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.
I may end up eating my words about this. We’ll see.
James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him.
I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now.
A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster.
Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years.
So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand.
Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care.
Initially, that may be true. Then what happens?
First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them.
Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need.
If a lot of physicians opt out of Medicare, the health care system will turn chaotic. Maybe a few of the well-to-do elderly patients will pay out of pocket to continue seeing their current physician. However, most will start calling around to find other physicians who still accept Medicare. The wait lists with those physicians will grow from weeks to months.
In the meantime, elderly patients will go to emergency departments for their health care needs because we emergency physicians will always be there to help them when their doctors aren’t available (I’m already starting to see this happen in my ED) and because the hospitals won’t dare to opt out of Medicare.
Hospitals accept Medicare … Medicare pays for care rendered to seniors … seniors go to hospitals. Seniors who come to the emergency department tend to get BMWs (but remember, folks, defensive medicine doesn’t exist), therefore costs to Medicare go up, not down. Medicare goes bankrupt sooner than anticipated.
A crisis like this is what we need to get legislators back to the table to create a better health care plan. It needs to happen. Even the status quo is unacceptable.
Gutsy move by Congress letting things get this far, though. No matter what happens, this is turning into one helluva game of chicken.
UPDATE FEBRUARY 28, 2010
See Throckmorton’s blog for another good point – with the cuts to reimbursements also come a cut to reimbursements for medical care to all of our soldiers. What happens to Congress? There are already reports that a bill will be introduced this week to delay the effective dates of the cuts for another 30 days. And the AMA is actually showing doctors how to drop Medicare, if they so choose, including samples of documents to file (.pdf file – also contains excellent explanation of options physicians have regarding participation versus non-participation)
The merry-go-round continues.
Some states are having difficulty finding enough physicians to provide needed specialty care to patients who come to the emergency department. If a patient needs neurosurgery or trauma surgery and there is no one on staff that is able (or willing) to perform the necessary services, then the patient must be transferred to another facility. Sometimes the waits involved in arranging and performing the transfers can lead to bad outcomes for the patients involved.
In a recent Healthcare Update, I mentioned an article about Oklahoma legislation providing tax credits to physicians to provide on-call care.
A friend forwarded me an e-mail from ACEP that listed several states which are contemplating tax credits for on-call care.
Hawaii has a bill that would provide physicians who provide at least 576 hours of on-call services per year with a tax credit totaling 5 percent of the physician’s liability premiums. For a policy premium of $30,000 per year, the credit would be $1,500. Another bill in Hawaii would waive medical licensing fees (usually several hundred dollars) for physicians who treat more than 20 percent Medicaid patients. Missouri considered a bill that would exempt Medicaid payments from a physician’s state income tax (currently 6%). Keep in mind that Medicaid reimbursements are generally low, so the benefit isn’t as significant as the bill would make it seem. In a chart I have from 2006, Missouri paid a whole $15 for managing a high complexity (life threatening) patient in the emergency department – the same as it paid for treating a kid with a runny nose. In the entire country in 2006, Missouri reimbursed the least for providing high complexity care in the emergency department. By 2008, the rates it paid were up to $20.23 for low complexity and $60.01 for detailed complexity patients – a little more than half of what Medicare paid for the same patients. Oklahoma’s Senate Bill 1604 would provide a $100 state tax credit per day for on-call emergency coverage in rural areas – to a maximum credit of $5000 per year.
So what do you think?
What do you think about providing tax credits to physicians for performing on-call emergency department care?
I'm not a physician and it think it's a GOOD idea (62%, 78 Votes)
I am a physician and these tax incentives wouldn't make me want to provide more on-call care (24%, 30 Votes)
I am a physician and I would do more on-call care if I got these tax incentives (10%, 12 Votes)
I'm not a physician and it think it's a BAD idea (4%, 5 Votes)
In October, I linked to an article about how Grady Memorial Hospital in Atlanta was closing its dialysis clinics due to the significant financial burden. Grady has agreed to pay for the patients to receive dialysis at a private dialysis clinic until January 3, 2010, but after that, the patients are on their own.
