You hospitals want to save money? Stop treating low income patients in your emergency department. After implementing its Urban Health Initiative, the University of Chicago doubles it operating profits for the year. During that same time period, ED visits dropped 22% and admits dropped 8.5%.
One problem, though. If more hospitals take this approach, where are the poor patients going to get the more “mundane” medical care?

Minnesota Governor Tim Pawlenty suggests that one way to cut health care costs is to change federal EMTALA laws so that “not every ER is required to treat everybody who comes in the door, even if they have a minor condition.”
He’s now getting flamed all over the internet. See here, here, and here for examples.
The thing is, EMTALA laws don’t require every “ER” to treat every patient. Hospital emergency departments are only required to provide a screening exam to everyone and to treat emergency medical conditions. Pawlenty already has his wish, and it’s not so radical, folks. To wit: (I saw that phrase in a lawsuit brief and am getting a kick out of using it, so leave me alone)

More hospital emergency departments are jumping on the “pay before you see the doctor” bandwagon. Burke Medical Center in Georgia stated that it was “following the trend of other facilities” when it implemented a policy of paying your insurance co-pay or $100 before receiving treatment. If you don’t pay and don’t have an emergency condition, you’ll be given a list of outpatient clinics where you can go for care.

In the same vein, do doctors in America turn away the uninsured? Absolutely. Read this HuffPo article to get a good idea of how and why. Good insights.

Nebraska physician advocates personal responsibility as one way to improve this country’s health care problems. I agree.

“Do you know where your son spent the night?” College students go to emergency departments for intoxication and college calls parents to narc on them. “Sent to the hospital.” “Alcohol poisoning.” “Not the first violation.” The schools also call home every time a student is caught with alcohol. Some schools allege that “telling mommy” decreases the amount of binge drinking on campus, but isn’t there some type of privacy issue going on there, though? What’s next, a voice mail message at mom’s work if you don’t finish your carrots in the cafeteria?
If an administrator did this to me when I was in college, I would have followed him all over campus and followed him home, calling his mommy and his wife every time he rolled through a stop sign or looked at me crosseyed. Then I would have written an article to the school newspaper chronicling all of his transgressions. Then I would just randomly go to his office with a notebook, wait in the waiting area, sit there writing for 30 minutes at a time, then get up and leave. Can’t be too careful about those college administrators, you know.

Reserved parking for the four pronged canes to the left, leave your brown paper bags of medicine on the counter. A geriatric emergency department – the wave of the future or a flash in the pan? Will they remain viable with Medicare cuts to physician payments or will hospitals use them as a loss leader to draw in patients for more profitable procedures?

Bad debt causes Arkansas hospital to implement unpopular policy – make a $50 down payment before you can see the emergency physician. What!?!?! That’s more than a carton of smokes and a case of PBR combined!

Anger management classes are down the hall. Cape Cod punk getting treated for cuts to his hand he sustained when he punched a mirror then puts emergency department security guard in headlock and starts punching him in the face when security guard started “staring at him.” Lighten up, Francis … oh, and enjoy your stay the Greybar Motel.

Deaconess Hospital emergency department closure “disastrous” and isn’t addressing “critical problems facing emergency patients” according to ACEP president Angela Gardner. Spot on, doc.

Michigan’s Medicaid system is out of control. One in 6 Michigan residents qualify for Medicaid and it covers 40 percent of all births and 70 percent of all nursing home care. How will Michigan close the Medicaid budget deficit? Tax doctors on their gross receipts. Yeah. that will work. Up to 45% of Michigan docs already refuse Medicaid patients. Watch that number jump.

Good news: Visits to Canadian hospital emergency department decrease during Olympics. Bad news: Number of patients suffering from drunkenness and assaults spiked. During the Olympic games, hospitals in downtown Vancouver were seeing an average of 17 assault victims per day – triple the usual number.

Medical malpractice cases at all time low and total malpractice expenditures only 0.6% of total healthcare budget … according to Public Citizen. Oh, tort reform in Texas is a failure and a 1999 IOM study showed that doctors kill 99,000 patients every year due to avoidable errors. Yeah, that about covers it.

