Archive for the ‘CMS’ Category
Tuesday, May 26th, 2009
I recently read an interesting article by Dick Morris called “Death of U.S. Healthcare” posted on The Hill. Morris was a former adviser to Trent Lott and to Bill Clinton. His opinion is that Obama’s health care reform will cause rationing of medical services and he cites several comparisons between the US and Canadian systems. Another article on The Hill cites President Obama’s promise to provide “basic” health care coverage for everyone.
I agree that rationing is going to occur, but there’s at least one thing that will prevent some medical services from being rationed. Let’s use one example.
Suppose you want to cut the costs of health care by no longer paying for costly medical care that does not provide a long-term benefit. You assign your employees to perform a “study” on costly medical care. The study done by your employees (kind of like a study on the effectiveness of a medication that is funded by the drug company making the medication) determines that patients older than 90 years of age on dialysis do not show a significant improvement in quality or duration of life. You then create a new medical practice “guideline” that says, based on this medical effectiveness study, dialysis will no longer be an included medical benefit for patients more than 90 years of age. What happens?
Some families might pay for the bill for future dialysis out of their own pockets.
Some families might just let grandpa die a slow death from his renal failure.
Most families will just call “911″ and the red taxi with the spinning light on top will come to pick grandpa up at his home and take him to the emergency department. At that time, grandpa will receive thousands of dollars in lab tests to document that he really is in renal failure and that he needs dialysis. If dialysis is necessary, grandpa will receive emergent hemodialysis thanks to EMTALA. He might even need a day or two in the hospital to make sure that he is “stabilized.” Then the red taxi with the spinning light on top will bring grandpa home where he will sit a few more days … until he needs dialysis again. One little phone call and the whole process starts all over again.
By excluding preventive care that averts an emergency, the government will create a situation in which the same care becomes more expensive. All grandpa’s family has to do is pick up the phone and hit three little numbers and he’ll get dialysis any time of the day or night.
The government will get its wish, though, as it will no longer have to pay for dialyzing nonagenarians. The burden of paying for emergent dialysis will shift from the government to the hospitals. You see, EMTALA requires that hospitals provide stabilizing treatment, but it says nothing about who will pay for the stabilizing treatment. Hospitals will be forced to eat the cost of providing care. As more of the costs are passed on to the hospitals, more and more hospitals will close. Then less medical care, and less emergency medical care will be available for everyone.
EMTALA and the numbers 9-1-1 are two reasons why healthcare rationing inherent with socialized medicine will never be a viable alternative in the United States. Rationing will cause cost-shifting which will in turn cause hospitals to close their doors.
Posted in Access to Care, CMS, Policy | 14 Comments »
Thursday, May 7th, 2009
According to this Medscape article, trying to get rid of Clostridium difficile spores by using traditional hand sanitizers won’t cut it.
C. difficile spores are everywhere, including tables, curtains, lab coats, scrubs, plants and cut flowers, computer keyboards, bedpans, furniture, toilet seats, linens, telephones, stethoscopes, jewelry, diaper pails, fingernails and physician’s neck ties.
The spores themselves aren’t harmful, but when they are ingested, they can transform and cause colitis. C. difficile spores are difficult to eradicate because they secrete a sticky substance allowing them to adhere to surfaces which, in turn, makes them difficult to remove. Think of little beads with a honey coating.
In the Medscape article none of the cleansing products – even the soaps – removed more than 90% of C. difficile spores.
According to this study, C. difficile can be cultured from the stool of 3% of healthy adults and 80% of healthy infants.
This MSNBC article shows that C. difficile is present in 40% of grocery meats.
According to this commentary, more than a third of patients in a North Carolina study had community-acquired C. difficile infections (i.e. not the hospital’s fault) and more than half of patients with C. difficile recently used antibiotics.
And … one of the quality measures forced upon us by CMS and Hospital Compare requires us to use antibiotics on ALL known or suspected cases of pneumonia within 6 hours of the patient’s arrival. These “quality measures” significantly increase antibiotic use without any improvement in mortality or hospital length of stay. At the same time, they increase the likelihood of C. difficile infections.
C. difficile is present in up to 40% of the meat we eat.
C. difficile is commonly present in the stool of healthy infants and adults.
We can’t completely get rid of C. difficile spores no matter how much we wash.
And … for the sake of “quality care,” the government forces us to give many patients unnecessary antibiotics that actually increase the chances that a C. difficile infection will occur.
