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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.

The Healthcare Ponzi scheme

Monday, February 16th, 2009

house-of-cards

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.

.

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.

Another Gash In The California Safety Net

Thursday, February 12th, 2009

broken-netAn 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.

Health Care Reform Survey Proves A Point

Saturday, January 17th, 2009

A new survey of 1,628 adults by the Kaiser Family Foundation puts the brakes on the notion that the desire for health reform is … well … universal.

Overall, healthcare reform ranks third on Americans’ priority list for the new administration – behind improving the economy and fighting terrorism, but ahead of reducing the budget deficit, improving schools, and dealing with Iraq.
There is general agreement on issues such as providing universal coverage, limiting administrative expenses of insurers, and getting rid of exclusions for pre-existing conditions. But public opinion changes when people learn about the effects of their decisions.

For example, 71% of people favor Obama’s idea to require employers to provide health insurance to their workers, but support drops to only 29% when told that the plan may involve employers laying off workers.
Two thirds of people also thought it was a good idea to require all Americans to have health insurance … until they found out that some people would be forced to purchase insurance that was too expensive or something they didn’t want. Support for that idea suddenly dropped to 19%.
Nearly 2/3 of people would be less likely to support a plan that increased their own costs and less than half of those polled were willing to pay higher insurance premiums or taxes to help cover the uninsured. Instead, 70% of those polled wanted to increase taxes for those earning more than $250,000 per year.

In summary, it seems that most people in the survey want “The best health care someone else can pay for.”

Got a news flash for all those who were surveyed: The concept isn’t flying now and it won’t fly in the future. If you’re expecting to get better medical care at a lower cost, you’re kidding yourselves.

If we aren’t careful about our choices, we might get neither.

Where’s the Handbasket?

Wednesday, January 14th, 2009

handbasket-picnic-basketI got two e-mails today asking for a comment on two recently publicized court cases. They both tie in to one common theme: It’s pretty clear where our medical system is headed – now it’s just a matter of the vehicle we’re going to use to get there. The one to the right is probably the most common one used to get to this destination.

One involved the California Supreme Court’s decision to bar emergency physicians from “balance billing” in the emergency department. Before this decision, there was a tension between emergency physicians who wanted to be paid fairly and insurers like United FraudCare that want to charge patients as much in premiums as possible while paying as little as possible to the medical providers so that they can keep earning their $45 billion per year and maintain their #35 ranking on the Fortune 500.

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Emergency physicians refused to sign on with the insurers given the low compensation that was being offered. Then, when an insured patient was seen in the emergency department, the emergency physicians received some of their fee from the insurer and “billed” the patient for the “balance” of the fee – hence the term “balance billing.”

 

Now, the California Supreme Court’s decision states that even if the emergency physicians have no agreement with the insurer, they have to take what the insurer pays them as compensation. Emergency physicians can’t bill the patients for the “balance.” If the providers deem that the emergency physician’s services are worth 25 cents, that is what the physicians have to take. The physicians can try to get the remainder of their fee back from the insurers. Patients can’t get billed for it. Of course, if the insurers don’t pay the remainder, what recourse do physicians have? Nothing. Can’t stop treating the insurer’s patients. Federal EMTALA statutes state that emergency departments have to provide an evaluation and stabilizing treatment to EVERYONE. So if emergency physician groups don’t like it, they are stuck filing more lawsuits and paying more lawyers’ fees to try to get paid fairly.

The other case involved a rheumatologist who was forced to pay $400,000 because he allegedly “refused” to pay for a sign-language interpreter for a deaf patient. The physician was only making $49 per visit from Medicare, but would have to pay $150 to $200 per visit for a sign language interpreter. Instead, the physician used the patient’s family and used written notes to communicate with the patient. The patient sued the physician for discrimination under the Americans With Disabilities Act.

My opinion of both of these cases is that they are a good thing.

Kidding aside. I really am glad that they are happening.