Phil Howard speaks on tort reform. Inspiring – at least to the non-lawyer commenters. (Thanks to Mad Rocket Scientist for the link)

When everything is an emergency, nothing is an emergency. Pittsburgh man calls 911 ten times in two days complaining of abdominal pain. Unfortunately, Pittsburgh just got socked with a snowstorm, there was two feet of snow on the ground, ambulances were unable to get through the roads, and paramedic calls were at twice their usual volume. At one point, 30 calls were waiting for ambulances to arrive. The man took pain pills and ended up dead.
Now the city plans to have firefighters respond to some 911 calls … between fighting fires, of course.
One commenter to a report of this incident on Medscape blogs noted that tax cuts can have the same effects of decreasing available personnel and increasing wait times. Another commenter stated that services in his area had been cut so thin that patients were better off taking a taxi.

Inner city emergency departments have nothing on Haiti after the earthquakes. Emergency physician Scott Plantz describes his experiences in a USA Today article.

Also see the Satellite Edition of this week’s Healthcare Update over at ER Stories.

Seven secrets of the ER … including quotes from GruntDoc. Among them, fretch if you want to get to a room more quickly and never lie to your ER nurse.
Secret #1 in my hospital: Stop calling it the “ER” already. It’s the emergency department.

Want to know why it’s called the emergency department? Here’s an explanation from About.com.

Defensive medicine accounts for $650 billion of the $2.5 trillion spent on healthcare annually – or about 25% of all health care dollars. Press release here. I know, I know. Propaganda. Even so, that number is just a little bit more than the figures that the AAJ is throwing around.

Study shows that repeal of malpractice caps in Illinois will increase liability claim costs by 18%. I know. More propaganda.

Treat me or I’ll BLAST ya’. Nurse and former hospital employee uses guns to get quicker care for a kidney stone, then gets a long-term admit to the Greybar Motel. If this guy got brought back acting all Yosemite Sam with me, I’d be like this:
“Yeah, we’re going to give you this IV pain medication that’s great for kidney stones. It’s called succinylcholine. Then, since the department is crowded today, we’re going to have you share a room with this other patient. By the way, you’re not wearing a G-string, are you?”

Medical malpractice caps are unconstitutional, huh? Fine, then we’ll change the constitution. After Illinois Supreme Court throws out malpractice reform due to concerns with constitutionality, Illinois State Senator Dave Luechtefeld introduces constitutional amendment that would allow legislation limiting non-economic damages.

Child dies when EMTs are dispatched to Avenue C in Brooklyn but the emergency was on Avenue C in Manhattan.

Canadian Premier leaves Canada to have minimally invasive heart surgery done in Florida, then writes a check to cover the cost.  I like the free market principles at work here, but what does this decision say about Canadian health care? Canadian docs aren’t very happy. Hat tip to 911Doc.

Coming soon to a ballpark near you – warning labels on hot dogs. According to the American Academy of Pediatrics, hot dogs are allegedly “too flexible” and are a choking hazard to children, necessitating a change in design. Worse yet, hot dogs could shoot your eye out (hat tip to Overlawyered)
Enter … the dogburger.
In other news, due to this report, JCAHO has now mandated that all patients eat only pureed food as a patient safety measure. Oh … and all children will have to get gastrostomy tubes placed so that they won’t choke when trying to swallow food.
I feel a rant coming on …

Alaskan psychiatrists being sued for prescribing unnecessary psychiatric drugs to children.

Six family members hospitalized, five in the ICU, after eating homemade beef stew. I’m no Emeril Lagasse, but when making a stew, pulling weeds out of the backyard and putting them in the pot probably isn’t the best idea … especially when one of the weeds isn’t “mint” but is instead hallucinogenic jimsonweed. Hat tip to LA Times Booster Shots.

See also the satellite edition of this Healthcare Update with more links over at ER Stories.

“The health reform bill sucks. Just start over.”
- 57% of Americans

Screw the client. According to the headlines of this news release (see above), juries have just started awarding verdicts directly to medical malpractice law firms, not to the patients who suffered the injuries. Foreshadowing?