After Grady’s announcement, approximately 50 illegal immigrants sued to keep the clinic open, alleging that closing of the clinic “violated their constitutional right to the health care service” and that closing the clinic amounted to “medical abandonment.”
The court held that the plaintiffs had neither a state nor a federal constitutional right to outpatient dialysis services and that Grady Memorial was not legally bound to provide those services.
The attorney representing the patients stated that she realizes that some people don’t believe the patients are entitled to such care because they are illegal immigrants. “They are human beings, and we all have the right to live.” The attorney also stated that “these people are going to die without this.”
The lawyer misrepresented the plight of the patients. Under current federal law, renal failure patients will always have access to hemodialysis, and that access will likely be more expensive than the current system that Grady uses. I called this one seven months ago.
High levels of potassium in a dialysis patient is an emergency medical condition. Under federal EMTALA laws, hospitals are required to provide stabilizing treatment to anyone with an emergency medical condition that seeks medical care in an emergency department. All the patients have to do is call “911″ and they will get door-to-door service to the hospital via ambulance, will get a bunch of expensive testing done to document their elevated potassium, will likely be admitted to the hospital, and will still get their dialysis.
The situation raises a second question, though: Should we be providing uncompensated care to illegal aliens?
I think that the answer should be “yes” – with an asterisk.
If people are violating federal laws, they should suffer the same consequences as anyone else who violates any other federal law. In this case, provide the patients with dialysis, contact police, take the patients into custody, and then initiate deportation proceedings – or whatever other action is appropriate under federal law.
If hospital personnel become aware that a patient has committed a crime, we already call police from the emergency department.
A patient has a gunshot wound? We call the police to report it.
A patient may be the victim of domestic abuse? We file a police report.
A patient in a car accident has an elevated blood alcohol level? We notify the police.
How hard would it be to contact the police to verify someone’s identity if a patient is unable or unwilling to provide a state-issued identification? Not only would doing so determine whether or not a person is in the country legally, but it would cut down significantly on health care fraudsters who obtain care in the emergency department using a fictitious name and fictitious address and then stiff the hospital for the bill.
If we don’t want to enforce our laws, that’s fine.
Then we need to stop complaining about providing care to those who violate the laws.
Lucy and Ethel worked on an assembly line and were responsible for wrapping all of the chocolates that came down the conveyor belt. At first, things were easy, but as more and more chocolates came faster and faster, eventually Lucy and Ethel became overwhelmed and the whole process fell apart. The result was a classic comedic moment.
In emergency medicine, things aren’t so funny. The chocolates are our patients. At times, patient flow is manageable. At other times, patient volume becomes so high that we have difficulty providing good medical care. When things get too busy, usually there is a relief valve called “bypass”. Hospitals have to meet certain criteria to go on bypass, but once a hospital declares bypass, no ambulances may bring additional patients, giving the emergency department time to stabilize patients already there and to open up beds to accept new patients.
Massachusetts is pushing the envelope in medical care and, in January, created a statewide policy that hospitals could not go on bypass. According to this article from the Boston Globe, the law seems to be having its intended effect … for now.
By refusing to allow hospitals to go on bypass, the state forces busy hospitals to keep accepting ambulance runs. It is then up to the hospitals to find a way to make room for the additional patients. Kind of like pushing a kid into the deep end of a swimming pool and telling him that he better figure out a way to stay afloat.
Hospitals are now opening up additional units and are hiring additional staff to get floor patients discharged earlier in the day. However, wait times haven’t changed much – still an average of about 5.5 hours for admitted patients and 2.5 hours for discharged patients since the rule went into effect.
So is forcing hospitals to work at above capacity a good idea or not? Is necessity the mother of invention? Or will we start to see a bunch of hospitals floating to the surface at the deep end of the swimming pool?
