WhiteCoat

Archive for the ‘Medicare’ Category

More Florida Medical Follies

Saturday, September 3rd, 2011

Yet another reason to stay away from Florida if you are a physician. The inspectors and health care agencies down there leave quite a bit to be desired.

The Florida Agency for Healthcare Administration cited an emergency department’s staff for failing to give “adequate care” to 13 week pregnant patient before she had miscarriage of twins.

The timeline of events for the patient was outlined in this article.

At 9:45 a.m. the patient came to the emergency department with pelvic pain and vaginal bleeding.
At 10:30 a.m., the patient was diagnosed with pain and bleeding, a urinalysis and a battery of blood tests ordered, but there was no test ordered that would have revealed her glucose level. There was also no discussion of whether to discontinue or maintain the patient’s insulin pump. Ultrasound tests were ordered, then changed, which “caused a delay.”
At 11:45 a.m., the patient was bleeding heavily and was “in obvious labor” according to state inspectors. The ultrasound scan showed both fetuses had normal heart rates. The state inspectors stated that the emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.”
At 12:25 p.m., the physician performed a pelvic exam and suctioned some large blood clots from the vaginal canal. The patient then “spontaneously aborted one of the fetuses.” Inspectors noted that the patient was not informed of any risks of performing a pelvic exam, nor did she give informed consent for the pelvic exam.
A second ultrasound was ordered.
By 2 p.m., the second ultrasound showed a normal heartbeat in the remaining fetus. At that point “the doctor took no steps to stop labor or maintain the second pregnancy.” Additionally, the emergency physician’s report showed that the second fetus had no heartbeat, which conflicted with the radiologist’s report.
At 4 p.m., the patient’s blood-sugar level was measured and found to be “critically low.” She then received orange juice and IV dextrose.
At 5:30 p.m., an obstetrician arrived and performed a pelvic exam. He ordered no additional procedures or medications.
At 6:15 p.m., the woman passed the second fetus.

The inspectors stated that the physician failed to monitor blood sugar levels, failed to respond to the patient’s bleeding and pain, and failed to intervene to stop her labor.

In eight of ten other cases that inspectors reviewed, the hospital was cited for failing to document the amount of the patient’s blood loss, failing to record vital signs, and failing to record other case information.

We need more information about the other cases, but even without extra information, I’m still calling out the inspector and the Florida Agency for Healthcare Administration. Many of these citations are uninformed and inappropriate.

#1 No discussion documented about whether to continue or discontinue the patient’s insulin pump.
Such discussions are rarely held in the emergency department. Should the patient’s blood glucose have been checked sooner? Probably. However, if a patient is not having symptoms suggestive of low blood glucose, how often should the glucose level be checked — especially with an unrelated complaint? Should hospitals be cited when glucose levels aren’t checked in a diabetic patient with an ankle sprain or laceration?

#2 The emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.”
How much bleeding was there? What were the patient’s vital signs? Notice how the report is vague about the findings? Also notice how the report doesn’t state what the emergency physician should have done, and only made vague accusations about what the emergency physician didn’t do? Expert testimony like this in court would be tossed. In state investigations, it is apparently normal procedure. The treatment of bleeding during a miscarriage is generally either letting the fetus pass or performing a D and C.

#3 The patient was not informed of the risks and benefits of performing the pelvic exam and did not give informed consent.
This citation is so far out in left field, that it makes me wonder whether the inspector knows anything about medicine. It also puts the emergency physician in a no-win situation. Let’s say that the patient doesn’t consent to a pelvic exam – even though she’s having vaginal bleeding. Then the physician would have been cited for failing to do the pelvic exam.
But the physician didn’t discuss the risks and benefits of pelvic exams? OK, oh wise state inspector … what are the risks and benefits that the physician egregiously failed to discuss? Again, you and your department allege error, but then fail to provide all of us other dangerous physicians with the proper procedures to use.
Then there was no consent on the chart. The concept of “implied consent” is well established. If a patient with a gyne problem is told that the physician wants to perform a gyne exam and she gets up in the stirrups, chances are pretty good that she has consented to the exam. But, oh wise state inspector … what procedures require consent and do not require consent? Educate all of us dangerous practitioners. While you’re at it, give us some shred of written documentation that supports your assertions.