More hospitals jumping on the “no dialysis for you” bandwagon. As they refuse to provide outpatient dialysis for patients, they have seen their emergency department visits increase.
Dialysis patients showing up in Grady Hospital’s emergency room receive dialysis only in “life-or-death situations.”
One Las Vegas hospital saw its number of emergency department visits for dialysis-related issues more than double in 2009. Now the hospital spends $700,000 per month providing dialysis services in its emergency department.
Doing some simple math, if the hospital spends about $8.4 million/year on emergency dialysis now, its costs have gone up by about $4 million in the past year – just for dialysis-related medical problems. In this hospital, the total number of emergency department visits for dialysis was 243, meaning that each patient gets about $35,000 per year in medical resources.

Ever wonder what kind of calls come in to a poison center’s hotline? Read the Illinois Poison Center’s blog and find out. 35 calls between midnight and 7AM. Some interesting, some sad issues. Those of you from Illinois who want to help keep the poison center in business can also use a link on the site to send an e-mail to Illinois’ governor or add a donation.

Guarantee: Get seen in this emergency department within 15 minutes or your visit is free.
The catch is that the clock starts ticking “after you finish your paperwork.”
I would be interested in seeing how this system is implemented.
It appears that they have the opportunity to cherry pick paying patients and filter out the patients who don’t have the means to pay before they put themselves on the hook for free services. “Sorry, ma’am, but part of the paperwork included with patients who have no insurance is a $200 co-pay and a satisfactory medical credit check. What’s that? No co-pay? You’ll need to go to the ancillary paperwork department.
The emergency department is new and there are only 8 beds. When it gets busy, the slow lady in the lunch line for non-emergent cases will probably be the long waits for the paperwork to be finished. I give them 9 months before they repeal the policy. Until then, the concept looks like it is bringing them a lot of good PR.

I mentioned this case in a previous Healthcare Update, but now it is going to trial. Will criminal charges against nurses who reported a physician’s actions to the Texas medical board affect the willingness of others to report actionable physician behavior? Interesting discussion in the comments section at Overlawyered.com.

Emergency visits in LA suburb more than double in less than 10 years. Of those patients, 50% have Medicaid, 30% are self-pay (where hospital collects less than 5% of bills), 10% are Medicare and 10% have other insurance. Will increased volumes offset lower payments?

Less access to health care for NY citizens. St. Vincent’s Hospital in New York closing due to massive debt.

Meanwhile, Deaconness Hospital in Indiana is expanding its emergency department. That way, when nursing homes send patients there and refuse to take them back, the patients will have a place to stay.

Edwin Leap has an all-too-appropriate post about what message boards in the emergency department should say. Some of the good ones:
‘Sorry about the wait, but after all, your symptoms started 10 years ago, right?’
‘We can access your recent narcotic prescriptions online. Creepy, isn’t it?’
‘If you can throw a chair, your back pain isn’t that bad.

Like a scene from that canceled NBC television show about emergency departments …
A 24 year old Ohio mom – who is pregnant with twins – starts having trouble breathing and left arm pain. She goes to the emergency department and is diagnosed with … a heart attack! At 24 years old!
Before she can go for her triple bypass surgery, the medical staff decides to deliver the 32 week old babies by Caesarian section … in the emergency department.
Now mom and babies are doing fine.
In other news, top Ohio plaintiff attorneys are recommending that the patient sue the hospital for $60 million because the scar from the Caesarian section makes her pubic hair line uneven and has forever ruined the patient’s sex life.

Britney Spears goes to hospital emergency department … in caravan … with police escort. Sounds like an emergency.

How far in debt is our country? Go to this web site to see real-time measures of our national debt broken down into multiple metrics. Just have someone ready to catch you in case you faint.

See more news stories from around the web over at ER Stories in the Satellite Edition of this week’s Healthcare Update.

When it’s dead and you don’t know what to do with it, send it to pathology. When it’s alive and you don’t know what to do with it, send it to the emergency department — and don’t take it back. Wesley Healthcare Center in Auburn, IN sent a patient to the Angola Hospital emergency department and then wouldn’t take him back after he was cleared for release. Demonstrating an efficient use of resources, Gregory George was forced to stay in the emergency department for a week with around-the-clock care.
One former employee of the nursing home stated that the “patient dump” had been planned because the nursing home staff was fed up with the patient’s “excessive complaints” to the State about the nursing home.
In other news, the Joint Commission has declared that this incident shows how nursing homes may be a danger to patient safety. All nursing homes must close. Immediately.