Think about the effects of cases like these.

How many emergency physicians are going to want to work in California? I know I wouldn’t even think about a job offer there – knowing that I would likely be able to collect little to nothing for my services because the California Supreme Court held that some magical contract is created between all emergency physicians and all insurers and that those contract terms de facto provide insurers with unlimited bargaining power. Once service contracts run out with the hospitals, I foresee a lot of hospitals having a difficult time staffing their emergency departments. Care will suffer, people will die on waiting room floors, public outrage will force immediate change.

How many private practitioners are going to want to accept deaf patients into their practices? If we’re talking about providing translation in general, how many physicians will want to accept anyone that doesn’t speak English into their practices? Paying money out of your pocket for a translator so that patients can come to you for treatment is not economically sustainable. If the results of this case are widely disseminated, a lot of physicians who were previously “getting by” with writing things on paper will now have a disincentive to keep deaf patients in their practice. There’s absolutely no incentive to accept new deaf patients into physician practices. As more and more deaf patients are unable to find health care, public outrage will force immediate change.

With cases like this, we’ll get to the “change” our system needs a whole lot quicker. Of course, physicians will stop practicing, those seeking to enter the health care field will think twice about it, care will suffer, and, unfortunately, lots of people will become sicker and will die sooner in the process.

But we will get the change we need.

Hopefully there will still be physicians willing to practice once all of these changes occur.

United “FraudCare”

Wednesday, January 14th, 2009

According to MSNBC, United HealthCare just paid $50 million to settle New York Attorney General Andrew Cuomo’s claims that United HealthCare manipulated its own proprietary pricing database to set an unreasonably low “fair market value” for medical care. By doing so, it is alleged that UHC forced its insureds to pay more out of pocket costs when using “out of network” providers – to the tune of tens of millions of dollars.

No criminal actions have been filed, but class action lawsuits are reportedly already in the works.

Other insurers are in the sights of several state Attorneys General.

A New York Times article about the suit and the basis behind the suit is here.

Also some interesting discussion going on at Newsvine.com.

The question I have is … with a company that has revenues of $45 billion, is a $50 million settlement enough to dissuade similar actions in the future?

That’s like a person who makes $100,000 per year agreeing to pay a fine of $100 – not exactly a big hit in the pocketbook.

Instead, why not disgorge all of UHC’s revenues for a couple of years? How about a fine of $50 billion instead of $50 million?

I can’t think of a better example of a corporate “never event” – can you?

If providers shouldn’t be paid for things that should “never” occur, neither should the insurers.

Medicaid Modus Operandi – Limit Access, Save Money

Monday, December 15th, 2008

barrel-wForget the fact that Medicaid payments to physicians amount to less than the cost of a lunch at McDonalds in some states.

According to an article published in the Dec 8 edition of AM News, bureaucratic hassles and delays in payments are also causing significant limitations to the number of physicians that are willing to provide care for Medicaid patients.

What good is health insurance if you’re prevented from using the benefits?

Pennsylvania and New York take an average of almost 4 months to pay a Medicaid claim. Some claims take even longer to be paid in those states. To put this in perspective, imagine starting work at a new job, then waiting an average of 4 months to get your paycheck (if you’re lucky you’ll get paid in 2-3 months, but if you’re unlucky, you might wait 6 months). Is that somewhere you could afford to work? How would you pay for your mortgage, your car payment, or your groceries? By delaying payments for services, states are forcing some physicians to close up shop.

Not only do Pennsylvania and New York withhold payments, those states also happen to be two of the states that pay the least for Medicaid services in the US. New York pays $20 for a one hour consultation on a new patient. Hell, my babysitter makes almost that much – and she doesn’t have to purchase a $1 million malpractice insurance policy. Now New York is going to cut Medicaid payments further? (h/t to Kevin for the link)

By encouraging hassles and purposefully delaying payments, states are limiting access to medical care.