But if C. difficile infections occur in a hospitalized patient, the government won’t pay to treat them because the infections are “never events” and should “never” happen.
Go figure.
Posted in CMS, Never Events, Policy | 6 Comments »
Friday, April 3rd, 2009
This NY Times article notes that many patients who become Medicare eligible are finding that the “insurance rug has been pulled out from under them.”
More and more physicians are dropping Medicare and patients can’t find physicians to take care of them.
“The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.”
There is already a shortage of internists in the US and the ones that are available are unwilling to accept new Medicare patients. Universal coverage doesn’t mean much if no one takes your insurance.
The more I think about this, the more I wonder whether this is exactly what the feds are looking for. They keep taking 15+% out of everyone’s paychecks to fund a Medicare system that fewer and fewer doctors participate in – until everyone pays a lot of money to end up with little or no access to medical care.
Posted in Access to Care, CMS, Medicare | 4 Comments »
Monday, March 30th, 2009
 There’s suddenly a lot of conjecture flying about a patient who died in the University of Chicago’s emergency department a couple of months ago. Everyone that reads this blog had a heads up on the event way back on February 8.
According to news reports, a 78-year-old man was brought to the emergency room by ambulance about 12:30 PM. He was put into a wheelchair in the waiting room, but was neither triaged nor logged in. At 4:15 PM, the patient’s daughter wheeled the patient to the triage nurse to ask about the delay. The triage nurse noted that the man wasn’t breathing and called a code, even though rigor mortis had already set in. Unfortunately, rigor mortis is one of those things that usually precludes a successful cardiac resuscitation.
We don’t know anything about the man’s health or his complaints. All we know is that he was brought in by ambulance, sat in the waiting room for 4 hours (at least some of the time accompanied by his daughter), and was dead for a while (rigor mortis takes several hours to set in) before anyone noticed it. Be careful drawing conclusions without knowing all the information.
The University of Chicago admitted that procedure wasn’t followed. In other words, given the recent adverse publicity at the University of Chicago, a couple of nurses had to take the fall for what happened. The University of Chicago posted a statement about the incident emphasizing the U of C’s commitment to quality and safety.
Illinois State, the Medical Marijuana Advocates, and federal investigators are all looking into the incident. Some news reports stated that the feds have now cited the University of Chicago Hospital for an EMTALA violation.
Then comes the big stick. CMS allegedly sent the University of Chicago a letter threatening to take away the University of Chicago’s Medicare funding.
What an idle threat.
If I were the CEO at the University of Chicago, and the feds told me they were considering whether to revoke the hospital’s Medicare funding, I’d give them a double dog dare to go right ahead.
The Emergency Medical Treatment and Active Labor Act (“EMTALA” for short) only applies to “participating hospitals” – those hospitals that receive federal funding under Title 42 of the US Code. If the feds kick the University of Chicago out of the Medicare program and it no longer receives federal funding, then, just like free-standing emergency departments, the University of Chicago has no further duties under EMTALA. It wouldn’t have to provide a screening exam to patients. It wouldn’t have to provide stabilizing care to patients. If the patient doesn’t have insurance, the University of Chicago could essentially tell patients to “go to the county hospital.” It could even call an ambulance and have the ambulance transport the patient to another hospital. It could transfer patients to other hospitals without the transfer being “appropriate” under the EMTALA rules. EMTALA requires that hospitals accept transfer of patients if the hospital provides specialty services, so the receiving hospitals would be stuck taking any patients that University of Chicago decided to send them. Added bonus: the Joint Commission would no longer have any business in University of Chicago’s affairs.
A termination from the Medicare program could be a blessing in disguise. Without being subject to EMTALA, the University of Chicago could technically engage in “patient dumping” and only accept patients with insurance. True, a hospital would lose the income from Medicare (which is the dominant player in the market), but maybe that shift to providing only funded care would make up some of the difference because the hospital would no longer have to provide unfunded care or underfunded care. Would people with insurance go to University of Chicago preferentially if there was less crowding in the ED, if they were treated like royalty, and if appointments were easier to obtain? Might take some number crunching, but an entirely for-profit hospital might be sustainable – especially in a large city.