Here’s a good way to help clear up California’s budget deficit. Start fining hospitals for mistakes.
If this takes off, soon they’ll be fining housing contractors for using the wrong pipes, police stations for arresting the wrong people, schools for failing to use the right curriculum, law firms for filing the wrong motions, and legislators for drafting crappy legislation. Instant riches!
Ooooh ooooh, I know! Maybe they can fine citizens when they move out of the state. Then California would have a budget surplus in no time.

Can’t take the heat? Get out of the kitchen. California city mayor has been to the emergency department five times in past six years suffering from chest pains after getting into arguments at city council meetings. Maybe it’s time for a career in horticulture?

Difficult decisionmaking. An elderly patient with multiple organ systems failing goes to the emergency department for an exacerbation of heart failure and decides he wants “everything done”. He is put on a ventilator, goes on dialysis, requires a feeding tube, and dies after six months in the hospital. The patient’s daughter questions whether her father’s decision was the correct one.

Attorney wins $3.8 million verdict for client in bad faith medical malpractice insurance claim, then takes $1.7 million in attorneys’ fees. When costs of the suit are paid, the attorneys will likely make more money from the case than their injured clients. Now the attorneys are suing each other about how the attorneys’ fees should split. Ironic how the attorney with the money is now referring to the ones suing him as “bank robbers.”

“Now craziness has a name … it’s called CYA.” This editorial in the Chicago Flame about health care reform and defensive medicine is spot on.

Interesting paper about defensive medicine and “disappearing doctors.” This 2005 study finds that increasing malpractice premiums generally don’t affect the numbers of physicians practicing in each state, but that increasing premiums do affect the willingness of some specialists to remain in practice – such as rural surgeons who tended to just retire. This study showed that “direct tort reform increases physician supply in the short run by 2.4 percent” and reduces growth of expenditures between 5 and 9 percent. Note that the paper was published shortly after tort reform was enacted in Texas and that there have been significant and sustained increases in physician supply in Texas since tort reform was enacted.
A graph in the paper notes that between 1993 and 2001, malpractice insurance premiums for internists in Texas increased by nearly 150%. After tort reform was enacted in Texas, medical malpractice premiums dropped by more than 40%.
What else do physicians do when faced with increasing malpractice payouts? Order tests. Significant increases in cardiac catheterizations and CT scans were noted with increased malpractice payouts.
Don’t worry, though. According to the trial lawyers, defensive medicine doesn’t exist.
Hat tip to Ezra Klein

What’s with the bizarre viral infections coming out of Africa? AIDS, ebola virus, now the chikungunya virus. Get bit by a mosquito carrying the disease and you could come down with high fevers, a rash, and severe arthritis for several years. Yes, you can sign me up for the vaccine, thank you. More about the virus from Wikipedia and from the CDC.

Minnesota is the 34th state to begin monitoring the prescription of narcotics. According to this article, 117,000 Minnesota adults abuse prescription drugs each year. Next month, prescription records for patients will be available in a centralized database. The comments section to the article has many anecdotes about people who fear they won’t get needed pain medications and about how people currently abuse the system. One post wonders whether everyone will just begin using aliases and fake addresses. That may work until you have to show a copy of your ID when picking up a prescription. No ID? No Vicodin.

More evidence that insurance doesn’t equal health care. Rural senior citizens in Arizona are having difficulty finding physicians who accept Medicare. Doctors state that they are reimbursed about 55 cents of every dollar they bill for Medicare patients, and they have to hire additional office workers to deal with all of Medicare’s paperwork. Instead of dealing with the bureaucracy and the hassles, the doctors just stop seeing Medicare patients.
Adding to the problems … Arizona has cut funding for graduate medical education, so less training spots are available. Result for the patients with “insurance”? Waits for 6 weeks to 10 months to see a physician. Some drive several hundred miles to Phoenix and pay for a hotel room to get sooner appointments.
With the 21% Medicare reimbursement cut about a month away, seniors can expect things to get a lot worse. I won’t hold my breath for a 21% cut in Medicare taxes being taken out of our paychecks.

Being 50% underfunded, the Indian health program in South Dakota boils down to simple economics: No funding, no health care.

Delaware had one large pharmacy chain threaten to pull out of its Medicaid system due to … you guessed it … low reimbursements. Walgreens made the threat and got some changes to its reimbursement rates. CVS pharmacies and Rite Aid are also feeling the squeeze.

