Archive for the ‘Insurance’ Category
Friday, September 25th, 2009
In 2008, St. Johns Hospital and Mary Immaculate Hospital in Queens had a total of 119,883 outpatient department visits.
In February 2009, the two hospitals went bankrupt and closed.
In June 2009, the New York City Office of Policy Management published a paper showing that once St. Johns and Mary Immaculate Hospitals closed their doors, the patients that previously went to those hospitals didn’t just vanish. Instead, the patients flocked to other nearby hospitals which were already operating at capacity.
Guess what happened?
Those nearby hospitals – such as Jamaica Hospital in Queens, are now “overwhelmed.” According to the report, Jamaica Hospital’s daily census went up 50% — from 350 visits per day to “well over” 500 visits per day. On May 27, 2009, Jamaica Hospital had 663 visits – more than double its usual number. Other area hospitals such as Elmhurst Hospital, Queens Hospital Center and New York Hospital Queens noted increases of at least “an extra 100 patients a day.”
The number of patients being boarded in the Emergency Department of nearby hospitals also “soared.” Jamaica Hospital, Queens Hospital Center, and Long Island Jewish Hospital all noted dramatic increases in the numbers of patients being boarded in their EDs.
One emergency physician with twenty years of experience was quoted as saying “the state of emergency medicine in the borough of Queens is the worst I’ve seen it in my career.”
At the heart of the hospital closures was funding.
New York City was subsidizing St. Johns Hospital and Mary Immaculate Hospital to the tune of $61 million over the years leading up to the hospital closures. The City was unable to sustain that commitment. Without the city’s support, the hospitals went bankrupt.
Availability of ambulance services is also now in question. When St. Johns and Mary Immaculate hospitals closed, the ambulance services operated by the hospitals also ceased operations. None of the remaining hospitals was interested in providing ambulance services to the area served by Mary Immaculate Hospital, so ambulance service in that area was temporarily taken over by New York City Fire Department EMS. NY City is cutting the budget for the EMS service by $3 million which will result less ambulance availability. One mother noted that it took 25 minutes for an ambulance to reach her home after her son had a seizure. A $60 million Medicaid reimbursement reduction anticipated in the near future will likely result in even less care being available.
Whatever health care reform package that is chosen will necessarily involve an attempt to cut this nation’s health care costs. This country simply can’t sustain its current level of health care spending.
But we need to be very judicious in where spending cuts are made.
Many hospitals are not “rolling in the dough.” Cut funding for health care too much and we risk further hospital closures. The decrease in the quality and availability of care in Queens, NY is just one example of the impact hospital closures can have on the medical care in a community.
Remember this point in the health care debate: We can talk all we want about providing health care insurance to everyone in this country. Health care insurance means nothing if there is no one available to provide the care for you.
Posted in Access to Care, ED Closures, Funding Crisis, Insurance | 20 Comments »
Saturday, August 8th, 2009
Mass left some questions in the comment section that I thought were insightful and added to the discussion about health care policy. So I’m treating them like an interview.
1) I’d like to know how Dr Whitecoat is an “Independent Voice for Emergency Physicians”? Does that mean that all or most independent ER docs are conservatives or Republicans or anti-HR 3200? It would seem so as there are plenty of references in his blog to the loaded phrase “socialized medicine” as well as (at times indirect) links to groups like CAHI (the health insurance lobby) or the NCPPR (a conservative lobby) or to other conservative blogs. Either admit you’re a proud conservative or give some left-leaning blogs and groups some links.
First, I’m not, nor have I ever asserted, the “Independent Voice for Emergency Physicians”. That phrase refers to the magazine Emergency Physicians’ Monthly, and you won’t find a better forum in emergency medicine for emergency physicians to express their views. You could even submit an article and have it published if it was germane to the practice of emergency medicine. Dis me, but don’t dis the mag.
I actually had to go look up conservative versus liberal qualities on a web site before I could respond to your challenge. I’d have to agree that if I had to choose between personal responsibility and government intervention, I’d pick the former. However, the news is replete with stories about how people and businesses, when left to their own dealings with the public, take advantage of others. Government intervention is necessary to establish and enforce rules by which everyone must abide.
2) How would WC doc define “socialized medicine”? Are patients in the VA system, or those who have Medicare or Medicaid part of such a system? Does it matter that Medicare patients have higher satisfaction than other insured patients? I would submit that if WhiteCoat Doc would term universal healthcare as “socialized medicine,” then I can call the present system, “Darwinian every-man-for-himself medicine.” Unwieldy, but accurate.
Socialized medicine = publicly funded health care. Period. I don’t think that anyone can draw a line between “socialized” medicine and “single payer” medicine (in which government pays, but does not participate in delivery of care). The “golden rule” always applies – he who has the gold makes the rules. Look at the Medicare system now. The government pays for care, but conditions payment on a plethora of byzantine rules. Fail to follow the rules – even if you provide the care – and you don’t get paid. Technically, even though the government is not “providing” the care, it is orchestrating the care – sometimes on an “ubermicromanagment” level.