Healthcare insurance does not equal healthcare access. Physicians are suing the state of Florida because more than 1.2 million children on Medicaid are not receiving access to critical medical care. Some children covered under Medicaid are unable to find any orthopedists willing to fix their broken bones. More than 750,000 children received no dental care because “reimbursement rates are among the lowest in the country” and 30% of Florida counties have fewer than two dental providers willing to treat Medicaid patients. A Florida official stated that “We have a system that is growing by-double digits, where providers are paid less and less each year. Access is limited, outcomes are not measured … I’d say that’s a bad system.”
Oh, and Florida’s defense to the lawsuit? The plaintiffs don’t have legal standing to pursue the claims because “the Medicaid program promises money but not necessarily the delivery of health services.”
Hey, but at least all the Medicaid patients have insurance. Wonder how much their insurance will be like the insurance proposed in this new health care bill …
These insured patients still end up in the emergency department. Before state Medicaid cuts, many dentists would not accept Medicaid patients because of low reimbursement rates. After Michigan cut dental coverage to 400,000 Medicaid recipients, officials expect emergency departments visits to increase by 10%. One woman recently died from complications that went untreated due to loss of Medicaid dental benefits. Hey, but at least all the Medicaid patients have insurance. That’s what everyone needs from this health care bill. Insurance.
One way NOT to get faster care: Threaten to kill the staff in the emergency department because they aren’t seeing your child quick enough. Grabbing the security guard by the throat and attacking the nurse won’t help either. Enjoy your stay in the Greybar Motel, ma’am.
In other news, due to the throwdown given to the mom by the security guard during the incident, JCAHO is now mandating that hospitals remove all security personnel as a patient safety measure.
Should hospitalists be performing pelvic exams on admitted patients if those pelvics have already been performed in the emergency department? Do women prefer males or females performing their pelvic exam? And who goes singing “come out come out wherever you are” to the cervix when performing a pelvic exam?? These answers and more at Happy Hospitalist’s blog.
One lucky dude (or “dood” if you’re Nurse K). Man walks into emergency department feeling “sick and disoriented.” Shortly afterwards, his heart stopped beating and he collapsed. 47 minutes, 4,500 chest compressions and 8 defibrillator shocks later, he was back in the land of the living. Doctors kept him in a medically-induced coma and cooled his body with special cooling pads. Three days later, he woke up and started talking. Not many people survive codes and even fewer end up well enough to walk out of the hospital.
Ohio balances budget on backs of patients. Ohio legislators recently imposed a “franchise fee” on hospitals amounting to 1.5% of all operating expenses (not a percentage of profits, mind you). That fee amounted to $19 million for one hospital and $22 million for another hospital. In order to balance their own budgets, now hospitals are cutting staff and cutting services. “More layoffs and service reductions will mean longer waits and higher costs for all patients.”
Minnesota hospitals “shed jobs and services” as they brace for $43 million in revenue cuts when the state terminates some programs for indigent care. Such cuts would “tip this hospital over” and “would mean unacceptable deaths for patients who can’t get care” according to one emergency physician. One hospital will no longer provide non-emergency care to uninsured patients from outside its county and plans to cut 150 to 200 jobs.
A spokeswoman for the Catholic Charities noted that “homeless shelters and community health centers — as well as police — will have their hands full with the drug-addicted and the mentally ill who will be off their medications and on the streets.”
A picture within the article of a man holding a sign says it all.
Health care reform ideas from a retired physician. Some good ideas, including mandatory co-pays for all non-emergent medical care, pre-trial malpractice screening panels, and committee review for treatment options of complex medical cases.
A well-written story about the life of one Washington DC area “frequent flyer” in the Washington Post. The article also highlights how frequent flyers can harm themselves by reinforcing the “boy who cried wolf” phenomenon. It mentions how another intoxicated mugging patient was treated with a “sequence of blunders” after medics smelled alcohol on his breath and assumed that he was drunk. In reality, the patient had a head injury. The frequent flier in the story, Kenny Farnsworth, repeatedly called 911 for choking sensation but never followed up with a primary care physician. Eventually he was diagnosed with a deformed hyoid bone and the problem was corrected with surgery. Now, Mr. Farnsworth’s “911 call volume has fallen dramatically.” The comments section to the article is brutal.
