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Highlights from the Health Reform Bill

Monday, August 3rd, 2009

These highlights were sent to me in an e-mail.

I have not read the entire bill. However, I did check some of the highlights against the text of America’s Affordable Health Choices Act of 2009 (H.R. 3200) and they are generally on point, although some of the commentary isn’t entirely accurate.

As one example, the Advance Care Planning Consultation in Section 1233 does not permit the government to “order” your end of life care, but only requires that a physician discuss the matter with a patient and denote the patient’s preferences (Section 1233(a)(hhh)(5)(A)(ii).

However, the government does plan to establish a “quality reporting initiative” for end of life care that will essentially coerce physicians into doing what the government wants under the threat of being deemed a “low quality provider” if the physician does not comply. If the government states that “quality care” for end of life involves removing life support on patients that show no improvement after 72 hours, any physician that keeps comatose patients on life support longer than 72 hours will get quality “demerits” from the government. The government may then use those demerits to dock the physician’s pay or to post the physician’s name as providing “low quality” end of life care on some web site. Think about a tremendous database of physicians similar to the “HospitalCompare.gov” web site now. Because of Hospital Compare, hospital administrators strive to be at 100% “quality” even though “good” care may sometimes cause excessive costs without benefit, may be more likely to misdiagnoses and wrong treatments (I commented on this issue previously and the link to the actual article on a government website mysteriously went bad), or may even be more likely to contribute to patient deaths.

Draw your own conclusions after reading the sections in the bill. Commentary (from unknown source) is contained below.

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• Page 22: Mandates audits of all employers that self-insure! (Section 142(b))
• Page 29: Admission: your health care will be rationed!
• Page 30: A government committee will decide what treatments and benefits you get (and, unlike an insurer, there will be no appeals process)
• Page 42: The “Health Choices Commissioner” will decide health benefits for you. You will have no choice. None.
• Page 50: All non-US citizens, legal or not, will be provided with free health care services.
• Page 58: Every person will be issued a National ID Healthcard. (Section 163(a) – not entirely accurate – potential action, not mandatory)
• Page 59: The federal government will have direct, real-time access to all individual bank accounts for electronic funds transfer. (Section 163(a) – not entirely accurate – potential solution, not mandatory)
• Page 65: Taxpayers will subsidize all union retiree and community organizer health plans (read: SEIU, UAW and ACORN)
• Page 72: All private healthcare plans must conform to government rules to participate in a Healthcare Exchange.
• Page 84: All private healthcare plans must participate in the Healthcare Exchange (i.e., total government control of private plans)
• Page 91: Government mandates linguistic infrastructure for services; translation: illegal aliens
• Page 95: The Government will pay ACORN and Americorps to sign up individuals for Government-run Health Care plan.
• Page 102: Those eligible for Medicaid will be automatically enrolled: you have no choice in the matter. (Section 205(b)(3))
• Page 124: No company can sue the government for price-fixing. No “judicial review” is permitted against the government monopoly. Put simply, private insurers will be crushed. (Section 223(f))
• Page 127: The AMA sold doctors out: the government will set wages. (Section 224)
• Page 145: An employer MUST auto-enroll employees into the government-run public plan. No alternatives.
• Page 126: Employers MUST pay healthcare bills for part-time employees AND their families.
• Page 149: Any employer with a payroll of $400K or more, who does not offer the public option, pays an 8% tax on payroll (Section 412(c))
• Page 150: Any employer with a payroll of $250K-400K or more, who does not offer the public option, pays a 2 to 6% tax on payroll
• Page 167: Any individual who doesn’t have acceptable healthcare (according to the government) will be taxed 2.5% of income.
• Page 170: Any NON-RESIDENT alien is exempt from individual taxes (Americans will pay for them) (Section 401(a)).
• Page 195: Officers and employees of Government Healthcare Bureaucracy will have access to ALL American financial and personal records.
• Page 203: “The tax imposed under this section shall not be treated as tax.” Yes, it really says that. (Section 441(a))
• Page 239: Bill will reduce physician services for Medicaid. Seniors and the poor most affected. (Section 1121(c))
• Page 241: Doctors: no matter what specialty you have, you’ll all be paid the same (thanks, AMA!)
• Page 253: Government sets value of doctors’ time, their professional judgment, etc.
• Page 265: Government mandates and controls productivity for private healthcare industries.
• Page 268: Government regulates rental and purchase of power-driven wheelchairs.
• Page 272: Cancer patients: welcome to the wonderful world of rationing! (Section 1145)
• Page 280: Hospitals will be penalized for what the government deems preventable re-admissions. (Section 1151(a))
• Page 298: Doctors: if you treat a patient during an initial admission that results in a readmission, you will be penalized by the government.
• Page 317: Doctors: you are now prohibited for owning and investing in healthcare companies!
• Page 318: Prohibition on hospital expansion. Hospitals cannot expand without government approval.
• Page 321: Hospital expansion hinges on “community” input: in other words, yet another payoff for ACORN.
• Page 335: Government mandates establishment of outcome-based measures: i.e., rationing.
• Page 341: Government has authority to disqualify Medicare Advantage Plans, HMOs, etc.
• Page 354: Government will restrict enrollment of SPECIAL NEEDS individuals. (Section 1177)
• Page 379: More bureaucracy: Telehealth Advisory Committee (healthcare by phone).
• Page 425: More bureaucracy: Advance Care Planning Consult: Senior Citizens, assisted suicide, euthanasia? (Section 1233)
• Page 425: Government will instruct and consult regarding living wills, durable powers of attorney, etc. Mandatory. Appears to lock in estate taxes ahead of time.
• Page 425: Government provides approved list of end-of-life resources, guiding you in death.
• Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.
• Page 429: Advance Care Planning Consult will be used to dictate treatment as patient’s health deteriorates. This can include an ORDER for end-of-life plans. An ORDER from the GOVERNMENT.
• Page 430: Government will decide what level of treatments you may have at end-of-life. (Section 1233(b))
• Page 469: Community-based Home Medical Services: more payoffs for ACORN.
• Page 472: Payments to Community-based organizations: more payoffs for ACORN.
• Page 489: Government will cover marriage and family therapy. Government intervenes in your marriage. (Section 1308(a))
• Page 494: Government will cover mental health services: defining, creating and rationing those services.