The thing is … if University of Chicago takes that gamble and is successful, how many other hospitals would consider whether or not to make the same leap? Would a successful large for-profit-only hospital system be the first step to creating a “two level system” where the best doctors go to entirely privately funded hospitals because they receive more compensation, but those doctors aren’t available to patients without a means to pay? Would all patients on public funding then get sheep herded into the public hospitals where they get free care that might not be as high quality or as accessible as at the for-profit hospitals?
Or maybe the University of Chicago will be so affected by the lack of federal funding that it will go out of business like so many other Illinois hospitals.
In either case, remember all those patients that were having difficulty obtaining emergency medical care? Remember Dontae Adams whose face was “chewed off” by a pit bull? Close the University of Chicago or turn it into a strictly for-profit institution that is not subject to EMTALA and guess what happens to all the patients who have public funding or no insurance at all? NONE of them get any care at the University of Chicago. They all get sent to other hospitals that are still required to provide EMTALA-mandated care.
With the new onslaught of low paying patients, wait times at surrounding hospitals will increase and quality of care will inevitably decrease. Eventually, the volumes of patients will overwhelm the surrounding hospitals’ resources to the point that patients will die in other emergency department waiting rooms. More CMS investigations. More hospitals will close.
Lather. Rinse. Repeat.
Less hospitals, more patients in the emergency departments. Yeah. That will go over real well.
So CMS, if you’re playing a game of “chicken” with University of Chicago, you better be driving something larger than a Cooper Mini.
I’ve got another idea: How about fixing the funding of emergency care in this country before waiting room deaths become an everyday occurrence?
Like this.
Or this.
Or this.
Or this.
Or this.
Or this.
Fast care, free care, quality care. Pick any two.
As Scalpel once said, sometimes you only get to pick one. “Free” doesn’t always cut it.
===
Also see related articles at:
Huffington Post – University Of Chicago Hospital May Lose Medicare Certification After ER Death
Chicago Sun-Times – U. of C. admits problems with ER death
WBBM Chicago Radio – Feds Threaten Action Against U of C Med Center
The bad blood between the Chicago Tribune and the University of Chicago continues. While most sources had one article about the incident, the Chicago Tribune has had three (and will probably have about a half dozen more):
U. of C. Medical Center says ‘protocol’ not followed in ER death
Medicare warns U of C Medical Center after ER death
University of Chicago Medical Center in violation of emergency room services law, U.S. alleges
UPDATE MARCH 30, 2009
Leave it to Shadowfax to set me straight. See his post related to the above here.
I didn’t consider the funding that training programs receive from the federal government in my equation and agree that removal of such funding would be a death knell for the training program and, more likely than not, the affiliated teaching hospital.
Shadowfax and I are looking at the same problem from two different angles, though.
Shadowfax’s post brings forth some criticisms about the University of Chicago using factual allegations to which I’m not privy.
I’m looking at the issue more from the angle of what happens when a bully picks on too many nerdy kids or what happens when you back an animal into a corner. Right now, hospitals are too afraid that they’ll go bankrupt if they stop taking Medicare funding. Medicare the bully is still winning. At some point, a couple of hospitals are going to stand up to the bully, punch him in the nose, and tell him to stick his paltry payments and all the micromanagement that goes along with them.
If those hospitals survive, others will undoubtedly follow, resulting in huge market shifts. Will lofty professors of specialty medicine remain with their university programs if suburban hospitals pay their specialists twice the salary that professors earn? What if there are one tenth of the documentation and administrative hassles? No JCAHO? Get paid more so you can spend more time with your patients?
Primary care physicians and their patients are finding concierge practices quite rewarding. It’s only a matter of time until a hospital takes the leap.
CMS may still be driving a Hummer when playing chicken with residency programs, but powerful hospital systems in affluent suburban areas might just be driving a Bradley Fighting Vehicle. One of these times, CMS is going to lose … and it will liberate the practice of medicine.
I can’t wait.
Posted in CMS, Medical-Legal, Medicare, News Commentary, Policy | 21 Comments »
Wednesday, February 25th, 2009
 The University of Chicago case is getting a lot of press and is polarizing the people on either side of the argument about Dontae Adams’ care.
Read about it at one of my previous posts, at ShadowFax’s place, over at Kevin’s blog, or at Scalpel’s blog. The Chicago Tribune is getting a lot of play out of the controversy. It has published several articles already and just put up another one last night.
Just by the sheer number of people writing about the topic, you should be able to tell that the outcome of this topic is going to help define how medical care will be provided in the future.