A couple of news headlines paint a bleak picture about the future of healthcare in this country.
First are some comments made by US Republican Senator George LeMieux. During a news briefing (video here), LeMieux expressed a concern that Obama’s healthcare plan would amount to “Medicaid for the masses” and would put all Americans on a government run or government controlled health care.
The Palm Beach Post News also ran a story regarding a speech given by Senator LeMieux where he stated that the cost of the bill over the next 10 years was grossly understated due to “funny math”. He estimated the true cost of the bill to be more than $2.5 billion over 10 years rather than the projected $849 million.
LeMieux stated that in order to decrease costs, the bill intends to cut Medicare spending by more than $500 billion – through $400 billion in cuts to home health providers, hospitals, hospices and others while decreasing subsidies to Medicare recipients by more than $100 billion.
My favorite quote from the article is the following: “If we really want to provide health care for Americans, why shouldn’t we give them the tools to go out into the marketplace and be a consumer, which we know will end up driving down costs.”
Another free market advocate. I love it.
As our legislatures plans to significantly cut spending on the Medicare program, today several Massachusetts hospitals are filing a lawsuit against the state of Massachusetts because the current reimbursements from Medicare and Medicaid are already too low. According to this article in the Boston Herald, Massachusetts currently reimburses hospitals for only 40% to 86% of the costs of providing care. Because at least 63% of patients going to these hospitals have Medicare or Medicaid, the low payments are pushing many hospitals “to the brink of financial ruin.” The state countered by stating that it recently increased payment to the hospitals by 10 percent. Unfortunately even a 10% increase still leaves hospital payments at 44% to 95% of the cost of providing care – still below the break even point.
No business can stay afloat when the costs of doing business exceed revenues.
So the plan in Massachusetts to insure all of its state residents has resulted in almost every state resident having insurance … and in more people having trouble finding care.
The greater number of insured patients increases the costs of providing care to those patients.
Then, to control costs, the government cuts or maintains ridiculously low payment schedules to providers – to the point that the providers are having difficulty staying in business.
Welcome, ladies and gentlemen, to your new national health care system.
What good will your new health insurance be few providers are willing or able to provide care for you?
The biggest myth of this health care debate is that having “insurance” is equivalent to having “health care.” The two are not the same, nor will they ever be the same. Just ask people who have Medicaid “insurance.”
If the hospitals in Massachusetts want to get more reimbursements, suing the state is the wrong way to go about doing so. In this case, lawsuits are a costly lose-lose situation. All the money the hospitals spend in attorneys’ fees and court costs could be put to better use. Boston Medical Center already tried suing the state for the same reason and the litigation is still dragging out in court.
A lobbyist once told me that the quickest way to enact change is to cause a public outcry.
You hospitals want an increase in funding? Drop the lawsuits and just shut your doors. Take your ball and go home. Too many patients and almost every legislator in our government take their access to health care for granted. Let patients walk up to your facility with their insurance card in hand and let them jiggle the handle on on the door a few times before realizing that they cannot get inside. Stop providing care until the state and federal government provide better reimbursement.
If it costs these hospitals more to provide care than the hospitals are being paid, closing the doors would save the hospitals money each day that the doors are closed. Divert ambulances. Transfer admitted patients to other facilities. The 1.5 million patients each year, including more than 300,000 emergency department patients each year that are being treated at the near-bankrupt Massachusetts hospitals will have to be redirected to another facility to find their care – if care is available.
At the entrances of each closed hospital, post giant pictures of the state and national legislators and an explanation of how their actions or failures to act have caused the hospital to close. Make sure to include the date that the legislators are up for re-election.
Then give the local news stations a call to let them know what’s happening.
