WhiteCoat

Healthcare Update Satellite — 11-14-2013

See more news from around the web over at my other blog at DrWhitecoat.com

An example of the downside to government-run health care. Patients in Venezuela can’t get proper medical care. 300 cancer patients were just sent home when supply shortages and “overtaxed equipment” made it “impossible … to perform non-emergency surgeries.” 70% of the radiation therapy machines are inoperable. Basic supplies such as needles, syringes, medications, operating room equipment, X-ray film, and blood needed for transfusions are all in short supply. There is no anesthesia for elective surgery. Patients can no longer get organ donations or organ transplants.
The most important point in the article is that Venezuela’s constitution guarantees free universal health care to its citizens. They don’t just get government-mandated health “insurance,” they get free health care … and look what happens.
We need to be very careful about what type of health care system we ask for in this country. The government that has the power to give everything to you also has the power to take everything away from you.

Another example of what can happen with “free” medical care. Don’t have a heart attack after 5PM on weekdays or any time on weekends in Kaslo, British Columbia – the ED is closed. If your body doesn’t pay attention to those hours, you’ll have to travel an hour over mountainous terrain to get to the next closest hospital. Hope there’s no snow.

Interesting study in Annals of Emergency Medicine showing that sending daily text messages to poorly controlled diabetic patients improved medicine compliance (.pdf file). There was no statistical change in the HbA1c, but patients receiving text messages used the EDs less than the control population and patients actually liked receiving the messages. Kudos to the investigators for thinking outside the box.

LA County Medical Center board approves $7.5 million settlement to formerly homeless patient after patient was discharged from labor and delivery department at 39 weeks gestation with abdominal pain without being evaluated by obstetrician. Patient returned 12 hours later with ruptured uterus and child born with severe brain damage.

Idaho man suffers broken ribs after being hit by drunk driver … while playing cards in his living room. But there’s more to the story. The man’s dog went missing after the accident. A town resident found the dog wandering … near the emergency department of the hospital where the patient was taken. Happy and amazing reunion.

Entering the emergency department with atrial fibrillation? You have a 69% chance of being admitted according to this American Journal of Cardiology study.

Patients gone wild. Arizona man arrested for being aggressive with emergency department staff and trying to bite a male employee several times. Must have been a full moon.

Patient at Chicago-area Riveredge psychiatric hospital hangs herself with bedsheet. Hospital cited for putting patient in a room with a 7 foot ceiling and having the wrong type of vent covers which placed the patient in danger of “immediate jeopardy” by making it possible for the patient to hang herself.  Beware the bad outcome.

Another reason not to practice medicine in Florida. Predicted medical malpractice loss ratios in Florida for 2014 are highest in the nation – and more than nine times greater than the predicted loss ratios in states such as Indiana and Minnesota. Pennsylvania comes in second highest on the predicted loss ratio list. Check out the link a the top for other reasons not to practice medicine in Florida.

A pair of settlements paid by Iowa State underscore two important points. First, lumbar punctures are not complication-free. One 69 year old patient received $1.75 million after a lumbar puncture left him paralyzed in his lower extremities. In another non-medical case, a patient was awarded $125,000 for a retaliatory discharge from her job after she filed a workplace violence complaint. If hospital administrators take action against ED staff members for complaining about patient violence, there can be liability for doing so.

21 Responses to “Healthcare Update Satellite — 11-14-2013”

  1. David says:

    Interesting comment about the Kaslo, BC Emerg closing, not to mention very misleading.

    Kaslo has a population of 300. I wonder how many communities in the United States that have populations that low have an 24 Emerg?

  2. Mark says:

    The patient in the “Violent ER patient goes to jail” really didn’t want to be a patient.

  3. Pär Areskoug says:

    Regarding the first link about Venezuela and government-funded healthcare:

    How is it worse to have free healthcare for everyone and then having to revoke some than having a default setting of not providing everyone care? Obviously it backfired in Venezuela, but are you really comparing USA to Venezuela in terms of economy? If you look at for example my country Sweden, where I work as a doctor, we have a universal healthcare-system funded by the government and we have substantially lower healthcare costs than in the USA…

    http://www.oecd-ilibrary.org/social-issues-migration-health/total-expenditure-on-health-per-capita_20758480-table2

    • Gordon says:

      Sweden is a tiny little monarchy, a bit bigger than California but with only about a quarter of the population, less than 1% of which is black or hispanic.

      It is simply inappropriate to compare their outcomes to ours.

    • VA Hopeful says:

      You also have a healthier population

    • WhiteCoat says:

      The difference between Sweden and the US is that Sweden provides “healthcare” while the US provides (and will soon force everyone to purchase) “insurance”.