Many people are content with Medicare because they get what they want at no current cost to them. Don’t forget that most people receiving Medicare have paid into the system through payroll deduction for all of their lives. I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”. Being “insured” by Medicare doesn’t mean much if no providers accept it. Our Medicaid crisis right now is what Medicare will look like 10 years from now unless the system changes.
3) Is this blog written from the perspective of a professional concerned about his income, independence, status, the overall health of his patients, or some mix of these? While I too am a physician, I don’t believe that physicians’ and patients’ interests always go hand-in-hand. There is no shame in defending our incomes and status – let’s just not delude ourselves that our positions are always for the good of the patients.
This blog is written from the perspective of what a single speck in the universe of physicians happens to find interesting at the moment. I’m not going to go through a psychiatric profile to answer your question. If you like the blog, let me know. If you don’t agree with me, post a comment and challenge me. If you don’t like it, go read a blog that aligns more with your interests. I won’t be offended.
Physicians’ and patients’ interests can’t always go hand-in-hand. Physician interests should be aligned with patient interest, but at some point, paternalism must occur. We have to do what we believe is in the patient’s best interest even if the patients don’t realize it. Patients interested in multiple narcotic prescriptions from multiple physicians shouldn’t be allowed to receive them. Patients who think antibiotics cure colds shouldn’t just get antibiotics because they want them. Patients, and a lot of physicians, have to learn that sometimes doing nothing is better than doing everything.
Are there some specialists who go “scoping for dollars”? Absolutely. That practice must be stopped, but unfortunately, there is little disincentive to doing too much right now. In fact, our government has created monetary incentives for performing procedures. Guess what many physicians make their living doing.
4) If some believe that it is not our health care system’s fault — but other factors like income disparities, personal habits, etc — that we have much higher per capita healthcare costs but worse infant mortality and lower life expectancy than other countries, isn’t it incumbent on us as advocates for our patients’ health to see money directed AWAY from the medical system into areas of the economy that actually WILL improve those health statistics?
Some of the largest costs in US health care are provision of end of life care and caring for critically ill patients. The same things that make our system so unique are also crushing our system under the weight of their expenses. We have to choose what we as a society want out of health care. Do we want to provide coverage for everyone at the cost of rationing or eliminating payment for many expensive treatments? That might mean limited or no cancer treatment, curbs on who is eligible for dialysis, limits on chronic ventilator care, and governmental “quality control” oversight on who is and is not resuscitated during a code. We’re probably headed down this path anyway because the system is hemorrhaging so much money, but the government is now faced with the frog in the boiling water conundrum. Throw a frog in boiling water and it jumps out. Put a frog in a warm pot and turn up the heat until the pot boils and the frog doesn’t leave. I personally think that the government is floating a bunch of health care trial balloons to see just how fast it can turn up the heat without too many frogs jumping out.
5) Which Republican health care bill currently being proposed ought we to support as an alternative to the current “Obamacare” legislation?
I haven’t read them all and probably won’t. I posted some of my ideas on how to improve health care here, here, and here. Scalpel also had a great set of posts a couple of years ago. I just went over to his blog to link to them and he re-posted them two days ago for everyone. See here, here, here, and here. Incorporate some of these ideas into a bill and see what kind of traction it gets.
6) Given that the US spent 8.8% of GDP in 1980, up to 13.9% of GDP in 2001, and then most recently 16% of GDP for health care in 2007,
(http://www.kff.org/insurance/snapshot/chcm010307oth.cfm) — does anyone think this is sustainable and if not, what are our options? If “rationing” is out and no one (doctors, hospitals, health insurance) wants to get paid less and no one wants any restrictions of any kind on costs, should we all fly to other countries for health care?
Medical tourism is a free-market alternative for medical care. If cost is what is most important to people, then they will go to the centers that provide care at the lowest cost. However, if you fly to another country, do you know the qualifications of the doctor treating you? Do you care? If cost is all that is important to you, why not get Lucy VanPelt from the Peanuts to give you psychiatric counseling for five cents? Lower costs have to be weighed against quality. It will be difficult to legislate our way to higher quality medical care – if that is what we want. We’ll never have low cost, fast care, and quality care.
Two quick ways to drop costs and increase quality in the current system:
1. Divorce employment from health care coverage. Employers use health care benefits as a means to obtain and retain employees, but employers also try to find the least expensive ways to provide such coverage. Just let patients purchase their own insurance. Let the companies reimburse all or part of their premiums if that’s what you want. Then employees wouldn’t have to worry about COBRA coverage and insurance companies could extol their virtues to the consumers who actually seek their services – not to the employers whose bottom line is cost.
2. Create a government mandate (there’s my liberal side kicking in) that all prices for health care services must be clearly posted before a patient receives the services. Everything down to the last Kleenex box. If you don’t post a price for it, by law it is provided at no cost to the patient. Once people saw the wide disparity in pricing, they wouldn’t have to go to other countries for their care. They would just flood hospitals that provided the lowest prices in the US. Those hospitals would reap larger profits and expand. Other systems would either compete or fail. I guarantee that prices would drop significantly.