#4 After the patient passed one fetus, “the doctor took no steps to stop labor or maintain the second pregnancy.” This has to be the nadir of medical misinformation. Most pre-med college students know that a fetus is not viable until roughly 24 weeks of gestation. If a woman is having labor with a gestation less than 20 weeks, it is called a miscarriage. There is no treatment to save the pregnancy. A 13 week fetus is never, and will never be, viable outside of the uterus — unless the patient is a lion or some other member of the animal kingdom with a short gestation.
So, oh wise state inspector, exactly how should medical personnel “intervene” to stop the labor of a patient who is 13 weeks pregnant? You’ve accused the medical staff of doing something wrong, what should they have done different?

To illustrate the problems in lay terms, imagine being arrested for failing to drive the correct speed. You aren’t told what the correct speed is, you just have to pay a fine because you weren’t driving the correct speed. You have to apologize and promise to drive the correct speed in the future in order to keep your driver’s license.
Or imagine that you were arrested for failing to properly raise your child. No allegation as to what you should have done different, only the assertion that what you are doing is wrong.
These are they types of allegations that the inspector is making against the medical staff in many of these instances.

I hope that everyone realizes the significant effect that “investigations” such as this have on the access to medical care in the communities.

Doctors are publicly accused of inappropriate medical care.
The public trusts that the publicized accusations are accurate … when they may not be accurate.
Public perception that medical care at a hospital or by a caregiver is “bad” then increases.
Hospitals then increase expenditures to correct the publicized “bad” care and to comply with inane and unsubstantiated governmental citations.
Fewer funds are then available to provide medical care.
More doctors leave the state or leave medicine entirely because they’re sick of the administrative burdens.
More hospitals close.
Less care is available.
Safety is paradoxically worsened because fewer providers are available to manage patients.

Oh and throw in some unjustified lawsuits as well. You know that if a governmental agency states that doctors “didn’t do anything” to stop a patient’s 13 week old miscarriage, however uneducated and inappropriate the statement may be, the patient is going to believe that she was wronged and will find a malpractice attorney to file a suit against the physician.

Don’t take this post as me advocating for less oversight of medical practice in the states. I fully believe that there needs to be oversight of medical care and that dangerous physicians need to either improve or have action taken against their licenses. Investigations need to be based in sound medical practice, though.

The issue I have here is that the investigator in this case made multiple vague unsubstantiated and medically inappropriate opinions about several providers’ care and those opinions were taken as fact when instead they should have been recognized largely as calumny. Based on the investigator’s calumny, the hospital was cited and the medical practitioners were publicly chastised. I’d bet that there was action taken against the providers at work as well.

By the way, if someone can get me a copy of this inspector’s actual report, I’d love to post it for further discussion.

Yep, between the “three strikes” rule, the criminalization of medicine, the high medical malpractice premiums, and the quality of the state inspections, doctors would be plum crazy to practice medicine in Florida right now.

Sorry, Senator Bill Nelson, things like this are going to drive doctors away from a state that “desperately needs more doctors.” Have fun rearranging the deck chairs on your Titanic, though.

 

Is Protecting Yourself a Joint Commission Violation?

Saturday, January 8th, 2011

There are a lot of bonehead stories about the Joint Commission in the news lately. I just had to post this one.

CMS and JCAHO are now investigating Lehigh Valley Hospital in Pennsylvania for using stun guns on unruly patients.

In one instance, a patient was using an IV pole as a pugil stick before security guards used a TASER to put him to the ground. In two other instances, patients were beating on security guards when they were “tazed.”