In order to respond to the threefold increase in ambulance calls from patients with influenza-like symptoms, Medstar Ambulance Service is considering a change in policy where patients are evaluated after a call and then told that they “don’t need to go to the hospital.” If the patients still insist on transport, they won’t be taken to the hospital by ambulance. Instead, Medstar will arrange a taxi ride – and not necessarily to the hospital, either. Patients might get taken to an emergency clinic instead.
Oh, and when they’re discharged they’ll still have to find a ride home.
When an unconscious intoxicated multiple trauma patient was brought to the ED, we did a bunch of CT scans to look for injuries. Fortunately there wasn’t anything life-threatening. He was admitted and was later discharged in good condition.
I then got a memo from the hospital several days later stating that Medicare would not pay for the CT scan of the patient’s cervical spine. There is a list of diagnosis codes for which Medicare will reimburse hospitals for performing a CT scan of the cervical spine. That list is contained below. If one of the selected codes is not on the patient’s final diagnosis list, then Medicare tells the hospital “tough luck” and pays the hospital nothing for the scan. As part of Medicare’s Conditions of Participation, the patient may not be charged for the exam unless the patient specifically agrees to the charges. When Medicare doesn’t pay, almost always the hospital gets stuck holding the bag.
If a patient is a victim of multiple trauma and is unconscious, CT scans of the cervical spine are more likely to show significant injury. This study showed that in multiple trauma patients, CT scans picked up on 98.5% of fractures while cervical x-rays only picked up 43% of fractures. It is uncommon to pick up ligamentous injuries on x-rays or CT scans – generally need an MRI for those.
If physicians choose to do a CT scan on an unconscious or poorly responsive patient, according to the “permissible” diagnosis codes, in most cases hospitals have to hope that either an injury or some type of cancer shows up on the CT scan. Otherwise, the CT scan won’t be reimbursed and the hospital eats the cost.
What are the other options in multitrauma patients?
We could just do only x-rays of the cervical spine, and, if negative, tell patients that everything is OK because the government won’t pay for CT scans unless you meet certain criteria. The 57% of patients with cervical spine fractures missed on x-rays will have all their medical needs met under the new health care reform measures anyway.
Or, while bleeding to death and strapped to a backboard wondering if they’re going to live or die, we could give patients an ABN form to sign. “Medicare might not pay for this test, if Medicare doesn’t pay for this test, do you agree to pay the cost of the test yourself — assuming that you live, of course?”
We could always perform x-rays on everyone’s necks first and make up notice some “abnormality on radiological or other exam of the musculoskeletal system” to justify the CT scan. That will be a 793.7 to all you CPT coders.
We could just say that notice that the patient winced in pain when the neck was palpated – causing “cervicalgia.” That’s CPT code 723.1.
Or we can just practice good medicine and let the hospitals get shafted by the system.
Of course, if hospitals get shafted enough by the system, they end up closing or reducing services. Then access to care suffers. You get what you pay for. Do a search for “hospital bankruptcy closures” and see how often it happens. Here are a fewexamples.
CT scan payments are just one example of the cat and mouse game that constantly goes on between those providing the services and those “paying” for the services.
It is also an example of the “Golden Rule” – he who has the gold makes the rules.
In 2008, St. Johns Hospital and Mary Immaculate Hospital in Queens had a total of 119,883 outpatient department visits.
In February 2009, the two hospitals went bankrupt and closed.
In June 2009, the New York City Office of Policy Management published a paper showing that once St. Johns and Mary Immaculate Hospitals closed their doors, the patients that previously went to those hospitals didn’t just vanish. Instead, the patients flocked to other nearby hospitals which were already operating at capacity.
Guess what happened?
Those nearby hospitals – such as Jamaica Hospital in Queens, are now “overwhelmed.” According to the report, Jamaica Hospital’s daily census went up 50% — from 350 visits per day to “well over” 500 visits per day. On May 27, 2009, Jamaica Hospital had 663 visits – more than double its usual number. Other area hospitals such as Elmhurst Hospital, Queens Hospital Center and New York Hospital Queens noted increases of at least “an extra 100 patients a day.”