      The point of the post is that the US government wants us to believe that the new system of “insurance for all” which will necessarily morph into “single payer” is a panacea for what ails our current system. It is not. When costs are greater than income, the Golden Rule applies: He who has the gold makes the rules. A system in which everyone had “free” healthcare and now in which basic medical needs are not met is not one to emulate.

      Regarding comparing economies versus medical care, Sweden may have universal health care and lower costs, but there are many other variables that need to be addressed before comparing systems to see which one is “better.” Industry overregulation, lawsuits, education costs, reimbursement are just a few. You and other commenters noted additional variables below.

      Sweden may very well have a better health system than the US. With a responsible government, single payor may work. My point is that with an irresponsible or financially insolvent government, single payor may be a disaster. Venezuela is one example of what could happen.

      Sweden’s debt is 160 million Euros and has been steady for more than 10 years. Our debt per capita is about four times that of Sweden and is growing significantly. How well would Sweden’s health care system work if its debt was suddenly quadrupled and rising?

      On another note, I would sincerely appreciate it if you would be willing to write a post describing how the health care system in Sweden works. I am always interested in how health care systems work in other parts of the world and would be happy to post any comments that you had regarding the pros and cons of the Swedish system.

      • Pär Areskoug says:

        Thank you for your comments!

        As you say it seems like it´s rather the whole american system that should be adressed rather than single issues. Quite hard to do though..

        I can try to describe the Swedish system in a short summary:

        Everyone of our patients are listed at a primary care center which is “responsible” for that patient. They do basic follow up for non urgent and semi urgent conditions (as I´m sure they do in the US).

        Then we have the hospitals with the wards, emergency department and specialist clinics with their receptions. Patients need a referal to the specialist receptions but not to the ER, hovewer we have nurses (and sometimes doctors) doing triage. Every visit to the ER costs about 25-30 US dollars but there´s a maximum cost for all care you recieve of about 150 dollars/year. The same goes for medications, about 150-200 dollars/year is max and the rest is funded by the government and the “regional government” (regional politicians elected every 4 years who runs the healthcare, collective traffic etc).

        We do have some private practitioners and a few private hospitals, but not many. And these facilities often have deals with the regional government which means they work the same as the non-private ones.

        For us doctors we have to do 1,5 years of practice in several areas (medicine, surgery, orthopedics, psych and general care) before our license. Then we can start residencies. I don´t think we earn as much as you in america, but we seldom have more than 40 our weeks.If we make a mistake at work it´s either taken care of internally or reviewed by a commitee who can suspend us or give warnings.

        Long post, but I hope it gives some insight in our system

        cheers

      • WhiteCoat says:

        So I have some questions about the Swedish system based upon what you’ve written.
        What happens if a patient comes to the emergency department and doesn’t have the $25? We have long debated using a “co-pay” for the emergency department in this country, but the law here says that patients have to be evaluated to make sure they don’t have emergency medical conditions and leaves little recourse if patients don’t pay their bills.

        Does the maximum out of pocket cost for medications cover all medications – for example, even expensive chemotherapy drugs? Are there any prerequisites to obtaining expensive medications?

        If a patient is a victim of malpractice, how is the case handled?

        Who pays for medical education and how much does medical school cost?

        I assume that the government docs are salaried. How is overtime handled? For example, trauma surgeons. What about holidays and weekends?

        How are private physicians paid?

        Obviously if the government pays for care, then the money comes out of taxes. What is the tax rate in Sweden?

        Finally, are there differences in care between poor patients/middle class/upper class?

        I could ask you questions all night. I very much appreciate you taking the time to answer these. It isn’t often that we get an accurate look at how the medical systems in other countries work.

      • Pär Areskoug says:

        Patients doesn´t have to pay up front, they can also get a bill sent home (and some just doesn´t pay at allnut thats another matter). Every patient will get evaluated either by a triage nurse who refers them to a primary care center, refers them home with simple advice or lets them in.

        Not all medications are covered by the cost-reduction system, but most of these are drugs like strong anti-coughing medication. Patients never have to pay for expensive drugs such as chemoterapy, either it´s financed by experimental trials or by the hospitals budgets (given from the government).

        If malpractice happens the patient and/or the hospital reports it to the government branch “socialstyrelsen”, which then decides how to proceed (using experts of course). Patients can´t sue a doctor (there´s very little suing in general in Sweden),but they can sometimes get payout from special funds if they´ve had serious damage.

        Medical school is free all the way through, all educations in Sweden are free (unless you come from outside EU and some other countries). However you need top grades in our hig shcool to get in, up untill recently maximum grades in every subject.

        Yes of course all docs ar salaried ;). We have a standard pay per month (I´m a junior doctor and i earn about 4100 US dollars/month) and of cours it rises quite a bit further along. I think the avarege salary for a doctor is about 7500 dollars/month. Private physicians tend to earn more, I can´t say how much though.