On one side of this issue is Dontae Adams and his mother.
Dontae happened to be in the wrong place at the wrong time. He was bitten in the mouth by a pit bull and had a large cut on his lip. It is obvious that he needed medical care. Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program.
Stop here for a minute.
If you read through the comment boards at the Chicago Tribune web site, they are rife with people who criticize indigent/uninsured patients who may or may not be citizens of this country for “clogging up the emergency department” by going there for “routine” care. It’s easy to look down on someone is viewed as “abusing the system.”
So let me ask you this: Suppose you lost your job tomorrow and had no insurance. Suppose you had to take a minimum wage job at WalMart to keep food on the table for your kids and you weren’t eligible for health insurance. What would you do for medical care?
If you called a random doctor’s office and told them you needed an appointment for “routine” care and could only pay a small amount of cash, what are the chances that you’d get seen that same day? What are the chances that you’d be seen at all? Our family has good insurance, my daughter needs to see a specialist, and the earliest appointment is 4 months away.
Let’s say you’re living on a fixed income and want to pay for your doctor’s visits in cash. How can you afford to spend well over a hundred dollars for a single doctor’s office visit?
Ah, but there are free clinics all over the place, right? In the rural hospital where I moonlight, the closest free clinic is about 40 miles away and has very strict criteria on who it will treat at no cost. Cook County, IL, where the University of Chicago is located, is in the midst of a budget crunch and has closed down many free clinics. See articles HERE, HERE, and HERE.
There’s also an issue of whether or not the care some people seek in the emergency department is “necessary.” Clearly, much of the care that emergency physicians provide is not “emergent.” But I can say that because I have had eight years of medical training plus all the continuing medical education each year. Going to the emergency department to get an excuse for missing work, or trying to get a three day government-paid babysitter for grandma so you can leave on a trip is one thing, but in general, we have to give the benefit of the doubt to the patients.
Back to Dontae.
According to federal EMTALA laws, patients must receive a medical screening examination when they present to an emergency department seeking care. If an emergency medical condition is found, the condition must be stabilized or the patient must be transferred. If no emergency medical condition exists, the hospital’s duty under EMTALA ends.
From what I’ve read in the newspapers, according to EMTALA, Dontae’s injury was not an “emergency medical condition,” so the University of Chicago did not have a legal duty to treat Dontae once the emergency physicians determined that no emergency medical condition existed.
Now let’s look at things from the other side of the coin: Outside of federal EMTALA laws, what services should hospitals and physicians be “required” to provide?
Some believe that medical providers should be on the hook for everything. Expand EMTALA laws to require that patients receive everything they ask for. We need to provide for all of a patient’s needs. Whether it’s cardiac stents, kidney dialysis, Vicodin prescriptions, Lasik surgery, hair plugs, or a sex change operation, all medical care should be free to everyone. Sound silly? That’s the way our system is headed. If you think that some things should be free, but others should not, then you’re engaging in the same thought process that the University of Chicago used when it discharged Dontae Adams. Where ever you draw the line between free and not free, someone who would have to pay is going to criticize you for your decision.
That “free care” medical system is akin to expecting government to provide services with no one paying income taxes, expecting cities to provide services without anyone paying property taxes, expecting newspapers to run all of your advertisements for free (and to be delivered for free, too), or expecting professional medical societies to stay solvent without charging membership fees.
If we head down the free-for-all route in medicine, then why have insurance? If hospitals are required to provide all services to everyone regardless of the ability to pay, there’s no need to have any insurance. Hospitals can’t refuse care and all we have to do is show up at the front door to have access to the latest and greatest medical technology.
That’s a great idea, except for one problem: Who’s paying for it?
Medical care isn’t cheap. Government reimbursements for medical care are shrinking or nonexistent. New York pays a whopping $17.50 to physicians who provide lifesaving care to patients in the emergency department. California’s whole medical system is in shambles. Very few patients can afford huge medical bills. That leaves the physicians and hospitals holding the bag.
A “provide everything” approach becomes a system where hospitals and doctors are essentially paying for patients to come and receive medical care. That type of system is unsustainable. Providers have gone and will continue to go bankrupt. In addition, the more we lessen the incentive to go into medicine, the less physicians we will have. Who will want to spend twelve years of their life for medical education and take out several hundred thousand dollars in loans just so that they can provide unreimbursed care to anyone that demands it?