If you can’t get in to see a doctor, then the states don’t have to pay the doctor.

Great way for states to minimize budget shortfalls – receive a portion of the 15.4% taken from every working person’s paycheck, pay a pittance for the services … and delay payment for the services, piss off enough medical providers so that very few people provide the services, and then keep most of the money.

If I had a business that accepted money for services and then provided half-assed results, I’d be sued and probably charged with a crime. The state Attorney General may even come after me.

Sure don’t see the Attorney General stepping in and going after states to make them pay the money they owe to medical providers.

Strange how things work sometimes.

Picture credit here
Full AM News article below for those who don’t have access to the AM News site

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Mandated Employer-Paid Health Insurance

Friday, December 5th, 2008

employer-insurance

Among many “changes” advocated by President-Elect Obama is a plan for mandated employer-based health insurance. I can’t find a clear description on exactly how the plan is going to work (the plan is outlined on Obama’s site here, and there is a NEJOM summary here), but there are many opinions out there on what the effects of the plan will be. See posts at Hot Air Blog, The Health Care Insurance Reform Blog, The Cato Institute, and John Goodman’s Health Policy Blog

I’m all for changing the current system, and I’m committed to giving Obama a chance to turn things around, but is mandating that employers pay for insurance going to improve healthcare in this country? I admit that I haven’t taken an in-depth review into the pros and cons, but in principle, I think it’s a bad idea. Reminds me too much of the “Hats” post I put up last year.

If you’re an employer whose bottom line is hit by a tough economy and you’re now forced to spend additional money to either “pay” a percentage of your payroll into a national plan or to “play” by purchasing “health insurance” for your workers, what are you going to do?

You’re going to find the cheapest way out.

If I were an employer faced with this directive, I’d probably do one or more of several things:
1. I’d have to fire some of my employees to cut the amount of money I was required to spend on insurance.
Now think about the repercussions of employers having to decrease the number of employees. Those former employees will have difficulty finding another job because most companies are downsizing because of the poor economy and to avoid paying extra for insurance for their employees. The former employees then end up sucking money out of the system by applying another mandated insurance plan called “unemployment insurance.” Instead of maintaining productive employees who contribute to the economy, mandated insurance will create out of work employees who take out of the economy.
2. I would purchase the cheapest insurance I can find.
As in “Yeah, I’ll take that $100,000 deductible plan right there.” Hey – the mandate says you have to purchase insurance, it doesn’t say what kind of insurance you have to purchase. Exclusions for pre-existing conditions? So? Five thousand dollar policy limit? Big deal. Only pays providers three cents on the dollar so no provider will accept patients who have that type of insurance? Who cares? According to the mandate, insurance is insurance … right?
3. I would consider whether or not to cut my remaining employees’ wages to offset the cost of the insurance I am forced to buy.
Depends on how far my company is in the black. If I’m having trouble making payroll and the economy is bad, where do you think the money is going to come from? Now consider the real-world impact. Employees who haven’t been fired will effectively receive less income so that employers can pay for the least expensive insurance they can find. In essence, the mandate is forcing the employees to pay for crappy insurance.

Who wins?
Not the States. They’re going to lose out with all the extra people using programs for the indigent because they are unemployed. Bigger drain on the system and I don’t know too many States that want to throw more money into social programs – most are trying to figure ways to cut back.
Not the employers. They’re losing money by being forced to purchase insurance for the employees.
Not the employees. The ones who haven’t been let go are probably going to get paid less so that their employers can afford to pay for mandated health insurance – health insurance that probably won’t cover them for very much in the “real world.”
The only winners are the insurance companies. They sell more policies, and if they make the policies very inexpensive but with huge deductibles, low policy limits, and multiple exclusions, they probably will have to pay out very little on those policies. Cha-ching.

No problem.

President-Elect Obama is a smart guy. He and his staff will then just create more rules for the mandated employer-paid health insurance so that employers can’t game the system.

