’ll have to be admitted another day for serial cardiac enzymes. Spending will go up not down because of this rule. Mark my words.

Oregon surgeon criminally charged and loses her license after patient dies from reaction to anesthetic in doctor’s office during a cosmetic procedure. Doctor faulted for not having equipment in the office to respond to medical emergencies, for performing a procedure in her office at night without staff support, and for failing to respond appropriately to a patient in distress. When another patient experienced dizziness and tachycardia after a cosmetic procedure, prosecutors alleged that the doctor put the patient at “substantial risk.”
State medical board hearings are becoming as serious as medical malpractice lawsuits.

Fascinating case report in the International Journal of Clinical Medicine. Patient suffers from Auto-Brewery Syndrome, otherwise known as Gut Fermentation Syndrome. 61 year old patient is constantly intoxicated without drinking alcohol – sometimes reaching levels of 400. Overgrowth of a certain fungus in the man’s intestine causes fermentation of excess carbohydrates into alcohol. After treating the patient with antifungals and temporarily putting him on a zero carb diet, then re-colonizing the gut with probiotics, the symptoms resolved.
Even more interesting is that the responsible fungus, Saccharomyces cerevisiae, is used to ferment beer and antibodies against it are markers for inflammatory bowel disease such as Crohn’s Disease and ulcerative colitis.
In addition, a related fungus, Saccharomyces boulardii, has been found effective in reducing symptoms of inflammatory bowel disease, irritable bowel syndrome, Clostridium difficile infections, and traveler’s diarrhea.
We have so much to learn about the microbiome in the gut and its effect on human health.

What happens when emergency physicians are routinely pressured to work overtime in high-stress and increasingly complex work environments? They leave. The UK’s NHS is concerned that there will be a staffing crisis in UK hospitals because fewer doctors are choosing to go into emergency medicine and more experienced doctors are leaving the country to practice elsewhere … which will increase the stress on the remaining physicians … which will cause more of them to leave … which will increase the crisis.
Who suffers? Patients.
But at least the care is free.

Interesting topic on Medscape discussion boards. Should a patient who attempted suicide be resuscitated in the emergency department? Or should the patient’s intent be honored?
Even more interesting is that much of the discussion focused upon liability associated with making the wrong decisions.
Another example of how human behavior is shaped by fear of liability.

Healthcare “superusers” are back in the news. This Kaiser article states that 1% of patients are responsible for 21% of all healthcare spending while 5% of patients are responsible for 50% of all healthcare spending. Reducing costs involves integrating their care.

What happens when relatives ask for information about an unconscious patient in the emergency department? Many times they get the “we can’t tell you anything due to HIPAA laws.” Such an assertion is not necessarily true. Disclosures in such situations are permissible, so staff can choose to do so based on their own discretion. But with increasing penalties for HIPAA violations under the HITECH Act, many practitioners choose not to take the chance. And don’t believe this attorney’s statement that “health care providers are only penalized when they act unreasonably.” Even incidental disclosures are subject to statutory penalties (see the HITECH Act link above) and the complaint of a HIPAA disclosure is easily enough to cause a hospital to terminate a healthcare provider’s job.
An example of what happens when we try to regulate (and or sue) our way to better health care.

According to this article in the American Journal of Emergency Medicine, more than one third of pulmonary emboli have a delayed diagnosis in the emergency department. Factors associated with misdiagnosis in patients admitted to the hospital included chronic pulmonary diseases such as asthma and COPD. Factors associated with misdiagnosis in patients sent home included fever, coughing up blood, and infiltrate on chest x-ray.

Wait times an issue in hospital emergency departments all over the world. Number of admitted patients waiting more than 24 hours to get a bed in Australian hospitals nearly triples in the past year.

An app to notify the emergency department about your symptoms before you arrive? I think this is a total waste of money. It is highly unlikely that there is going to be any ED “preparation” for a patient before the patient arrives. In many cases, the patients will be lucky if there is a bed available. And if forced to answer phone calls, all that will happen is that providers will be taken away from caring for other patients. While I think it may be an idea of limited utility, the docs who created the system and then sold it to Aetna are laughing all the way to the bank.

More on patients gone wild. St. Louis area’s St. Mary’s Hospital has had three attacks on emergency department nurses in two weeks. Two of the cases involved intoxicated patients.