Do an internet search about hospital closings. Here’s a list of 50 hospitals that have closed in Illinois since 1980. Here’s another example of a hospital closure this month in Queens, NY. Is the University of Medicine and Dentistry in New Jersey next?
Where do we draw the line between care that must be provided and care that doesn’t have to be provided?
The line is already there. We just have to stop trying to redefine it.
The more we try to force medical providers to provide comprehensive free care for everyone, the closer we get to a system in which fewer and fewer patients have access to any care.
Posted in Access to Care, CMS, Funding Crisis, Health, Insurance, Medicare, Policy | 14 Comments »
Monday, February 23rd, 2009
 It isn’t just the patients who think I’m a bad doctor.
Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous.
For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ.
I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site.
In other words, Medicare thinks I’m a bad doctor.
Let me tell you about the patients I screwed up on.
The first patient was a gentleman in his 70′s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction.
According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (“clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine.
Now I’m faced with a choice:
A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him.
-OR-
B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window.
If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov‘s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!”
If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines.
I chose “B.”
According to HospitalCompare.hhs.gov, my decision made me a bad doctor.
The second patient was an elderly lady who came to the hospital with leg pain and weakness. She was in a lot of pain. We did some testing and she ended up having a blown disc in her back that was pressing on a nerve root. She was admitted and had surgery. Five days after she was admitted, she ended up having a heart attack while she was recuperating on the medical floor.
According to the quality indicators at “HospitalCompare”, if a patient has a heart attack and does not have contraindications to receiving aspirin or beta blockers, the patient must receive aspirin and beta blockers within 24 hours of their arrival in the hospital.
The brainiacs at Medicare who run this HospitalCompare site expect that I put on my Amazing Kreskin glasses, bust out the crystal ball, and predict with 100% certainty which patients I admit will later have a heart attack while in the hospital. A patient might get admitted for an infected hangnail. If the patient later has a heart attack and I didn’t give aspirin and beta blockers or document a contraindication to those medications, CMS considers me a bad doctor.
(Note: The “beta blocker on arrival” metric has since been dropped from the list of current measures – the first of several indicators that CMS apparently is admitting it was wrong about. However, the aspirin on arrival metric still exists and is calculated in the same retrospective fashion)
By looking out for my patients and by failing to be a prophet, I’m a bad doctor.
So be it.
Add these to the reasons why so many doctors and nurses are getting fed up and leaving medicine … at a time when more doctors and nurses are needed to care for sick Americans.
If you believe all of the information on the HospitalCompare.hhs.gov web site, you deserve what happens to you.
Maybe you’ll get lucky and have a “good” doctor who treats your heart attack and head injury the “right way”.
Posted in CMS, Medicare | 40 Comments »
Tuesday, February 17th, 2009
Here’s a conundrum for a VA Hospital.
According to this article in the Oregonian, the widow of a patient who fell to his death from the roof of a Veterans Affairs Medical Center is suing the hospital and the doctors for $4.5 million.
The federal government has already stated that a patient death associated with a fall while being cared for in a healthcare facility is a “never event.”
I wonder whether the widow’s attorney will use the federal government’s new classifications of never events as proof that the government hospital was negligent. After all, if the government states, in effect, that such events should “never” happen, shouldn’t the occurrence of such an event be used as prima facie evidence of the government hospital’s negligence in this matter?
Strict liability.
Hello, summary judgment.
Posted in CMS, Medical-Legal, Never Events | 9 Comments »
Thursday, January 15th, 2009
According to a Yahoo News article (similar article in the Washington Post) a medical records software upgrade in the VA Hospital computer system put the lives of all hospitalized veterans at risk late last year.
According to the article, the “computer glitch” caused patients to get the wrong medications, to receive the wrong doses of medications, to experience delays in treatment, and to receive blood thinning medications for longer than the doctor had ordered them.
The VA was quick to point out that it was not aware of any patient injuries from the “computer glitch,” but the article noted that the VA also tried to “keep the problems quiet” and didn’t initially notify the patients involved in the mix-up.
The article also quotes Dr. Bart Harmon, a former Pentagon chief medical information officer, as saying that “the VA’s problems could become more common as more hospitals and doctors’ offices move toward electronic records.”
The VA system currently includes 153 medical centers and cares for 5.5 million patients. What’s going to happen if a similar system becomes responsible for 5756 hospitals and more than 1 billion patient care visits every year under “socialized medicine”?