Kids may drive you crazy, but they keep your blood pressure under control. This study shows that adult parents have lower blood pressure readings than childless adults.
Personally, I think it has to do with all the booze parents drink after the kids go to bed.

What are hospital operating costs per patient? About $2800 if you’re in Oregon. That totals about $7.5 billion per year which is as much as is spent in Oregon on schools, universities, prisons, police and social services combined. More and more of that care is becoming uncompensated or undercompensated, leaving hospitals “very definitely in trouble.”
The article even includes a breakdown of sample charges from Legacy Good Samaritan Hospital in Oregon including $203 to inject medication through an IV line and a $10.15 charge for a medication that costs less than 10 cents wholesale. The entire cost for a four day stay in the hospital for a colon infection was $12,674.

The game of medical funding hot potato continues. Miami hospital system stops providing dialysis for indigent patients due to mounting budget losses. Instead, patients are encouraged to go to the emergency department so that Medicaid will be forced to pay the cost for the visits.
Rather than risk crowding in their hospital emergency departments, three other Miami area hospitals contributed $100,000 to pay for outpatient dialysis for one month while seeking a longer term solution

Boston Medical Center lawsuit accuses Massachusetts of illegally cutting payments to hospital for indigent care and of “financ[ing] its health insurance law, a model for national healthcare overhaul, on the backs of poor residents.”
BMC President Elaine Ullian makes similar comments in a speech to hospital donors. Massachusetts Governor Deval Patrick gets offended and writes letter to hospital’s board of directors calling Ullian’s comments “wrong” and “unhelpful.”
In other news, Ullian was then seen sneaking around Governor Patrick’s neighborhood at night carrying a carton of eggs and several rolls of toilet paper.

Need to see a mental health counselor? OK, our next open appointment is January 2015. The average wait in Polk County, Iowa is about 14 months for mental health care and can be “up to five years before some people can receive care.” At last count, there were more than 500 people on the waiting list. Cuts in services are being made as the state tries to balance its budget.

Medical malpractice judgments and settlements are now being posted online. The North Carolina Medical Board’s site is here. A story in Fox news about the innovation is here. According to the article, about two dozen licensing boards in several states publish malpractice information.
A number of years ago, there was a public outcry when a group in Texas posted names of plaintiffs who filed malpractice suits against physicians. Everyone seems content when physicians are exposed to public scrutiny.
Also interesting that the President of the NC Board, Donald Jablonski, was reprimanded by the Florida Board of Osteopathic Medicine. Amazing what you can learn on these sites.

It is an emergency department or a hockey rink? Patient punches emergency physician in the face (link from Gladwin, MI now changed to subscription only, so article unavailable). Meanwhile, a different patient punches emergency department nurse in face. Then, a mother threatens to kill ED staff then grabs security guard by throat. I need me a stun gun.
Then I read about a police officer being stabbed in the neck and killed while sitting in his car in an emergency department parking lot.
What is wrong with people?

More budget woes affect medical care. Cook County’s $75 million health care budget shortfall results in even more cuts in medical services. Nine hundred hospital positions were cut last year and an additional 450 positions will be cut this year. A patient notes that a 10 hour wait in the Stroger Hospital emergency department waiting room “isn’t bad” and that the longest wait he’s seen is 30 hours.

Gunshot victim seeks emergency care from naturopath? And the naturopath agrees? Somehow, I don’t think herbal extracts and rolfing are going to cure internal bleeding.

Increasing medical malpractice claims in Tennessee. Out of more than 3000 cases filed in 2007, only 7 went to trial and 492 were settled. The remainder “died on the vine.”

Emergency department staffing company Team Health’s IPO was disappointing, as they only opened at $12 per share rather than the $14 to $16 they were expecting. Even so, Team Health’s net income last year was nearly $2 billion. Talk about “going green” …

Also check out Part 2 of today’s update over on ERP’s site at ER Stories.