So …

In addition to the employer mandated insurance the government would also have to require …
mandated maximum insurance premiums so that employers don’t go out of business trying to pay for it
plus …
guaranteed acceptance of enrollment so that insurance companies can’t cherry-pick healthy patients while excluding the chronically ill patients who will use so much more health care resources
plus …
mandated maximum fees that the healthcare providers can charge so that those who provide the care don’t gouge the insurance companies
plus …
mandated provider acceptance so that doctors and hospitals can’t refuse patients care to patients because the insurance doesn’t pay enough.

Oh … wait. We already have something pretty close to that.

It’s called Medicare.

Picture credit: American Medical News

P.S. Anyone want to go in on starting up an insurance company?

Medical Tourism

Friday, November 14th, 2008

sas_airplane_1The Chicago Tribune has an AP story about how WellPoint is going to start a pilot program of medical tourism where it will send some non-emergent patients to India for surgeries in order to save money. A knee or hip replacement costs between $65,000 and $80,000 in the U.S., but only costs between $8,000 and $10,0000 in India. As a carrot to get patients interested, insurers will pay for travel, lodging, and the medical procedure for a patient AND will pay travel costs and lodging for a companion.

I think medical tourism is a good idea. I especially like the concept because it cuts out the middle man. Patient pays for care, doctor and hospital provide care. Maybe patient and provider haggle over price. Maybe patient calls around to different hospitals and comparison shops – not unlike reading through the Sunday paper and comparing grocery ads.

It concerns me that now a “middle man” wants to get involved.

I also foresee all kinds of new issues popping up once American insurance companies actively engage in sending people to other countries to have medical procedures performed.
Right now (and this is pure conjecture on my part), unless there is a catastrophic injury I believe that medical tourists effectively give up their right to sue a foreign doctor for malpractice. The patient will have to submit to another country’s malpractice laws. Doubt that the payouts would be anywhere near as big as they are in the US (although the docs might get jail time and 1500 lashes with a whip). To get started, the patient would have to retain an attorney (or attorneys) experienced in both malpractice and in international law.  Think you’ll be able to get some of those on contingency?
Will the insurance company be liable in the US if there is malpractice in another country and the insurance company “brokered the deal”? Maybe you can’t sue the insurer for medical malpractice, but can you sue the insurer for negligent contracting? Will the ERISA shield apply to these types of lawsuits against insurers?
What happens if there are surgical complications? In the US, the price for surgery includes a certain amount of follow-up care (30-90 days?). With foreign surgeries, does the patient stay in India until the complications are resolved? Will the insurance company pay for that care as well? What if there is a complication and family wants to visit? Who picks up the travel and lodging tab?
What if the patient is OK when leaving India, then returns and develops a surgical complication? Surgeons in the US are often hesitant to “become involved in someone else’s screw up” (as I have heard more than one surgeon put it). A “screw up” is already more likely to end up in court. If a US surgeon tries to fix an Indian surgeon’s screw up and the patient doesn’t get better, then the US surgeon may be stuck holding the bag in the event of a lawsuit. If there is a “screw up” do the patient and a companion get shipped back to India to make good on the care?
What happens if, during the trip, the patient has another medical problem?
What happens if the surgery has to be canceled? Free trip for two to India?
Aaaaack! What happens if there is a “never event”? Free care?? Or do those never event thingees only happen in American hospitals?
The most pressing question of all is: Who gets to keep the frequent flyer miles?

The Chief Medical Officer interviewed for the article hinted that insurers are trying to use medical tourism to put the squeeze on doctors to lower their prices for non-emergent procedures like joint replacements. “It may change the game in terms of local contracting conversations,” the CMO said.