7) Since physicians seem strangely wedded to the idea of the private health insurance industry being the intermediary in our medical system, does it bother anyone that most areas of the US now have near-monopolies by private insurance companies in the markets for medical insurance? (http://www.marketwatch.com/story/study-confirms-health-monopoly-fears)
How does one reconcile the facts that “socialized medicine” in places like France, Germany and the UK are associated with frighteningly “high taxes” (used in menacing ways in posts) but that we spend at least 50% per capita more on health care than any other country? Is it possible that higher taxes are offset by…. something else lower?
Think about how the insurance industry monopolies affect care in those areas of the US.
Are you prepared for a country-wide monopoly and the restrictions that will go with it?
9) When the following post recommended by WhiteCoat doc (http://www.fundmasteryblog.com/2009/07/16/reform-healthcare-culture-and-politics-first/) explains how the free market indeed does work for the medical system, are there, um, more practical examples available than Lasik (a cash-on-the-barrel and completely elective procedure) and traveling abroad for health care? Does any ER doc discuss with a patient the pros and cons of all proposed tests (CMP vs BMP vs cardiac panel vs cardiac enzymes, etc) and radiological studies (MRI vs CT vs ultrasound) including full disclosure of the costs of these tests?
I don’t think that any time-dependent service can be entirely free-market. If people are unconscious or having a heart attack, they can’t request transfer to a less expensive facility.
Regarding non-emergency care, few, if any, emergency DEPARTMENT physicians discuss cost, risk, benefits of any procedure. I bet that 99.9% of physicians don’t even know what the tests cost. Probably the biggest reason for nondisclosure is what you alluded to – everyone wants the best health care that someone else can pay for. Patients want the latest and greatest … as long as it is covered by insurance. If everyone had to pay out of pocket for everything, you better bet there would be a lot more discussion. Patients would demand it. I’ve had patients refuse helicopter transport to tertiary care centers because of cost. They would rather accept a larger risk of dying than be saddled with any portion of a $15,000 transport bill. The discussions would result in a better-educated patient and would be a good thing.
The malpractice climate encourages low-yield testing to “prove” that disease doesn’t exist. Right now the “defensive medicine” mindset is so deeply ingrained in many physicians’ minds that it will be difficult to change. The best way to mitigate that risk is to educate the patient and let the patient make a decision. But as the Happy Hospitalist says, FREE=MORE and until patients have some skin in the game, little disclosure will happen because there is no disincentive to not providing it.
Posted in Access to Care, Insurance, Medicare, Policy | 43 Comments »
Tuesday, April 14th, 2009
I started blogging because I enjoy telling stories. Always have, always will. I think that many people read what I write because they like reading stories.
A recent comment by Max Kennerly, an attorney that frequently comments on this blog, made me sit back and think quite a bit. I don’t always agree with Max or with Matt, the other attorney whose comments drive me nuts sometimes, but I do respect their opinions. Another goal of this blog is to create an atmosphere of debate and debate runs deep on some posts. That’s a good thing.
Max wrote:
I still don’t understand your EMTALA obsession; the Chicago example makes quite clear an ER can cheaply and quickly comply, and still engage in profitable patient dumping. EMTALA isn’t a big deal from the policy perspective, you just find it personally annoying.
Frankly, the ease with which you (and other physicians) conflate issues makes it very hard to take any of you seriously. Do you want to be treated like a private industry or like a public utility? In the same breath you complain that the state is not providing funding and that the state imposes too many limitations on you. Who you think you are, Wall Street?
Normally, we do not give an industry state funding without substantial controls on it, including controls to ensure widespread availability of the industry’s services. But you apparently want the former but not the latter. Well, so do I. I want taxpayer money to go about my private business. Ain’t gonna happen.
I, personally, favor the public utility route, and would be happy to pay the extra taxes to fund it. Where do you fall?
After reading Max’s comment, I read back through my most recent posts on this blog (some imported to this blog – see Archives at right). Then I read back through the earlier posts on my old blog. Max is right. My mindset has definitely changed.
Then I thought about why my focus has changed.
I’m worried about health care in this country. I’m not worried for myself, but I am worried for so many hardworking people who are denied health care or who have no access to health care. Policies like “never events,” agencies like JCAHO, misguided and medically unsubstantiated sites like “HospitalCompare,” and laws like EMTALA all start out with noble intent (I presume), but they all end up causing ripple effects that degrade the practice of medicine.
So in answer to Max’s comment, my “EMTALA obsession” wasn’t intended to be focused on EMTALA. Rather, my focus is on the ability of every American citizen to access healthcare. I have several Google news feeds that arrive in my e-mail each day. One of them is for the term “emergency room.” I know. I know. I cringe when I type it, but people haven’t caught up with the times. “Emergency department” hardly gets any news … yet. Every day I read posts about how hospitals are closing or losing money because of unfunded medical care. At the heart of unfunded care is EMTALA. So many of my posts reference EMTALA because EMTALA is abused to the point that medical care in this country is doled out arbitrarily. Patients that need urgent care are often neglected or do not seek timely care because they cannot afford it while patients who want “free” pregnancy tests or narcotic prescriptions pillage the system.