15 Responses to “Healthcare Update Satellite — 10-09-2013”

  1. John Payne says:

    You disagreed with my statement regarding HIPAA that “health care providers are only penalized when they act unreasonably.” I challenge you to find a case where a doctor was penalized for discussing an unconscious or incapacitated patient’s medical condition with a friend or family member when the doctor reasonably believed that providing information would be in the patient’s best interest.

    • WhiteCoat says:

      “I challenge you to find a case where a doctor was penalized for discussing an unconscious or incapacitated patient’s medical condition with a friend or family member when the doctor reasonably believed that providing information would be in the patient’s best interest.”

      I agree that penalties in the above scenario are unlikely, but that’s not the statement you made. You said that “health care providers are only penalized when they act unreasonably.”

      Now go click on the link to the HITECH Act that I provided to everyone in the post, scroll to the top of the third page, and read about the regs before you complain. No, in fact, don’t bother. I’ll paste the pertinent language for you all nice and pretty.

      the Secretary shall (the word “shall” means that the penalty is not discretionary) impose on any person who violates a provision of this part … in the case of a violation of such provision in which it is established that the person did not know (and by exercising reasonable diligence would not have known) that such person violated such provision, a penalty for each such violation of an amount that is at least the amount described in paragraph (3)(A) but not to exceed the amount described in paragraph (3)(D);

      Read down a little further on the page and you’ll see that the stated penalty is between $100 and $50,000.

      In other words, even HIPAA violations that were unknown and, when acting reasonably could not have been known, are subject to a mandatory fine of between $100 and $50,000.
      That doesn’t include all of the non-statutory penalties, either.

      Any more legal questions that this doctor can answer for you, counsel?

      • Elmo7@yahoo.com says:

        Sadly this is just another example of a law screwing up it’s intended effect. How many times have I as a treating MD been unable to obtain records due to a clerk or administrator at another institution refusing to release them (even though as the treating MD I have every right to them as per the law)? More times than I can count, so I easily see how it happens to families. Personally, I and I am sure most docs would talk with the family. Frankly, I tend on focus on the right thing to do for my patient and ignore the legal system that is fucking up healthcare.

  2. Skeptical Scalpel says:

    I enjoy your posts. We think alike most of the time.

    I want to point out that the Oregon “surgeon” who lost her license after the death of a patient is actually not a surgeon. Her bio on her website (http://www.drsorayaabbassian.com/bio.html) states that she was trained in internal medicine only.

    I think it’s important to set the record straight. She should not have been doing surgery at all.

    • WhiteCoat says:

      I agree with you that internists should not be performing major surgeries in offices and believe that traditional liposuction falls within that category.

      However, there is a big difference between doing a colectomy and suturing a wound – both of which are considered “surgery.”

      Minor surgeries are not that hard to learn and I don’t think they are – or should be – outside the realm of non-surgeons. I’m not going to debate effectiveness because I don’t know enough about them, but should modalities such as laser lipo (which is advertised at ED educational conferences), “lifestyle lifts” and mesotherapy be restricted to only those practitioners who have completed a surgical residency?

      The article doesn’t specify exactly what the doctor was doing, but the fact that the medical board didn’t disclose the specifics of her alleged transgressions leads me to believe that the procedures the doctor was performing were probably on the “wound suture” side of the spectrum rather than the “colectomy” side of the spectrum.

      • Skeptical Scalpel says:

        According to another report, the decedent’s family said she was to have undergone a “tummy tuck.” That is not minor surgery. (http://www.dailymail.co.uk/news/article-2419984/Oregon-doctor-Soraya-Abbassian-pleads-contest-death-employee-gave-free-tummy-tuck.html)

        My quibble here is the identification of the doctor as a “surgeon.” She is not a surgeon. She is an internist who thought she could do surgery. She missed the part about the potential toxicity of xylocaine.

        Question: As an ED MD who performs many procedures, do you call yourself a surgeon?

      • WhiteCoat says:

        Agreed that the classic “tummy tuck” is not a minor surgery. But if it was a “laser lipo” that they were calling a “tummy tuck,” then I maintain my position. Notice how your cited article says that “no incisions were made.”

        I haven’t read every article on the topic, but was the internist representing to the public that she was a surgeon or were the news reports calling her a surgeon because she was doing the cosmetic procedures? Again, big difference.