Giving unnecessary infusions, delaying care, and trying to “keep problems quiet” aren’t included on the quality indicators list the the government’s “Hospital Compare” web site.
Oh – I forgot. It doesn’t matter. The government won’t put its own hospitals up there for everyone to compare, anyway.
Posted in CMS, Health, News Commentary | 6 Comments »
Tuesday, December 23rd, 2008
 The December 29th edition of American Medical News has an article about how patients choose physicians.
For primary care physicians, more than half of patients choose their doctor by word of mouth and another third choose their doctor based upon a referral from a health plan or from another health professional.
With specialists, a vast majority of patients choose them based upon a referral from the primary care doctor or another physician.
Almost 90% of the time a hospital is chosen based upon where a patient’s physician has privileges or based upon the recommendation of another physician. Friends and co-workers often ask me where they should go for treatment.
One of the interesting things about this survey – which was a national survey of more than 13,500 adults – was that very few patients chose physicians based upon internet sites and only a little more than 4% of patients chose hospitals based upon either the internet or upon “books, magazines, or newspapers.”
The Cliff Note’s version is as follows:
1. If you are a primary care physician, be nice to your patients and take good care of them. Not only will they stay your patients, but they will help you build your practice.
2. If you are a specialist, be nice to the primary care physicians. They account for more than two thirds of your business.
3. If you are a hospital administrator, see #1 above. Invest in your patients and your docs and the rest will follow.
Oh, and all that advertising isn’t doing much to gain you market share. Likewise, no one is paying much attention to that comparison bullhokey at www.hospitalcompare.whatever.com. Stop worrying so much about “quality indicators” that have no basis in science and start worrying more about being good to your patients and your staff physicians.
Word of mouth will get you a lot farther than that ad in the paper.
Posted in CMS, Health, News Commentary | 26 Comments »
Monday, December 1st, 2008
Nice study in the Journal of Emergency Medicine by Shapiro et al. showing that many of the blood cultures performed in the emergency department are low-yield.
At one institution the study was able to decrease the number of blood cultures by 27% and therefore decrease the health costs by nearly $125,000.
At this single study institution’s emergency department, there were 3901 blood cultures drawn over a 1-year period. The study analyzed patient characteristics and determined which patient characteristics were associated with a greater likelihood of bacteremia or “bloodstream infections.”
The symptoms more likely to be associated with bacteremia were divided into “major” and “minor” criteria.
Major criteria included temperature > 39.5°C (103.0°F), indwelling vascular catheter, or clinical suspicion of endocarditis.
Minor criteria included temperature 38.3-39.4°C (101-102.9°F), age > 65 years, chills, vomiting, hypotension (systolic blood pressure < 90 mm Hg), neutrophil% > 80, white blood cell count > 18 k, bands > 5%, platelets < 150 k, and creatinine > 2.0.
If a patient has either one major criterion or two minor criteria, then blood cultures were indicated. Otherwise, patients were considered “low risk” and did not need blood cultures.
Using study criteria, the researchers were able to reduce the number of blood cultures by 27%, resulting in approximately 1053 fewer cultures per year. At an estimated cost of $15.91 per culture and a charge of $118 per culture set, there was a potential savings of $16,758 in costs and $124,286 in charges at ONE HOSPITAL.
In addition to preventing low yield blood cultures, the study also noted additional cost savings. Nearly 5% of patients in the study had false positive cultures, meaning that the cultures grew out an organism when there really wasn’t an organism present. In other words, the samples were accidentally contaminated. The study cited another study showing that patients with contaminated blood cultures have a hospital stay that is an average of 4.5 days longer and costs an average of $4385 more.
Contamination is one of those problems that it is difficult to guard against. Skin is cleansed with iodine and alcohol, but you can’t eradicate every single organism on the skin that could contaminate the needle. The more cultures you draw, statistically speaking, the more contaminated specimens you are going to get.
This study enrolled 3730 patients. Out of those 3730, only about 8% had true bacteremia and more than half that many – almost 5% – had false positives.
Using the study criteria, the researchers were able to identify more than 99% of patients who had positive bloodstream infections. Only 3 of the 3730 patients studied had infections in the blood that were not caught by using these criteria.
Yet, the government requires that we draw blood cultures before starting antibiotics on every patient that might have pneumonia.