I have repeatedly said that a free market approach to medicine is the only way to save the system. Patients must have some “skin in the game.” Unfortunately there will never be a truly free market because, unlike almost any other industry, medicine is a human “need” – not a human “right,” but a human “need.” What other industry has such a closely entrenched human need? Those who can’t pay for a Lexus simply don’t get their Lexus. They can ride a bike or hitchhike. Those who can’t afford a civil lawyer may have their rights trampled, but they still get to go on with their lives. Those who can’t pay for health care – especially emergency health care – will die. Lack of medical care has an immediate and significant effect on morbidity and mortality. I can’t think of any other industries more necessary than medicine – including law. Sorry, Gerry Spence, you’re just flat out wrong.
The intent of all my policy posts is to make people think about the secondary effects of the choices they make, not to force my opinion down anyone’s throat. For example, many who clamor for true “socialized medicine” have this dream that they will get fast, free, and quality care. Such a system will never occur. NEVER. Rationing will be necessary and significant in any socialized system. I try to emphasize that point by illustrating all of the cuts taking place in our current system as we move toward socialism and by showing articles about the lack of access to care in other socialized systems. If we’re going to choose this system, at least we should have an idea of what we’re in for.
You want me to pick public versus private industry? I pick private industry. You pay me, I treat you. No third parties. Screw the government. Every medical provider would have free choice to choose who to treat and who not to treat. No provider would have to treat patients without insurance any more than a grocery store would have to give groceries to someone without money. “Patient dumping” wouldn’t mean anything other than a medical provider making sound business practices. Lawyers couldn’t threaten health care providers with EMTALA violations or all of their other creative iterations of negligence solely because providers choose to make a profit. If patients can’t afford their cardiac catheterization or their expensive medications, they die. Sucks to be them. Is that the system you want? You wouldn’t hear very many providers complaining, but at the same time, thousands of people would die because they had no money for medical care. I’m all for free market, but we can’t let purely “free market” medicine happen to patients.
So let’s impose strict “state controls” on medicine. Everyone is a comrade and gets their government-sponsored Yugo and bowl of gruel. We can already see what happens with a purely government controlled model. Look up North or across the pond. Sure, care for healthy patients is easily accessible. But become one of those “high utilizers” and it’s a different story. Long waits. Less care. People die waiting for surgery. Expensive treatments for sick patients are denied because some government accountant says the treatments are “not medically necessary.” Impose your controls. Go ahead. You won’t be able to pay enough in extra taxes to fund a system that provides good and timely care to every denizen in this country.
What I foresee happening is a system similar to the legal system in this country. For emergency care and surgical care/hospitalizations, there is a “public defender” type system. If you can’t afford to pay for a top notch “defense” physician, then the “courts” appoint a “public defender” physician for you. You get average care if you don’t have the cash, but you have the option to pay for Mark Geragos if you can afford him. Top surgeons or emergency physicians could demand and receive a premium. Just like the Mayo Clinic or M.D. Anderson, now. People pay extra for extraordinary care. Market forces at work. The “public defender” system is already emerging in emergency medicine with the proliferation of freestanding emergency departments that can cherry pick paying patients. Those without money go to the “public defender” emergency departments at public hospitals that still fall under … EMTALA laws. See, I mentioned it again.
Routine medical care will drift toward the “civil law” practice model. Pay to play. No money, no care. Maybe you can go to public clinics – the equivalent of law schools or charitable organizations – to get primary care if you demonstrate a need. Once the governments decide to cut funding to public clinics, patients will either have to pay up or go sit in the untenable lines in the emergency departments for their care.
I will be able to care for myself and my family regardless of the system that is chosen in this country. I have the contacts, the resources, and the knowledge to do so. One of the benefits of having a six figure student loan debt, I guess.
I truly fear for the health and livelihoods of those who aren’t as fortunate as I am.
That’s where my posts are coming from.
On the flip side, I really do have to get out of my writing rut. Thanks for setting that straight, Max.
Posted in Access to Care, Funding Crisis, Insurance, News Commentary, Policy, Random Thoughts | 16 Comments »
Tuesday, April 7th, 2009
Gramma WhiteCoat is getting foot surgery this week. She’s in her Golden Years, so her care is paid for courtesy of the Medicare National Bank.
I spoke to her last week and she stated that she was examined by 4 different doctors, 2 nurse practitioners and 3 nurses for preoperative procedures. Her primary care physician (not one of the 4 doctors providing a preoperative exam) saw her about a month prior to her surgery, cleared her for surgery, and ordered preoperative labs. Because the labs were more than 3 weeks old, the surgeon wouldn’t accept the normal results and ordered a second set of preoperative labs.
Grandma WhiteCoat’s response: “I know they’re doing all these exams and blood tests to pad the bill. But I don’t care — I’m not paying for it.”
From the mouth of my own mother.
Just another example of why any system in which the consumer has no stake in cost containment is doomed to fail.
FREE = MORE
Patients must have some skin in the game in order for any medical system to work.
Posted in Access to Care, Funding Crisis, Insurance | 43 Comments »
Thursday, March 26th, 2009
Another thought-provoking article was just published in EP Monthly about how Medicare is cutting more payments to physicians. It will be interesting to see the unintended effects of Medicare’s decision.