Here come those unintended consequences. If doctors get pinched on performing non-emergent surgeries, how are they going to make up for that monetary loss? You got it. Guess what’s going to happen to prices for surgeries that can’t be sent overseas.
That acute cholecystectomy just got more expensive. Don’t want to pay it? Fine. Get on an airplane with your companion and go register in one of those insurer-approved New Dehli “ERs”. Just hope your gall bladder doesn’t explode somewhere over the Bay of Bengal.
Have a hip fracture? Hope your travel companion is someone qualified to administer narcotic pain medications because sitting in an economy class seat with a busted hip for 20 hours is going to hurt. Then again, maybe a hand full of Vicodins will be part of the insurance travel package.

These are all issues that can occur regardless of whether the trips are brokered by an insurance company.

The problem occurs when a third party tries to squeeze in the middle of the doctor/patient relationship – making the consumer pay more and making the provider accept less – so that the third party can make a profit. Some aspects of insurer-brokered medical tourism may work. Ultimately I think that issues like those above will become the tail that wags the dog.

I have a bad feeling about this.

UPDATE MARCH 30, 2009
CNN published an article on medical tourism echoing several of the points above.

More On Medicare Never Events

Thursday, August 14th, 2008

I have to stop reading Kevin’s blog.

Lately, every time I read through his posts, I get all riled up over something. The most recent thing to get my blood boiling was Kevin’s link to a nice rant on Buckeye Surgeon’s blog about these looming Medicare “Never Events.” There’s a journalist in Cleveland named Diane Suchetka who published a “blind leading the blind” article about “never events” in the Health News section of Cleveland.com.

I know that I’ve beaten this whole “never event” horse before, but the whole concept is just so remarkably brain dead that I had to get my whip out again.

The thing that concerns me the most about the “never event” concept right now is that many members of the general public are jumping on this bandwagon. Like foie gras ducks being force-fed corn, the citizens of this country are being force fed the notion of “never events” by the government and insurance agencies. Even more disconcerting is that the feeble minded among us actually believe that all of these “never events” should never happen. Just look at the comments to Ms. Suchetka’s article.

After reading the article and the comments, I added my own comment:

It is unfortunate that someone so misinformed about the effects of “never events” on the practice and accessibility to medical care is allowed to publish an article like this. It is even more unfortunate that so many of the members of the general public support Ms. Suchetka’s ramblings.
First of all, look at the contradictions contained within this article itself. She quotes someone from “SHIC” as saying that “If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented.” Wait a second. “Vast majority?” I thought that these were “never events.” Shouldn’t Captain Obvious have stated that the events would “never” happen if the policies were followed?
Medicare calls the “errors” “reasonably preventable.” If they are “never events,” shouldn’t they be called “entirely preventable”? If they are “never events” then I want to see the people who came up with that term treat patients for a year and show me their results in preventing them.
There are other misstatements. Realitynurse states that “C. diff is a medical mistake.” Uninformed and untrue statement. C. diff is an organism that lives and grows just like every other organism on this planet. Antibiotic use may increase the prevalence of C. diff, but antibiotic use does not “cause” C. diff. Your statement is akin to saying “mosquitoes are a mistake” or “uninformed nurses are a mistake.”
Why has C. difficile become so ominous? Up to 20% of people prescribed clindamycin can develop C. difficile. What exactly should we do to make sure that not one single patient ever develops a C. difficile infection? Go on. I want all you smart people to tell me. Stop prescribing all antibiotics? Sounds like a plan. Then Medicare will deem all the other infections as “never events,” too.
If any of the people reading this column want to avoid never events, here’s how to do it: Don’t go to doctors and stay away from hospitals. That’s right. Boycott us. If you want to create a manual on how to provide perfect medical care while you’re treating yourself for a ruptured appendix, I’d be happy to read it.
Ms. Suchetka is right that these Medicare rules will affect all of us, but she has the wrong reasoning. They will affect all of you that develop these conditions because physicians and hospitals will avoid you like the plague. If you are prone to falling, good luck finding a doctor to treat you. Immunocompromised and likely to develop infections? Better read up on those medical journals. You’ll be treating yourself soon.
“Medicaid expenses could drop”? Get a clue. They won’t drop, they’ll increase. No one will accept Medicaid patients with predispositions to these conditions and the patients will end up in the emergency department where the care is really inexpensive. Maybe Medicaid should focus its efforts on reigning in those that misuse their access to health care in order to score some pain meds. That would save a lot more money than this all this hogwash about those things that are and are not preventable.
Hospitals are “get[ting] the message” alright. They’re closing. Doctors are getting the message, too. Fewer and fewer specialists are treating patients from emergency departments because they don’t want to deal with people who expect perfection and who then try to sue when they don’t get it.
When your local hospital closes down or when the wait for care is so long that you or a loved one develop a bad outcome because of it, you can thank people like Ms. Suchetka for putting pablum to paper.
Boy am I glad I’m a doctor.
WhiteCoat