        Do I call myself a surgeon? Are you kidding? Why would I want to lose all of my friends, have my wife leave me, and forsake all respect from the hospital staff? ;-)
        OK, you have to admit. You set yourself up for that one.

    • Mike T. says:

      Non-surgeons perform surgery, but they shouldn’t be called surgeons just because they do surgery.

      Otherwise, those nurses, midwives and physician assistants who do abortions in the states that allow that could call themselves “surgeons”. And they’re not.

      (Although I have no doubt that the nurses already introducing themselves as “Doctor” because they have a PhD in nursing, would love to introduce themselves as a “surgeon” because they’re allowed to do abortions).

  3. Matt says:

    What was the problem that HIPAA was designed to fix?

    • VA Hopeful says:

      I’ve often wondered that as well. If you read the HHS website about the very question, the answer reads like a combination of “Each state had different laws and 1 standard was needed” and “with more and more EMRs out there, we needed rules that covered electronic records”.

      http://www.hhs.gov/hipaafaq/about/188.html

  4. SeaSpray says:

    I can’t read the article, but will share my thoughts anyway.

    YES – save the person from their suicide attempt and get them into mental health facility!

    I didn’t read the article – but I think there has to be many people who are grateful they didn’t succeed. I can think of 3 in my personal life. (all went on to have good, full lives and 2 of them have been such blessings to other people in so many ways …probably saving a few lives too. I remember that I commented on this in your other blog some years ago.

    I think sometimes people really don’t want to die …but that they just don’t know how to live in or get out of their bad circumstances. But we never know what is around the corner. Sometimes the sun just has to come up the next day. And I don’t mean to trivialize it in anyway, but something can happen to give them encouragement and they’d be grateful for another chance. Counseling is in order, but SAVE them.

    One of them …I met after she went thru these things became a best friend and mentor of 29 years and I am a better person for having known her. She became a counselor in the later years of her life. I remember she once told me that we meet people at the level of our brokenness. And sometimes it is the wounded person who can best facilitate healing in another …at least in certain circumstances. The other is an elderly woman I call my spiritual mom who has blessed so many people. She was 28 at the time and has just said she didn’t know God back then and everything changed when she did …soon after. She is so POPULAR at 84 and we should all live to have a full, quality life as she does. I LOVE when she leaves a cheerful, encouraging message – which is always. And the third one was so young, I don’t believe really wanted to but was an immature/desperate act that I know she regretted and went on to marry, have several beautiful children and is still raising them all beautifully today and has her whole life ahead of her.

    I had a HS classmate kill himself one night by closing the garage door and lying under the car. they said it was over the breakup with his girlfriend. he was so popular and well liked and had his whole life in front of him. if only there was intervention.

    How sad that worry about liability should even enter into the decision to save someone’s life. And wouldn’t that go against the Hippocratic oath?

    • A. Noni Mouse says:

      The suicidal patient’s intent should be honored.

      Dang meddling thought police!

      Yes, over twenty years later, I am still upset that I was stopped. Also, for the second time over fifteen years ago. Two stays on the psych ward. Dang meddling thought police!

      Too disabled to work, but not disabled enough to qualify for any assistance.

  5. Mandy says:

    Not related to this round-up, but perhaps a tip for your next one:

    Prosecutors May Seek Death Penalty for Pain Clinic Doctor, Even Though They Probably Can’t Convict Him

    Florida, of course!

    • Mandy says:

      As an addendum, the Sentencing Law and Policy blog rather likes this precedent:

      As this very post reveals, simply mentioning the possibility of a death sentence ensures this case gets a lot more attention, and that attention should (and likely will) lead many more doctors in Florida and elsewhere to be at least a bit more careful when writing scripts for potent and potentially lethal prescription drugs. In addition, as in many other cases involving lots of human carnage, the prospect of capital charges might encourage a guilty defendant to plead guilty to lesser (and more fitting) charges.

      Lawyers, it would appear, are great fans of show trials. Pour encourager les autres.

      For doctors, at least. I’m not sure how’d they’d go if someone recommended “off with their heads!” show trials for lawyers.

  6. eqvet2015 says:

    I guess I’m behind the times…what exactly was the “two midnight” rule supposed to fix?

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