Medicine is unique in that you can’t just leave one job on Friday and start another job at another hospital on Monday. Before you can get privileges to work in a hospital, you have to fill out a staff application, have all your references checked, go through committees, have the committees sign off on your application. Then you get your privileges. You also have to apply for all the new billing numbers, get insurance companies to change to your new location, yada yada yada.
All of this takes time. Sometimes a lot of time.
In emergency medicine, you used to be able to begin working at a new hospital a soon as you got your staff privileges – even if your billing paperwork had not been approved. You’d see patients, then hold your charges until you get your insurance approvals, then bill the insurance companies for all of the work you performed.
Medicare is now changing the rules.
According to the new Medicare Retroactive Billing Policy, Medicare will no longer pay for retroactive charges.
This policy doesn’t even make sense.
Provider payments are held up until Medicare gets around to approving the providers’ applications.
Think this policy is going to make Medicare work faster at processing applications?
Posted in Access to Care, Insurance, Medicare | 7 Comments »
Wednesday, March 25th, 2009
I’m trying not to make this blog like a broken record, but I have several “Google Alerts” for medical-related articles and I keep receiving abstracts describing the difficulties other countries are having with their health care systems.
I know that I keep using Canadian health care as an example of what could happen if a socialized system is implemented in the US, but Canada isn’t the only country having difficulty keeping its health care system sustainable.
This in-depth article from the McKinsey Quarterly (free registration required to read the entire article – definitely worth doing so) [hat tip to Head. S p a c e] notes that Japan’s health care system “has come under severe stress” and that its “sustainability is in question.” Demand for health care in Japan is increasing and Japan is having difficulty allocating available medical resources. As a result, patients are finding it more difficult to “get the care they need, when and where they need it.”
Japan’s emergency rooms turn away tens of thousands of people every year who need care – something which is beginning to happen in this country.
There is also an “ER [cringe] crisis” in Japan – because too few specialists are available for ED consultation.
Hospital reimbursements are low.
There is no incentive to modernize treatments.
Many poorly thought out cost-control measures Japan implemented have actually cost the system more money. Hmmmm. Where have I heard of that happening before?
When we switch to socialized medicine, we must be very careful not to replicate formulas for a failing system. Giving people unlimited access to free care seems to be a common denominator in more than one floundering national health care plan.
OK … as long as I mentioned Canada, I’ll throw in the latest article.
This article in the Calgary Herald describes how median wait times for available hospital beds are now 16.6 hours. In other words, half of Calgary patients wait more than 16 hours to get a bed. There is a shortage of nursing homes, sick elderly patients get sent to hospitals, and there are little if any “funded” beds available.
One story described an elderly patient who was experiencing a stroke and had to wait 24 hours to see a physician – by that time, the damage would have been long irreversible.
As with many health care articles, I think you can learn a lot about the underlying issues by reading the comments section. Comments to this article painted a vivid and familiar picture.
Many Canadians complained that nonurgent cases contributed to wait times and made statements such as “The emergency room [cringe] is for emergencies.”
Other commenters blamed the state of affairs on elected political parties. Sound familiar?
One of the ways that the hospital systems are apparently recouping some of the costs of care is by charging patients for parking at their facilities. Several commenters expressed their disgust with “paying for parking.”
The comment that made the biggest impression on me was one that claimed the Canadian government is “cutting costs/services, and making it look like it is in the red by underfunding it, only to make a greater case for PRIVATIZATION.”
I’m not sure if we should be telling Canadians to be careful what they ask for or if they should be making that statement to us.
Posted in Access to Care, Funding Crisis, Insurance, News Commentary | 3 Comments »
Tuesday, March 17th, 2009
According to this article in the NY Times, Massachusetts is getting crushed by health care costs. A vast majority of people in the state have some form of insurance, but the costs of providing health care in Massachusetts is expected to increase by 42% in 2009 alone.
Now Massachusetts is looking at whether it can regulate insurance premiums – i.e. limit what insurers can charge.
Massachusetts is also deciding whether or not to “bundle” payments for health care. In other words, if you need your appendix out, Massachusetts pays the provider one price to take care of you from beginning to end of treatment for that problem. If you get it done cheaper, the provider keeps the change. If there are complications or if expensive testing is needed, the provider pays out of pocket for whatever costs go above and beyond the flat fee. In theory, providers could lose significant amounts of money by treating high-risk patients who are prone to develop complications or bad outcomes.
This prepayment idea was also tossed about by Michael Canon at the CATO Institute.
On its face, the idea sounds good. But underneath the surface, I think that such a system encourages skimpy medical care and encourages cherry-picking of healthy patients.
Remember the HMOs that paid physicians a flat fee for taking care of all the patients? Remember fighting with physicians for appointments and testing because the physicians had to control costs? How will the system proposed in Massachusetts be any different?
In addition, I think there will be a lot of gaming of the system.
I was going to give examples of how the system could be gamed, but will hold off for now until more about the proposal is disclosed.
I continue to think that “prepayment” or “bundled payment” ideas will have an adverse effect on medical care.