The comments on the blog have to be approved by the blog owner and at this point Ms. Suchetka or whoever “owns” the blog has still not “approved” my comment about her uninformed article.

I just decided that I’m not finished yet. Now you’re getting both barrels, lady.

A DVT will soon be a never event. Indirectly what CMS is saying is that blood should never clot. If blood should never clot, then why doesn’t CMS make Coumadin ingestion mandatory for every person in the United States? We’ll just put rat poison in the water supply and force everyone to go for their monthly INR checks. Oh, wait – maybe it’s only that blood should “never” clot in the legs. Where do I get my own set of government-issued Ted Hose? And another thing – all you airlines better give me upgrades to first class or I’m not paying for my flights. What’s fair for medicine is fair for the travel industry. “Never” means never.

C. difficile and Staph aureus infections are also going to be considered “never events.” Think about the idiocy of this classification. Mircoorganisms should “never” happen. You sonofabitches in the government give us a vaccine to eradicate smallpox but you’re holding out on the C. diff vaccines so you can avoid paying for medical care, aren’t you? How long before strep throat, otitis media, pneumonia, H. pylori gastritis, and urinary tract infections will also be never events? Ooops. UTIs already are never events. Don’t forget about tooth decay, either. Stinking peptostreptococcus bugs. Oh yeah – yeast infections, too. Monistat will soon be mandatory for all women. The human body should be absolutely sterile.

“Never events” are and always have been “all about the Benjamins.” Look at this news release. The “background” section states that the “never events” were “required” pursuant to Section 5001(c) of the Deficit Reduction Act. Medicare wants to stop paying for things not because they “should never happen” but because it’s trying to save money. The whole “never event” moniker is just a spin they put on the cuts to make it look like someone else’s fault. Do “never events” never occur at government run hospitals? We’ll never know because CMS doesn’t even include government run hospitals on the “hospital compare” list.

Am I the only one that finds it odd that CMS is so willing to judge others but is so unwilling to allow others to judge it?

Just like the guy that cuts your lawn, your attorney, or any other entity that performs services for you – once you stop paying for the services, you stop getting the services. Medical care will be no different. Economic forces will make it more and more difficult to find care if you are predisposed to a “never event.”

In addition, medical providers will find loopholes in the “never event” system that will drive up the costs of care instead of decreasing it. Maybe your doctor will transfer you to another hospital for “specialist care” after you develop a “never event” so that the new hospital can bill for it. Maybe you’ll suddenly develop some other medical condition that the hospital can bill for while you are treated for the uncompensated “never event.” Trust me – medical providers are a helluva lot more creative than the people working at the Medicare National Bank.

Rest assured that whatever happens, the laws of unintended consequences will increase the costs of treating “never events” and Medicare’s inevitable decline into bankruptcy will occur even more quickly because of it.

Other countries must just be watching us, smirking, and shaking their heads.

Get your healthcare while you can. If you still believe that never events should never occur, you better get your treatment for delirium quickly – delirium is one of the conditions on the “never event” hit list.

Picture credit here

P.S. I’m still glad that I’m a doctor.

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