Protecting yourself is apparently a “violation of state and federal health rules.” As a result of the stun gun incidents, the hospital was ordered to retrain certain staffers in responding to behavioral emergencies. Security and emergency department staff had to be trained in comprehensive crisis management. The hospitals also had to establish a task force to track “incidents” and ensure that staffers had used the “least restrictive measures” when restraining a patient.

When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area.

Wouldn’t it be … interesting … to watch an “unruly patient” attack a CMS investigator and then watch hospital staff utilize mandatory CMS protocols to intervene?

Sir. SIR! How about you stop disarticulating that man’s elbow. Really now. Would you like some juice instead? We have apple, grape, and cranberry. Maybe some nice Saltines and peanut butter? No? Hey! Now if you don’t stop poking your fingers in that man’s eyes, we’re going to have to bring you to a secluded area. I’m not kidding, Mister. And you, Mr. Investigator – stop trying to fend off his attack with your clipboard. Don’t you know the patient could injure his knuckles if he hits that clipboard instead of your face? OK, Mister. I see the Investigator’s blood dripping all over the place. Someone might slip and get hurt. You are officially creating a patient safety hazard. NOW you’re getting CITED! SECURITY!

That should calm those unruly patients.

Death Panels and Access to Care

Saturday, December 4th, 2010

I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access.

Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture.

But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs?

That is the problem with which most governmental entities are now faced.

Arizona has taken a drastic step to reduce costs. It is now refusing to pay for expensive medical care to some Medicaid patients in need of organ transplants. According to the article, the decision amounts to “Death by budget cut.”

Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care.

Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them?

This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for.

If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine?

If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available.

As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least.

Don’t get sick and you’ll be just fine.

More Visits, Less Availability

Friday, August 13th, 2010

A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth.

Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics.

Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government.

The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession.

Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons),  homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents.

In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007.

Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program.

With the increase in visits, there are longer waits and less availability of medical care.

Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years.

The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures.

Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what?

I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.

Deconstructing Socialized Medicine?

Monday, July 26th, 2010

Socialized health care is great, and it’s a money saver, too. That’s why England is looking to decentralize it.
The health care budget in Great Britain has tripled in the past 13 years and the budget needs to stabilize.
According to the manifesto titled “Equity and excellence: Liberating the NHS” which was presented to the Parliament, England is planning to change the way in which health care is being delivered.
They’re planning to abolish primary care trusts, which currently make decisions about who gets what health care. They want to increase the choices available to patients. In fact, the plan sets out by stating that “Patients will be in charge of making decisions about their care.” “Shared decision-making will become the norm: no decision about me without me.” Patients will also be able to rate the quality of care provided at hospitals and clinical departments so that other patients can make an informed decision whether to go to those facilities.
Government micromanagement will also decrease. In fact, the document’s Executive Summary specifically states “The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.”
The Health System will only evaluate clinically credible and evidence-based outcome measures, not process targets. “We will remove targets with no clinical justification.” Does that mean that they won’t have to play medical Bozo Buckets in England?
Providers will also be paid based on outcomes and performance.

So far, sounds like a lot of changes heading in the direction of free market medicine.

The plan would also both increase payments to … and increase involvement of … primary care providers.
And there’s a lot of feel good discussion of how the plan will increase quality of care and efficiency of care – all while reigning in costs.

One of the experts in the Times article highlighted a problem with the plan “The real mistake [is creating a plan] motivated by the principle of efficiency savings. History shows clearly that quality will suffer as a consequence.” Goes back to that whole principle about “Fast care, free care, quality care. Pick any two.” It appears that British patients may be faced with a decision whether they want to pay more money for better quality.

But I still have to credit Great Britain for this new plan, because I think there are a lot of good ideas here.

I Suppose It’s Better Than Death Panels …

Monday, July 12th, 2010

Revealing article in Bloomberg online today about the latest way in which elderly patients are getting screwed by the system.