I previously commented about how the CMS “Hospital Compare” website is a bunch of hooey.
It doesn’t allow people to compare government hospitals with all the other hospitals.
It purports to show which hospitals meet “quality” measures by performing certain tasks in a timely manner, yet many of the indicators it uses have little scientific basis.
The whole blood culture requirement is just one of the site’s many big failures.
Performing blood cultures before giving antibiotics in pneumonia patients has absolutely no effect on clinical outcome.
False positive cultures increase the length of stay by 4.5 days and increase the cost of hospitalization by nearly $5000.
Now researchers have come up with a way to decrease the number of blood cultures performed in the emergency department by 27%.
Yet, the Department of Health and Human Services and its “Hospital Compare” web site just keep the “stay the course” attitude. Looking for those “bugs of mass destruction” when finding them costs millions of dollars and has no effect on clinical outcome.
I’m sure that not all blood cultures are done on pneumonia patients. If we say that half of blood cultures were done for pneumonias, we would be able to save an average of $60,000 in costs in each of the 5,708 hospitals in the US … actually … lets just round down to 4,000 hospitals so that we underestimate costs … we’d save $240 million in costs.
Some of the ill-conceived indicators on the Hospital Compare web site are causing laypeople and hospital administrators to pressure physicians into practicing bad medicine. The NEJOM study is just one more reason why neither administrators nor the lay public should put much credence in the HospitalCompare statistics.
Just think, we’d save almost a quarter billion dollars per year by ignoring just one inaccurate statistic.
How much could we save if we just took the whole “Hospital Compare” site off the web?
Posted in CMS, Funding Crisis, Health | 6 Comments »
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University of Chicago’s EMTALA violation
Monday, March 30th, 2009According to news reports, a 78-year-old man was brought to the emergency room by ambulance about 12:30 PM. He was put into a wheelchair in the waiting room, but was neither triaged nor logged in. At 4:15 PM, the patient’s daughter wheeled the patient to the triage nurse to ask about the delay. The triage nurse noted that the man wasn’t breathing and called a code, even though rigor mortis had already set in. Unfortunately, rigor mortis is one of those things that usually precludes a successful cardiac resuscitation.
We don’t know anything about the man’s health or his complaints. All we know is that he was brought in by ambulance, sat in the waiting room for 4 hours (at least some of the time accompanied by his daughter), and was dead for a while (rigor mortis takes several hours to set in) before anyone noticed it. Be careful drawing conclusions without knowing all the information.
The University of Chicago admitted that procedure wasn’t followed. In other words, given the recent adverse publicity at the University of Chicago, a couple of nurses had to take the fall for what happened. The University of Chicago posted a statement about the incident emphasizing the U of C’s commitment to quality and safety.
Illinois State, the Medical Marijuana Advocates, and federal investigators are all looking into the incident. Some news reports stated that the feds have now cited the University of Chicago Hospital for an EMTALA violation.
Then comes the big stick. CMS allegedly sent the University of Chicago a letter threatening to take away the University of Chicago’s Medicare funding.
What an idle threat.
If I were the CEO at the University of Chicago, and the feds told me they were considering whether to revoke the hospital’s Medicare funding, I’d give them a double dog dare to go right ahead.
The Emergency Medical Treatment and Active Labor Act (“EMTALA” for short) only applies to “participating hospitals” – those hospitals that receive federal funding under Title 42 of the US Code. If the feds kick the University of Chicago out of the Medicare program and it no longer receives federal funding, then, just like free-standing emergency departments, the University of Chicago has no further duties under EMTALA. It wouldn’t have to provide a screening exam to patients. It wouldn’t have to provide stabilizing care to patients. If the patient doesn’t have insurance, the University of Chicago could essentially tell patients to “go to the county hospital.” It could even call an ambulance and have the ambulance transport the patient to another hospital. It could transfer patients to other hospitals without the transfer being “appropriate” under the EMTALA rules. EMTALA requires that hospitals accept transfer of patients if the hospital provides specialty services, so the receiving hospitals would be stuck taking any patients that University of Chicago decided to send them. Added bonus: the Joint Commission would no longer have any business in University of Chicago’s affairs.