        Our tax system is in principal that you pay 31 % of your salary if you earn below 64 000 dollars/year. If you earn more it´s another 20% increase (roughly spekaing, there are quite a few subtractions that can be made).

        Naturally we have to work overtime as well. The basic principle is that we get whats called “compensated leave”, i.e we get time of work based on how many hours we´ve been on call during a night/weekend/holiday.

        We also have 4-6 weeks of fully paid leave every year, in addition to 80% payment fromday 2 if we are sick (same for everyone in Sweden).

        Finally, unfortunately there are not supposed to be differences between the care upper and lower class people get. However better educated people tend to know more and sometimes demand more, which probably means they end upp getting better care. And our current right-winged government is slowly working on allowing more private care, which I´m afraid will increase the differences further, even though we´re not there yet

        This was really interesting to reflect about the system. Could you perhaps give a short description of the american medical system? I have ageneral idea, although not any direct insights into it

      • WhiteCoat says:

        I’ll have to put up a post about the basics of health care in this country. I never considered how many people visiting this blog from other countries may have no idea how our system works.
        Too much for the comment section.

  4. Pär Areskoug says:

    Yes we have a healthier population, and I think it´s safe to say that our universal healthcare system is the major reason for that.

    And yes our population is less heterogenic and smaller than yours, that´s a very valid point. Nevertheless I don´t think it´s inappropriate to compare our results, clearly your system creates bigger inequalities and is clearly more expensive. Not to mention the lawsuits. My point is not to brag about Sweden or rack down on the american way (after all much of our knowledge comes from american research), but before you just discard our Swedish system (or any government-funded system as in this example) as expensive or restrictive, please think twice

    • David N says:

      I’ll add another difference. The Swedish government is responsible and competent and ours is clearly not.

    • VA Hopeful says:

      Your universal system doesn’t (and couldn’t) change the terrible dietary habits, substance abuse, and morbid obesity I see in the majority of my patients.

      I don’t doubt that those same patients would get good care in Sweden, but its those same patients bankrupting the American system – and I suspect they would do the same to yours if we gave you enough of them.

      • Pär Areskoug says:

        Also a valid point. However I think a big reason for our different types of patients stems from the big differences in economic equalities and education between our countries, which of course isn´t a strictly medical problem. Although something a government should be adressing

  5. Texophilia says:

    If you have a heart attack at any time of day in South Lake Tahoe, California, you’ll be traveling an hour across mountainous terrain because our local hospital doesn’t have cardiac facilities. And?…

  6. NCDoc says:

    “Another example of what can happen with “free” medical care. Don’t have a heart attack after 5PM on weekdays or any time on weekends in Kaslo, British Columbia – the ED is closed.”

    Wow, that is so misleading it’s almost yellow. This is a rural town of 300, which is clearly stated in the article. In NC we have much larger towns where the transport is well over an hour to the nearest ED.

    I like EP Monthly, but why they are giving a blog spot to an anonymous physician who is make such wild misrepresentations it beyond me. Credibility comes form two sources, individual reputation and quality of work. Dr.Whitecoat and EP Monthly has provided us with neither in this case. And before the comments start, no I am not some socialized medicine activist, I just really dislike misleading journalism.

  7. WhiteCoat says:

    So three people are upset because I linked to an article about how a small community is losing its emergency services and warned people not to have a heart attack there after business hours.

    First of all, the article stated that 300 people attended a meeting, not that the town’s population was 300. The population of Kaslo is 1,087.

    The point of the comment was to illustrate what may happen when a single “payor” suddenly deems that your community (or condition, or age, or any other demographic you want to use) isn’t worth paying for: You no longer get the care to which you are accustomed.

    Texophilia: Comparing a community where the ED is closed for 16 hours a day to a community where the ED is always open but doesn’t have cardiac facilities isn’t a fair comparison.

    NCDoc: Having an anonymous commenter deride me for being anonymous, then misrepresent the population of a town while telling me that I’m the one misrepresenting things, then call me low quality, misleading, and “yellow” for linking to an article that illustrates the point I was trying to make … well, that’s a new low in my 7 or so years of blogging.
    Congrats on the ad hominem attack with no substance or explanation of why I am allegedly low quality, misleading and yellow. You want to tell everyone more about the wild “misrepresentation” I made or are you just going to fold your arms, feign offense, and pout some more?