Mind Snap

Monday, July 6th, 2009

Donkey in BarnI’m getting just about fed up with the Medical Marijuana Advocates (AKA “JCAHO”, AKA “TJC”) and this whole bunch of HospitalCompare.gov bullhokey.

The chart police at our hospital audited a bunch of charts from the emergency department and I got letters about several “serious offenses.”

First, I got in trouble because I couldn’t be credited with giving antibiotics within the 4 hour … no … now make that 6 hour window for a patient with pneumonia. For the moment forget about the fact that this quality indicator may do more harm than good. Forget that most pneumonias are viral and that requiring doctors to give antibiotics for these viral infections, similar to using Raid to kill dandelions, increases bacterial resistance and helps to spread MRSA. But I digress.

It wasn’t that the patient didn’t get timely antibiotics. The patient got antibiotics not within just 4 hours, but within 2 hours. By the way, congratulations on your increased chances of acquiring MRSA due to our government agency’s blind directives, sir.
It wasn’t that the patient didn’t get appropriate antibiotics. The patient had allergies to several medications (that were from 50 years ago when he was an infant, so he didn’t know what the reactions were), and given his history, we used clindamycin.
My serious offense was that CMS supposedly couldn’t tell what medication was ordered. Instead of writing out “clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes,” the order said “clinda 300mg IVPB.” The nurse gave clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes. But it was still considered poor quality care not because the patient didn’t receive his medication … not because the medication wasn’t given in a timely fashion … but because micromanaging government clipboard patrols with apparently little medical background couldn’t figure out what medication was ordered.