Healthcare policy experts interviewed for the article hit the nail on the head:
Changes in payment practices will not be enough to slow the growth in spending, even when combined with other cost-cutting strategies. To truly change course, they say, the state and federal governments may need to place actual limits on health spending, which could lead to rationing of care.
“Really controlling costs requires just stopping spending,” said Stuart H. Altman, a professor of health policy at Brandeis University.
Posted in Access to Care, Funding Crisis, Insurance, News Commentary, Policy | 11 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 16th, 2009
Today I was going to finish a post I created about how emergency care in the US is now at a “tipping point.” Before doing so, I scanned some of my favorite blogs. A post by Dr. Wes is so insightful and so timely that I had to incorporate it into what I was writing about.
Dr. Wes coins a new term called the “Bernie Syndrome”, named after Bernie Madoff and his giant Ponzi scheme that took down so many wealthy investors. People got caught up in his scam because no one took the time to look at how Bernie achieved his remarkable results. No one cared. Bernie’s clients just got regular portfolio statements showing how great their investments were going. Meanwhile, behind the scenes, everything was crumbling. Even though Madoff’s business model was collapsing, everyone was still happy because of the rosy statements that Madoff was sending them … that is until the market got so bad that he couldn’t maintain his charade. Suddenly there was nationwide panic as people learned that the real picture was nothing like the picture that Bernie Madoff had painted.
Dr. Wes gives a couple of examples about the “Bernie Syndrome” and healthcare, including the recent SCHIP expansion and lowering Medicare eligibility to age 55 instead of age 65. US citizens suffering from Bernie Syndrome think that the added coverage is great. After all, just like Bernie Madoff’s investors, the public is going to get even more health care – for free – regardless of what the market or the deficit is like. SCHIP expansion will cover more kids. Medicare expansion will cover more seniors. Underneath these wonderful proposals, however, the medical care system in this country is being crushed under its own weight.
Before the Madoff collapse, several industry insiders questioned the returns Bernie Madoff achieved with his investment portfolios. No one seemed to listen – they were too caught up in the grand illusion that Madoff had created.
Now, at least in emergency healthcare, the Ponzi scheme, reinforced by the Bernie Syndrome, is starting to unravel.
George Bush embodied the Madoff Mentality when he told business leaders during a 2007 speech in Cleveland
“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”
The transcript of Mr. Bush’s speech used to be here, but for some reason the White House has now removed the text of that speech from its archives.
So patients with Bernie Syndrome now go to the “emergency rooms”. The widely held belief is that if you go to the emergency department, federal law requires the emergency departments to treat you. That widely held belief is only partially true.
EMTALA laws require that every patient be screened for an emergency condition. If no emergency condition is found, the hospital has no duty under EMTALA laws to provide any further care. If an emergency medical condition is found, the hospital is required to stabilize the condition, or, if the hospital cannot provide stabilizing treatment, then the hospital must provide an “appropriate transfer” to another facility that can provide such treatment.
The Ponzi scheme in emergency medical care was working well for a while. Then shrinking reimbursements closed some hospitals. Now unfunded emergency care is taking too much of a bite out of hospital budgets. You see, EMTALA may require that hospitals provide all patients with a screening exam and treatment for an emergency condition, but EMTALA makes no provision on how providers will receive reimbursement for that care. If a patient has no insurance and is not covered any of the social programs, the government won’t be on the hook. If the patient doesn’t have any money, the patient won’t be on the hook. Who is left holding the bag? Health care providers – hospitals and doctors. Hospitals may try to transfer the costs for some of that care back to patients with insurance, but as unemployment increases and the number of insured patients decreases, that shuffling will become unsustainable.
Health care providers are now trying to mitigate their financial risk. Specialists are avoiding EMTALA requirements by refusing to participate in emergency department call schedules. If specialists aren’t on call, they aren’t bound to treat anyone under EMTALA laws. The “free” specialist care has now dried up. In some rural communities, it may require travel of several hundred miles to obtain proper “on call” specialist care.
The latest way in which the Madoff Mentality is affecting emergency medical care is when hospital emergency departments provide the minimum amount of care required under EMTALA and then refer indigent patients to community clinics for further care. If a patient does not have an emergency medical condition, the hospital has no further requirements to treat the patient under EMTALA. EMTALA defines an “emergency medical condition” as
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in
(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part …
More and more hospitals are now providing an “EMTALA screen” to patients and then referring them to an outpatient clinic if patients do not have an emergency medical condition and cannot pay for their care.
Such was the case with the University of Chicago when it sent a child home last August after the child had been “mauled” by a pit bull. The story was just published in the Chicago Tribune on Friday.
After being bitten in the lip by a stray pit bull, 12 year old Dontae Adams was screened by emergency department staff. Part of his lip was “literally gone” according to Dontae’s mother. He was given antibiotics, morphine, a tetanus shot, and then was told to follow up at the County Hospital within one week. Dontae’s mother took him immediately to Cook County Hospital where he was “quickly admitted for surgery.”
While the case has sparked outrage among the public and among some medical groups, these are the difficult decisions that are being forced by the government’s Madoff Mentality and by those with Bernie Syndrome.