    • NCDoc says:

      I think the comment is still valid for a town of 1087, though I admit that was sloppy on my part. As for anonymity, I’m not publishing opinion pieces on a major ED newsletter website. You being anonymous on a blog is one thing, but allowing anonymous opinion pieces on a prominent publication is not generally considered best journalistic practices. It reads as yellow because you are using selective antidotes to with wild claims about the consequences of “free” medicine in an attempt to say users towards a politically charged viewpoint, this is colored even further by the fact that withholding your identity makes it impossible for people to look at questions like conflict of interest. Again, fine for a personal blog, not so good for a reputable publication. If you want to compare health outcomes in “free” and “not free” systems using validates data, that would seem to be a more journalistically valid approach. Does health-outcome data support your point? Are populations in Canada less likely to have nearby ED access than in the US? Looking at real data would feel like high quality journalism, making somewhat sensational claims based upon single anecdotal accounts does not.

      • WhiteCoat says:

        This wasn’t an “opinion piece,” Einstein, it was a comment with a link to an article. Your comments have more “opinions” than my post, so your logic backfires. I keep anonymous so that when I write stories about patients, there is less likelihood of people working backward from my identity and then identifying a patient I have written about.

        Do tell me about the potential “conflict of interest” involved in bringing to people’s attention the fact that a government can choose to stop providing emergency services if it deems a group of people insignificant enough.
        Maybe I’m a bookie in Las Vegas who is betting against the ED closing. Or maaaaybe I’m the owner of a life insurance company who insures the whole town of Kaslo and I want them to live until their policies expire. Curses. You’ve foiled my plot.

        You’re right, I do get to select my anecdotes (not “antidotes” – this isn’t a tox debate) to illustrate the points that I wish to raise. That’s the benefit of me writing the blog. You want to select antidotes important to you, go write your own blog. I’ll even link to it. Then I’ll make fun of your opinions.
        In the meantime, if you disagree with the points I’m trying to make, the better approach might be to raise factual issues to rebut them. Calling me “yellow”, “misleading,” and saying I’m making “wild” claims are things I’d expect from a third grader. OK … maybe from a seventh grader. Definitely not high school. Too immature for high school.
        So what about my comments was “misleading”, doctor? What about the comment was a “wild claim”? Are you alleging that the hospital isn’t closing during the nights? Are you alleging that people won’t have to travel an hour to the next closest hospital when Kaslo’s hospital isn’t open? Maybe the care isn’t “free” in a figurative sense? That’s why the quotes were there and why it followed the Venezuela article, but I recommend you go with that one. It’s your best shot at saving face.
        Don’t go off jousting with your little strawmen, either. Neither I nor the article said anything about “health outcomes.” Neither I nor the article said anything about whether there is more “nearby ED access” in US vs. Canada. The point of the comment was clearly intended to show how government controlled healthcare can be taken away at any time by the whims of the government.

        When you want to put on your big boy pants, stop calling names, and have a rational debate, come on back. I’ll be here.

      • NCDoc says:

        What’s misleading about the your link is the unsupported implications that closing an ED is somehow a danger unique to a free healthcare system. The article you were linking to did no analysis of the root cause of the ED closing nor the danger it posed, so that commentary was you’re opinion. I was offering simple examples of the way a responsible journalist might approach the comparison between systems, such as comparing overall ED availability and population health outcomes.

        As for the quality of our arguments, I think your choice to use sarcastic remarks like “Einstein” and flat insults like “third grader” and “big boy pants” speaks for itself. My big girl pant are feeling just fine at the moment.

      • WhiteCoat says:

        People like you annoy me to no end.

        First you get on your soapbox, call me “yellow”, moan that I’m anonymous, say I made “wild misrepresentations,” and say I neither have a good reputation or quality of work. Those claims were all either irrelevant or had no basis in fact.

        Then, when I call you out on it, you misrepresent my writing *a comment* as my writing an “opinion piece” for which I may have had a “conflict of interest” that you refuse to even try to elaborate upon. You also completely change the points I was trying to make in an attempt to refute arguments I never even suggested. Again, you made untrue and irrelevant statements in an attempt to make yourself look better. You also set yourself up as an authority to judge “journalistic validity” when it’s blatantly obvious that you have no idea what you’re talking about.

        Then, when I call you out on those claims, you again abandon your arguments and accuse me of making an “unsupported implication” in a link because I didn’t do an analysis of the dangers that closing an ED would pose. You haven’t done any type of analysis into any of untrue statements you have made in this entire thread. As if a reduction in medical care in an isolated community is somehow a good thing.

        Apparently realizing that your third attempt at defiling me wasn’t very compelling, either, you forget all your prior untrue statements about me, put on a pouty face and feign offense (as I predicted you would) because I … I … “insulted” you.

        I’m going to resist saying what I want to say right now because on this site what I say can still be partially attributed to EP Monthly and you’ve already tried to involve EP Monthly in your little diatribe. While I’m sure that EP Monthly’s editors would wholeheartedly agree with what I have to say about your loathsome assertions, I’m a better “journalist” than to put them into the middle of this.

        So pull up your “big girl pant” [sic] and just go away.

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