The number of patients being boarded in the Emergency Department of nearby hospitals also “soared.” Jamaica Hospital, Queens Hospital Center, and Long Island Jewish Hospital all noted dramatic increases in the numbers of patients being boarded in their EDs.
One emergency physician with twenty years of experience was quoted as saying “the state of emergency medicine in the borough of Queens is the worst I’ve seen it in my career.”
At the heart of the hospital closures was funding.
New York City was subsidizing St. Johns Hospital and Mary Immaculate Hospital to the tune of $61 million over the years leading up to the hospital closures. The City was unable to sustain that commitment. Without the city’s support, the hospitals went bankrupt.
Availability of ambulance services is also now in question. When St. Johns and Mary Immaculate hospitals closed, the ambulance services operated by the hospitals also ceased operations. None of the remaining hospitals was interested in providing ambulance services to the area served by Mary Immaculate Hospital, so ambulance service in that area was temporarily taken over by New York City Fire Department EMS. NY City is cutting the budget for the EMS service by $3 million which will result less ambulance availability. One mother noted that it took 25 minutes for an ambulance to reach her home after her son had a seizure. A $60 million Medicaid reimbursement reduction anticipated in the near future will likely result in even less care being available.
Whatever health care reform package that is chosen will necessarily involve an attempt to cut this nation’s health care costs. This country simply can’t sustain its current level of health care spending.
But we need to be very judicious in where spending cuts are made.
Many hospitals are not “rolling in the dough.” Cut funding for health care too much and we risk further hospital closures. The decrease in the quality and availability of care in Queens, NY is just one example of the impact hospital closures can have on the medical care in a community.
Remember this point in the health care debate: We can talk all we want about providing health care insurance to everyone in this country. Health care insurance means nothing if there is no one available to provide the care for you.
Sorry about the sparse posting lately – have been away in Washington at an ACEP conference
I may end up eating my words about this. We’ll see.
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some programs for indigent care. Such cuts would “tip this hospital over” and “would mean unacceptable deaths for patients who can’t get care” according to one emergency physician. One hospital will no longer provide non-emergency care to uninsured patients from outside its county and plans to cut 150 to 200 jobs.
A couple of news headlines paint a bleak picture about the future of healthcare in this country.
Banning Bypass: Good Policy or Tempting Fate?
Tuesday, December 15th, 2009Remember this skit from I Love Lucy?
Lucy and Ethel worked on an assembly line and were responsible for wrapping all of the chocolates that came down the conveyor belt. At first, things were easy, but as more and more chocolates came faster and faster, eventually Lucy and Ethel became overwhelmed and the whole process fell apart. The result was a classic comedic moment.
In emergency medicine, things aren’t so funny. The chocolates are our patients. At times, patient flow is manageable. At other times, patient volume becomes so high that we have difficulty providing good medical care. When things get too busy, usually there is a relief valve called “bypass”. Hospitals have to meet certain criteria to go on bypass, but once a hospital declares bypass, no ambulances may bring additional patients, giving the emergency department time to stabilize patients already there and to open up beds to accept new patients.
Massachusetts is pushing the envelope in medical care and, in January, created a statewide policy that hospitals could not go on bypass. According to this article from the Boston Globe, the law seems to be having its intended effect … for now.
By refusing to allow hospitals to go on bypass, the state forces busy hospitals to keep accepting ambulance runs. It is then up to the hospitals to find a way to make room for the additional patients. Kind of like pushing a kid into the deep end of a swimming pool and telling him that he better figure out a way to stay afloat.
Hospitals are now opening up additional units and are hiring additional staff to get floor patients discharged earlier in the day. However, wait times haven’t changed much – still an average of about 5.5 hours for admitted patients and 2.5 hours for discharged patients since the rule went into effect.
So is forcing hospitals to work at above capacity a good idea or not? Is necessity the mother of invention? Or will we start to see a bunch of hospitals floating to the surface at the deep end of the swimming pool?
I seem to remember a lawsuit that stemmed from emergency department not providing prompt enough care to a celebrity …
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