Failure to provide immediate treatment to Dontae’s lip laceration did not place his health in serious jeopardy, did not result in a serious impairment to any bodily functions, and was not likely to result in a serious dysfunction to any bodily organ or part. So technically, it does not appear the University of Chicago violated any EMTALA laws when it evaluated Dontae, provided basic treatment, and referred him to a county hospital.
As the giant healthcare Ponzi scheme starts to unravel, look for more and more hospitals to provide the minimum amount of medical care required under EMTALA and then refer patients without the means to pay for their care to community clinics. Need cancer treatment? Better have a substantial down payment if you go to the ED and want to be admitted. Have a broken bone? Chances are that you’ll get splinted and that you’ll just have to follow up in an outpatient clinic. There, without insurance, you’ll have to bring a down payment as well. Most of the time runny noses and coughs will be sent home from triage unless they have insurance.
For some hospitals, this tactic may be a way to increase profits, but for many hospitals, this policy will be a means to stave off bankruptcy.
We will never have a medical system in which health care is fast, free, and quality.
If you believe otherwise, I suggest that you also be careful on how you invest your retirement funds.
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UPDATE FEBRUARY 19, 2009
The American College of Emergency Physicians issued a press release regarding the University of Chicago case.
The Chicago Tribune immediately released an article noting ACEP’s response. The comments section of the Tribune article shows many divergent opinions regarding whether exhaustive medical care should be free to all.
Posted in Access to Care, Funding Crisis, Insurance, News Commentary, Policy | 12 Comments »
Thursday, February 12th, 2009
 An article in yesterday’s California Daily Journal (subscription only) by Evan George titled “ER Patients Use Court Ruling to Push for Billing Refunds” shows why Californians are going to soon have a lot more difficulty obtaining emergency care.
A man named Ariel Sabban is suing Scripps Memorial Hospital and its emergency physician group for $57.83 as a refund for a medical bill he paid more than a year ago after bringing his kid to the hospital and having the emergency physician sew up his kid’s head. In essence, since balance billing is now “illegal” in California, Sabban is stating that the hospital and emergency physicians shouldn’t have billed him for what his insurance didn’t cover. He is being represented by Vincent Slavens, a partner at Krause Kalfayan Benink and Slavens in San Diego.
The Daily Journal expects that if a wave of class action suits over the case occurs, “hospitals and ER doctors could be on the hook for hundreds of millions of dollars in collective refunds to patients.”
I “Googled” the terms “Ariel Sabban” and “San Diego” and the first thing that popped up was this link to the California Bar Association.
Is Ariel Sabban’s full name “Ariel Joseph Sabban” and is he a San Diego attorney with the firm Murray, Hayes & Sabban?
If Krause Kalfayan Benink and Slavens is able to obtain class action status in their law suit, they have the potential to get a large settlement on behalf of the “class” who will each likely end up with a pittance in “reimbursement”. You have to know that a class action is what the firm is shooting for – why else would they file a lawsuit over $57?
If Ariel Sabban is an attorney, he just might have a “referral fee” arrangement with the law firm representing him, which could mean that a class action settlement becomes a windfall for him — all over his $57 “overpayment.”
Whomever Ariel Sabban is, he can revel in the fact that his frivolous lawsuit will likely be the straw that breaks the back of the California emergency medical system.
Everyone in California should realize just how bad their emergency medical care is about to get. I already posted about the difficulties with emergency medical care in California HERE and HERE. According to the Daily Journal article, 70 hospital emergency departments in California have closed in the past 13 years. It’s not going to get better.
When your dad is dripping with sweat, can’t breathe and is clutching his chest with a heart attack and seconds count, the next hospital emergency department that closes because of lack of funding just may be the one down the street from you. When your child stops breathing and you have to drive an hour or more in traffic and hope that you get to the hospital before your child dies, think of the California Supreme Court’s ruling about balance billing and ask yourself whether the lives of your family were worth $57.
My advice to California emergency physicians: Leave.
My advice to California emergency physician groups: Give notice to each and every hospital that you work at that you will not renew your contract and send the notice to the editors of the newspapers. Then leave.
My advice to other groups that might want to do business in California: Avoid California like the plague.
My advice to Californians: Put some law firm phone numbers on your speed dials for when you have a medical emergency. After all, everyone knows that lawyers are more important than doctors, anyway.
I said that cases like this would create a public health crisis … here it comes.
Boy am I glad I’m a doctor.
Posted in Access to Care, Insurance, Medical-Legal, News Commentary, Policy | 49 Comments »
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My View
Tuesday, April 14th, 2009I started blogging because I enjoy telling stories. Always have, always will. I think that many people read what I write because they like reading stories.
A recent comment by Max Kennerly, an attorney that frequently comments on this blog, made me sit back and think quite a bit. I don’t always agree with Max or with Matt, the other attorney whose comments drive me nuts sometimes, but I do respect their opinions. Another goal of this blog is to create an atmosphere of debate and debate runs deep on some posts. That’s a good thing.
Max wrote:
After reading Max’s comment, I read back through my most recent posts on this blog (some imported to this blog – see Archives at right). Then I read back through the earlier posts on my old blog. Max is right. My mindset has definitely changed.
Then I thought about why my focus has changed.