A termination from the Medicare program could be a blessing in disguise. Without being subject to EMTALA, the University of Chicago could technically engage in “patient dumping” and only accept patients with insurance. True, a hospital would lose the income from Medicare (which is the dominant player in the market), but maybe that shift to providing only funded care would make up some of the difference because the hospital would no longer have to provide unfunded care or underfunded care. Would people with insurance go to University of Chicago preferentially if there was less crowding in the ED, if they were treated like royalty, and if appointments were easier to obtain? Might take some number crunching, but an entirely for-profit hospital might be sustainable – especially in a large city.
The thing is … if University of Chicago takes that gamble and is successful, how many other hospitals would consider whether or not to make the same leap? Would a successful large for-profit-only hospital system be the first step to creating a “two level system” where the best doctors go to entirely privately funded hospitals because they receive more compensation, but those doctors aren’t available to patients without a means to pay? Would all patients on public funding then get sheep herded into the public hospitals where they get free care that might not be as high quality or as accessible as at the for-profit hospitals?
Or maybe the University of Chicago will be so affected by the lack of federal funding that it will go out of business like so many other Illinois hospitals.
In either case, remember all those patients that were having difficulty obtaining emergency medical care? Remember Dontae Adams whose face was “chewed off” by a pit bull? Close the University of Chicago or turn it into a strictly for-profit institution that is not subject to EMTALA and guess what happens to all the patients who have public funding or no insurance at all? NONE of them get any care at the University of Chicago. They all get sent to other hospitals that are still required to provide EMTALA-mandated care.
With the new onslaught of low paying patients, wait times at surrounding hospitals will increase and quality of care will inevitably decrease. Eventually, the volumes of patients will overwhelm the surrounding hospitals’ resources to the point that patients will die in other emergency department waiting rooms. More CMS investigations. More hospitals will close.
Lather. Rinse. Repeat.
Less hospitals, more patients in the emergency departments. Yeah. That will go over real well.
So CMS, if you’re playing a game of “chicken” with University of Chicago, you better be driving something larger than a Cooper Mini.
I’ve got another idea: How about fixing the funding of emergency care in this country before waiting room deaths become an everyday occurrence?
Like this.
Or this.
Or this.
Or this.
Or this.
Or this.
Fast care, free care, quality care. Pick any two.
As Scalpel once said, sometimes you only get to pick one. “Free” doesn’t always cut it.
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Also see related articles at:
Huffington Post – University Of Chicago Hospital May Lose Medicare Certification After ER Death
Chicago Sun-Times – U. of C. admits problems with ER death
WBBM Chicago Radio – Feds Threaten Action Against U of C Med Center
The bad blood between the Chicago Tribune and the University of Chicago continues. While most sources had one article about the incident, the Chicago Tribune has had three (and will probably have about a half dozen more):
U. of C. Medical Center says ‘protocol’ not followed in ER death
Medicare warns U of C Medical Center after ER death
University of Chicago Medical Center in violation of emergency room services law, U.S. alleges
UPDATE MARCH 30, 2009
Leave it to Shadowfax to set me straight. See his post related to the above here.
I didn’t consider the funding that training programs receive from the federal government in my equation and agree that removal of such funding would be a death knell for the training program and, more likely than not, the affiliated teaching hospital.
Shadowfax and I are looking at the same problem from two different angles, though.
Shadowfax’s post brings forth some criticisms about the University of Chicago using factual allegations to which I’m not privy.
I’m looking at the issue more from the angle of what happens when a bully picks on too many nerdy kids or what happens when you back an animal into a corner. Right now, hospitals are too afraid that they’ll go bankrupt if they stop taking Medicare funding. Medicare the bully is still winning. At some point, a couple of hospitals are going to stand up to the bully, punch him in the nose, and tell him to stick his paltry payments and all the micromanagement that goes along with them.
If those hospitals survive, others will undoubtedly follow, resulting in huge market shifts. Will lofty professors of specialty medicine remain with their university programs if suburban hospitals pay their specialists twice the salary that professors earn? What if there are one tenth of the documentation and administrative hassles? No JCAHO? Get paid more so you can spend more time with your patients?
Primary care physicians and their patients are finding concierge practices quite rewarding. It’s only a matter of time until a hospital takes the leap.
CMS may still be driving a Hummer when playing chicken with residency programs, but powerful hospital systems in affluent suburban areas might just be driving a Bradley Fighting Vehicle. One of these times, CMS is going to lose … and it will liberate the practice of medicine.
I can’t wait.
Posted in CMS, Medical-Legal, Medicare, News Commentary, Policy | 21 Comments »