…

Medicare on Rye, Hold the Mayo. The Mayo Clinic is no longer accepting Medicare patients at one of its primary care centers in Arizona as the reimbursements are too low and the system lost more than $800 million treating Medicare patients last year.
According to the article, 92 percent of U.S. family doctors participate in Medicare, but only 73 percent of those are accepting new patients under the program. When Medicare cuts its reimbursement by 21% in a couple of months, look for those figures to drop precipitously.
I know, it’s like a skipping record, but I’m going to say it anyway … it sure is a good thing that all those Medicare patients have insurance, isn’t it? Because according to all the health care reformers, making sure that everyone has insurance is the most important part of reform.
Hat tip to 911Doc at MDOD.

From Dr. Wes … a gerontologist who opted out of Medicare because he couldn’t make ends meet at the rates Medicare was paying.
Medicare’s response? “Medicare was only too happy to have me opt out, because to them, I’m no longer part of their problem.”
This will be the modus operandi of the future, folks. Take money from our paychecks to “pay” for everyone’s medical coverage, then diminish payments until most of the providers leave. End result: we end up paying more and more to receive less and less – or to receive the promise of more medical care that never materializes. Heck, at this rate, Medicare might be turning a profit in 5-10 years.

Europeans express surprise about the speed with which an appendectomy is performed in the US.

See? At least one of us docs isn’t a malevolent quack. An emergency doc pays a patient’s rent so the patient will stay in the hospital.

We’re already closer to national health care than we think. According to a chart posted by Daniel Mitchell at the Cato Institute, American consumers pay for less than 12 percent of their health care costs. I’m not sure that is entirely accurate as a large amount of health care costs are funded by Medicare taxes taken from our paychecks, but the impression that we “aren’t paying for health care” likely explains why few people care about (or even know about) how much health care actually costs and why the system will crumble when 40 million members are added to its ranks.

Family awarded $20 million when woman aspirates stomach contents during surgery and dies.

Family of 3 year old child awarded $15 million when child dies after eighth surgery “in a desperate effort to save his life” from a heart birth defect. Surgeon leaves position as chief of surgery after lawsuit filed. Don’t worry, though. Direct medical malpractice is only a “tiny fraction” of all health care costs. Lawsuits like this are nothing to worry about.

Suing hospitals that “didn’t plan well enough” for Hurricane Katrina. The hospital systems “met or exceeded applicable electrical codes and standards,” but they didn’ t withstand flooding from the hurricane. With 200+ lawsuits now pending, some hospitals are deciding whether to spend money on equipment for the intensive care unit or on upgrading the emergency electrical system so they don’t get sued again.
Some lawyers just need to be castrated with a couple of bricks.
In other news, JCAHO has now deemed hurricanes a threat to patient safety and cited God for causing them. God has 30 days to come up with an action plan or risk being decredentialed as a deity.

Maybe we can sue our way to better health care. Opponents of the health care bill argue that the “individual mandate” in the health care bill is unconstitutional.

“Doctors Warn Cold Weather Causes Problems.” Phew. Glad they cleared that one up for me. Still have these nagging questions about loaded guns and intravenous drug abuse, though. Maybe they can do a follow up article.
The article states that “Flu, pneumonia, the common cold, even allergies can flare up, the problem arises when people assume they have these sicknesses and avoid finding underlying problems.” So rush to your doctors for all your snot noses boys and girls. Wouldn’t want to miss some underlying problem like nematode infestations or something.

Fudging numbers to please the pencil pushers. The NHS in Great Britain has a goal that no one waits to be treated in “casualty departments” (better than calling them “emergency rooms“, I guess) for more than 4 hours. According to the records, a “vast majority” of patients are seen within 3 hours.
Data collected from other sources shows that patients are often moved out of the departments and into other units prior to evaluation which stops the “four hour clock” from ticking. For example, some patients are put in “emergency assessment units” where the average wait is 17 hours and some patients are put in “medical assessment units” where the average wait is 22 hours.
A representative quote from the article: “Labour’s insistence on forcing doctors to focus on ticking boxes ahead of looking after patients means that more time is spent on devising elaborate schemes to satisfy the bureaucrats rather than making sure unwell patients get better.”
Quick care, quality care, free care. Pick any two.
In other news, as a result of this story, JCAHO is now requiring that hospitals close their emergency departments as a patient safety measure.

Paging Dr. Cheech. Paging Dr. Chong. Emergency physician testifies in Pennsylvania about the medicinal use of marijuana. From an emergency physician’s perspective??? Yeah, I see patients in emergent need of a bong hit just about every shift I do [eye roll].