I’m worried about health care in this country. I’m not worried for myself, but I am worried for so many hardworking people who are denied health care or who have no access to health care. Policies like “never events,” agencies like JCAHO, misguided and medically unsubstantiated sites like “HospitalCompare,” and laws like EMTALA all start out with noble intent (I presume), but they all end up causing ripple effects that degrade the practice of medicine.
So in answer to Max’s comment, my “EMTALA obsession” wasn’t intended to be focused on EMTALA. Rather, my focus is on the ability of every American citizen to access healthcare. I have several Google news feeds that arrive in my e-mail each day. One of them is for the term “emergency room.” I know. I know. I cringe when I type it, but people haven’t caught up with the times. “Emergency department” hardly gets any news … yet. Every day I read posts about how hospitals are closing or losing money because of unfunded medical care. At the heart of unfunded care is EMTALA. So many of my posts reference EMTALA because EMTALA is abused to the point that medical care in this country is doled out arbitrarily. Patients that need urgent care are often neglected or do not seek timely care because they cannot afford it while patients who want “free” pregnancy tests or narcotic prescriptions pillage the system.
I have repeatedly said that a free market approach to medicine is the only way to save the system. Patients must have some “skin in the game.” Unfortunately there will never be a truly free market because, unlike almost any other industry, medicine is a human “need” – not a human “right,” but a human “need.” What other industry has such a closely entrenched human need? Those who can’t pay for a Lexus simply don’t get their Lexus. They can ride a bike or hitchhike. Those who can’t afford a civil lawyer may have their rights trampled, but they still get to go on with their lives. Those who can’t pay for health care – especially emergency health care – will die. Lack of medical care has an immediate and significant effect on morbidity and mortality. I can’t think of any other industries more necessary than medicine – including law. Sorry, Gerry Spence, you’re just flat out wrong.
The intent of all my policy posts is to make people think about the secondary effects of the choices they make, not to force my opinion down anyone’s throat. For example, many who clamor for true “socialized medicine” have this dream that they will get fast, free, and quality care. Such a system will never occur. NEVER. Rationing will be necessary and significant in any socialized system. I try to emphasize that point by illustrating all of the cuts taking place in our current system as we move toward socialism and by showing articles about the lack of access to care in other socialized systems. If we’re going to choose this system, at least we should have an idea of what we’re in for.
You want me to pick public versus private industry? I pick private industry. You pay me, I treat you. No third parties. Screw the government. Every medical provider would have free choice to choose who to treat and who not to treat. No provider would have to treat patients without insurance any more than a grocery store would have to give groceries to someone without money. “Patient dumping” wouldn’t mean anything other than a medical provider making sound business practices. Lawyers couldn’t threaten health care providers with EMTALA violations or all of their other creative iterations of negligence solely because providers choose to make a profit. If patients can’t afford their cardiac catheterization or their expensive medications, they die. Sucks to be them. Is that the system you want? You wouldn’t hear very many providers complaining, but at the same time, thousands of people would die because they had no money for medical care. I’m all for free market, but we can’t let purely “free market” medicine happen to patients.
So let’s impose strict “state controls” on medicine. Everyone is a comrade and gets their government-sponsored Yugo and bowl of gruel. We can already see what happens with a purely government controlled model. Look up North or across the pond. Sure, care for healthy patients is easily accessible. But become one of those “high utilizers” and it’s a different story. Long waits. Less care. People die waiting for surgery. Expensive treatments for sick patients are denied because some government accountant says the treatments are “not medically necessary.” Impose your controls. Go ahead. You won’t be able to pay enough in extra taxes to fund a system that provides good and timely care to every denizen in this country.
What I foresee happening is a system similar to the legal system in this country. For emergency care and surgical care/hospitalizations, there is a “public defender” type system. If you can’t afford to pay for a top notch “defense” physician, then the “courts” appoint a “public defender” physician for you. You get average care if you don’t have the cash, but you have the option to pay for Mark Geragos if you can afford him. Top surgeons or emergency physicians could demand and receive a premium. Just like the Mayo Clinic or M.D. Anderson, now. People pay extra for extraordinary care. Market forces at work. The “public defender” system is already emerging in emergency medicine with the proliferation of freestanding emergency departments that can cherry pick paying patients. Those without money go to the “public defender” emergency departments at public hospitals that still fall under … EMTALA laws. See, I mentioned it again.
Routine medical care will drift toward the “civil law” practice model. Pay to play. No money, no care. Maybe you can go to public clinics – the equivalent of law schools or charitable organizations – to get primary care if you demonstrate a need. Once the governments decide to cut funding to public clinics, patients will either have to pay up or go sit in the untenable lines in the emergency departments for their care.
I will be able to care for myself and my family regardless of the system that is chosen in this country. I have the contacts, the resources, and the knowledge to do so. One of the benefits of having a six figure student loan debt, I guess.
I truly fear for the health and livelihoods of those who aren’t as fortunate as I am.
That’s where my posts are coming from.
On the flip side, I really do have to get out of my writing rut. Thanks for setting that straight, Max.
Posted in Access to Care, Funding Crisis, Insurance, News Commentary, Policy, Random Thoughts | 16 Comments »