Medicare reviews all admissions and if the patients don’t meet indications for admission, the hospital doesn’t get paid by Medicare. Medicare has also recently implemented a mercenary system called Recovery Audit Contractors (or RAC for short) in which third parties audit hospital charts to see whether Medicare “overpaid” for a patient’s visit. If the auditor finds an “overpayment”, the auditor gets to keep a percentage of that overpayment.  Just as an aside, most states have laws against percentage “fee splitting” such as this since paying someone on a percentage basis creates a conflict of interest that encourages the contractors to do things to enhance their income.

Hospitals have the ability to classify Medicare patients as an “observation” admission during the patients’ stay. “Observation” admissions are apparently paid at a lower rate, but don’t come under as much Medicare scrutiny. Additionally, under Medicare rules, “observation” patients may have to pay a 20% co-payment that wouldn’t be required if they were admitted. Medicare “observation” patients also have to pay full price for any subsequent care that is rendered after they have been discharged. For example, if a Medicare patient needs a nursing home care or physical therapy after a hospital stay, Medicare will pay if the patient has been admitted for three days or longer and will not pay if the patient is classified as an “observation” stay. The Bloomberg article gives an example of one 76 year old patient who was saddled with more than $36,000 in bills based on his “observation” stay for eight days.
Another 90 year old woman was billed more than $11,000 after fracturing her hip and then undergoing five weeks of physical therapy so that she could walk again. Sorry, grandma, you weren’t admitted. You were only “observation.” Pay up.

If a patient is a borderline case, hospitals appear to be leaning toward keeping patients in “observation” status. The number of patients receiving the “observation” designation doubled between 2006 and 2008.

Also note how Medicare is planning to penalize hospitals that re-admit too many patients, which will only increase the number of patients classified as “observation” status.

On one hand, hospitals get paid more for admitting Medicare patients.
On the other hand, hospitals could be accused of false claims and penalized for admitting Medicare patients who don’t meet Medicare’s strict admission criteria. Medicare’s RAC mercenaries will be combing through charts because they have a financial incentive to find patients who have been “inappropriately” classified as “admissions.”

So hospitals play it safe and classify more and more Medicare patients as “observation” status.

Who gets stuck in the middle?

The patients … many of whom worked their lives and paid into a system so that they would have medical care when they reached age 65.

Now they’re finding that they only have “insurance.”

Dr. WhiteCoat Goes to Washington

Thursday, May 20th, 2010

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference

Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference.

I attended some excellent lectures about leadership.

  • Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions.
  • I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional.
  • I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for.

There were other lectures about how health care reform fell short and some possible options for the future.
One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference.

And I went to legislators’ offices.
The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff.
I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input.

I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer for him. We sat there for 45 minutes talking. Below are some of the things we discussed.

“What do you think about the SGR?” He asked.

  • Honestly, I don’t think they should fix it. Nobody cares about it right now. All they know is that they can keep kicking it down the road until it becomes a big enough problem that someone is forced to fix it. The only way to deal with the issue right now is not to fix it. Cut payments to physicians. Let most of them drop out of the system. Let the patients who depend on Medicare be stuck without medical care. Almost immediately, the AARP will pay for a bunch of buses for all the grandmas and grandpas with their pink hair and canes with the tennis balls on them (probably my own mother included) to go to Washington and demand a fix. Only then will legislators realize that the current system is unsustainable and unfixable. We can’t patch this system and expect that it will continue to work. We must focus on starting over and creating an entirely new system that will be sustainable in the future. And a side note – if you try to create another system without extensive input from physicians, it will fail in the same manner that the current system is failing.

“Do you think that the AMA represents the views of physicians across the country?”

  • Not really. I believe there is a lot of attrition from the AMA and know of many physicians who have dropped their membership. At the same time, membership in specialty societies is growing. ACEP is a perfect example. ACEP’s membership is going up, not down.

“How would you make the health care system better?”