Fortunately for everyone involved, the ClindaCyanide and the ClindaDrano were on backorder in the pharmacy. Otherwise, the patient could have received some other dangerous medication beginning with “clinda” via his IV. Oh yeah, I forgot, there are no other medications beginning with “clinda” aside from clindamycin.

Just another reason why the whole HospitalCompare.org web site should be viewed with a healthy dose of skepticism. The statistics don’t necessarily tell you what they purport to tell you.

But that’s not all …

I also got dinged because I didn’t do one of the Medical Marijuana Advocates’ “time out” forms before doing a lumbar puncture and before draining an abscess.

“Time outs” are required before surgery so that surgeons don’t cut off the wrong appendage or do surgery on the wrong site. There are multiple requirements for a “time out” including preparing proper documentation (because that contributes so much to patient care), reviewing relevant images (if any), readying any necessary equipment, making an unambiguous mark near the procedure site with ink that will still be visible after any skin preparation (doctor’s initials are suggested), and double-checking the site mark before the procedure.
I’m not actually sure that these are the requirements, because I tried to look them up on the Medical Marijuana Advocates’ web site, but they keep the requirements hidden. Isn’t it great how an organization that is supposedly advocating for patient safety keeps all of its initiatives hidden from public view? But I digress yet again.
In theory, I don’t have any problems with marking the site to be operated on if a patient is going to be put under anesthesia prior to surgery and won’t be able to say “Hey doc, why are you starting to cut on my left leg when the abscess is on the right leg?” I’ll even go as far to say that the “time out” concept is a good idea under those circumstances.

But apparently the Medical Marijuana Advocates are now applying this “good” idea to areas where it does not belong and are now citing hospitals for compliance issues if there is not a “time out” form on file for every invasive procedure – even those done at the bedside. Of course I can’t find this on the TJC web site either. If this policy is true, it is asinine.

How exactly is it that I’m going to do a wrong site lumbar puncture? It’s not like I’m ruling out meningitis in many jellyfish. I haven’t had to rule out a subarachnoid hemorrhage in a Siamese twin lately. I don’t suffer from short term memory loss, so it’s not like I won’t remember the patient who just signed the consent form for me to do the procedure. Explain to me how drawing a circle and writing my initials on the back of a patient getting a lumbar puncture is going to improve patient safety.

Leg abscesses are just as bad. Good thing JCAHO is saving us from maiming people with abscesses in the emergency department. “Yeah, sir, that 10 cm abscess on your leg disappeared in the three minutes that elapsed between the point when I examined you and the point that I returned to the room after going to get a scalpel. Oh well, as long as you’re here, I guess I’ll just fillet open your thigh to look for ingrown hairs. Ooops! The abscess was on your other leg! Sorr-rry!”

If we’re going to do these forms on every invasive procedure, the lab is going to have a lot more work drawing blood. A spinal tap can be considered “drawing spinal fluid”, so drawing blood must also be an invasive procedure. Now doctors are going to have to be involved with every blood draw.

I’m most worried about a couple of other invasive procedures, though.

Not sure how the female patients are going to explain to their significant others how my initials got on their crotches if I have to do a pelvic exam.

And I could be wrong, but I don’t think that too many guys are going to let me draw a circle around their anus and put my initials there before I get out the glove and lube to do a prostate check.

Well … I’m going to go have a time out, write my initials on my right wrist, get all the proper equipment together (including a bottle and a frosted mug) and have 12 oz of ClindaBudweiser p.o. before I stroke out.

Why Rationing of Care Won’t Work in the US

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.

How to get rid of C. diff?

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.

Many Doctors Opting Out of Medicare

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.

University of Chicago’s EMTALA violation

Monday, March 30th, 2009

secret-service-agent-pointingThere’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.

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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.

Emergency Care – Where’s The Line?

Wednesday, February 25th, 2009

rat-under-yellow-lines-in-streetThe 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.

Why I’m A Bad Doctor – Part 2

Monday, February 23rd, 2009

Better Be Prompt!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”.

VA Never Events

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.

The Future Under Socialized Medicine?

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.

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