  • Patients must have more skin in the game. Right now many people think that the value of the health care they receive is their $20 copay. You can’t get work done on your car for that much. A plumber would laugh at you if you told him that was all you would pay him. But, in practical terms, all a physician visit is worth is $20. That mindset has to change. $20 per visit won’t even keep the lights on.
    There is a tremendous demand for high technology and for extensive testing that is often low yield. That is because a majority of patients have no direct responsibility for paying the cost of the testing. There is no incentive for patients not to want a test and there is no incentive for a physician not to order the test. In fact, with the push toward “patient satisfaction” as a basis for reimbursement, the incentive for physicians to order extensive testing will only increase. If patients don’t have skin in the game, costs will continue to rise no matter what regulations are put in place. I guarantee it.
  • The only instance in which patients and physicians work together to decrease costs is when patients have to pay out of pocket for their medical care. If a patient’s medication goes off formulary for their health plan, the patient goes to the physician to find an alternative or to get the physician to request an exception from the insurance company. If a physician would like an MRI on an patient’s back after the patient was injured at work, the patient will not get the exam done until worker’s compensation agrees to pay for the test. This is what we need – patients need to be responsible for the costs and physicians need to help them determine what they really need and don’t really need. If patients want a low yield test, no problem – but they have to pay for it out of their pocket. Let them have ten low yield tests if they want. The only one who bears the cost of the testing is the patient.
    Homeowner’s insurance doesn’t cover the cost of someone mowing your lawn and it doesn’t cover the cost of your kid breaking a window.
    Auto insurance doesn’t cover the cost of oil changes or fixing your tire.
    Why should health insurance cover routine medications and routine medical care? It shouldn’t.
  • Health savings accounts have to become an integral part of our culture. Use the money in those accounts to pay for routine health care costs. Make money in the accounts tax-free to encourage people to use them. Allow patients to carry some of the money in the accounts over to future years, but require that they spend at least some of the money in the account each year to encourage people to engage in preventative health care practices. Family practitioners could drop all their insurance plans and could all go “cash only.” No insurance hassles. Money at time of services. They’re happier and more productive. More people go into family medicine. Patients get seen quicker. What a concept.
  • Mandatory insurance isn’t fair and it probably isn’t Constitutional. You want everyone to pay into the system, increase taxes in an amount proportionate to the amount you’ll need to provide for medical care and provide the care at government-run hospitals for free. You don’t have to pay for an insurance policy, you have to pay 5% more in taxes. In return, you have access to health care at any VA hospital. Include county hospitals if you need more access. Will the care be the best available? Probably not. Will everyone get a same-day appointment? Not likely. Will everyone have access? Absolutely. Do this and you could eliminate much of the costs that are currently wasted on insurance companies.

“What do you think still needs to be included in the health care bill?”

  • Malpractice reform. The AAJ has talking points stating how direct medical malpractice costs are an infinitesimal amount of total medical expenditures in this country. The statistics are true, but are only half of the story. The AAJ states that instilling fear in medical practitioners is good for medical quality of care. That fear drives defensive medicine. Defensive medicine accounts for hundreds of billions of dollars in indirect medical costs – at little gain to the system. If lawsuits improve quality of care, then the trial lawyers have failed. They’ve been suing doctors for decades and mistakes are still being made. The only thing that seems to go up is the size of the judgments. We can’t sue our way to better health care. Yes, I said that and yes the assistant laughed. I think he even wrote it down on his pad.
  • Damage caps are a tricky subject. Capping a patient’s damages at $250,000 isn’t fair to the patient, but neither is making a doctor liable for a $60 million judgment. There has to be some reasonable limit to damages, but even those limits won’t decrease the physician fear of being sued. [I actually agree with Matt on this point - in almost all cases, caps don't save physicians money, they save insurance companies money - but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won't be able to practice. There has to be a happy medium].
  • Like it or not, we will likely need to provide some type of limited liability protection to certain providers if we want to increase the numbers of those providers. Few physicians like being on call at hospitals because they know that they probably won’t be paid for the care and that they are highly likely to be sued if anything goes wrong. We have to ask ourselves whether we value the ability to find a physician to care for us in an emergency more than we value the right to sue that physician if anything goes wrong. Which is more important to us: Perfect care or available care?

We had other discussions, but this post is already getting too long.

You naysayers want my ideas? Here they are.

Now try to show me how they won’t work and come up with some better ideas.

Medicare Cuts Delayed Again — PHEW

Thursday, March 11th, 2010
fat-cat4
I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare.

While perusing the morning news, I discovered that once again the Senate has made a last-minute decision to delay the Medicare pay cuts — this time until October 1, 2010. I’ll be linking back to my Brinksmanship article somewhere around September 15, 2010, I’m sure.

According to one Senate Republican, this means that the federal deficit will increase by $100 billion.

Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion.
That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12)

Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars.

Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year.

Lets say that there are 50 million Medicare enrollees (these Kaiser numbers are from 2008, so I increased the estimate from 44.8 million to 50 million).

Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year.

Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country.

So what are all of us rich doctors complaining about?

How about politicians who are full of hot air.

Where’s the money really going?

Here is the Problem

Saturday, October 10th, 2009

ERP here again while WC recovers from the revelling in Boston

Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up.

The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars.

Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.

How Payments Affect Care

Monday, September 28th, 2009

When an unconscious intoxicated multiple trauma patient was brought to the ED, we did a bunch of CT scans to look for injuries. Fortunately there wasn’t anything life-threatening. He was admitted and was later discharged in good condition.

I then got a memo from the hospital several days later stating that Medicare would not pay for the CT scan of the patient’s cervical spine. There is a list of diagnosis codes for which Medicare will reimburse hospitals for performing a CT scan of the cervical spine. That list is contained below. If one of the selected codes is not on the patient’s final diagnosis list, then Medicare tells the hospital “tough luck” and pays the hospital nothing for the scan. As part of Medicare’s Conditions of Participation, the patient may not be charged for the exam unless the patient specifically agrees to the charges. When Medicare doesn’t pay, almost always the hospital gets stuck holding the bag.

If a patient is a victim of multiple trauma and is unconscious, CT scans of the cervical spine are more likely to show significant injury. This study showed that in multiple trauma patients, CT scans picked up on 98.5% of fractures while cervical x-rays only picked up 43% of fractures. It is uncommon to pick up ligamentous injuries on x-rays or CT scans – generally need an MRI for those.
If physicians choose to do a CT scan on an unconscious or poorly responsive patient, according to the “permissible” diagnosis codes, in most cases hospitals have to hope that either an injury or some type of cancer shows up on the CT scan. Otherwise, the CT scan won’t be reimbursed and the hospital eats the cost.

What are the other options in multitrauma patients?
We could just do only x-rays of the cervical spine, and, if negative, tell patients that everything is OK because the government won’t pay for CT scans unless you meet certain criteria. The 57% of patients with cervical spine fractures missed on x-rays will have all their medical needs met under the new health care reform measures anyway.
Or, while bleeding to death and strapped to a backboard wondering if they’re going to live or die, we could give patients an ABN form to sign. “Medicare might not pay for this test, if Medicare doesn’t pay for this test, do you agree to pay the cost of the test yourself — assuming that you live, of course?”
We could always perform x-rays on everyone’s necks first and make up notice some “abnormality on radiological or other exam of the musculoskeletal system” to justify the CT scan. That will be a 793.7 to all you CPT coders.
We could just say that notice that the patient winced in pain when the neck was palpated – causing “cervicalgia.” That’s CPT code 723.1.
Or we can just practice good medicine and let the hospitals get shafted by the system.

Of course, if hospitals get shafted enough by the system, they end up closing or reducing services. Then access to care suffers. You get what you pay for. Do a search for “hospital bankruptcy closures” and see how often it happens. Here are a few examples.

CT scan payments are just one example of the cat and mouse game that constantly goes on between those providing the services and those “paying” for the services.

It is also an example of the “Golden Rule” – he who has the gold makes the rules.

Things aren’t going to get better.

(more…)

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