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Archive for the ‘Policy’ Category

Excuses

Thursday, March 27th, 2014

ekg-jiggle

I recently got into a rather … shall we say “colorful” … discussion with another doctor about lawsuits. I’m involved in another one. This one is even more screwy than the one I wrote about before. But this lawsuit isn’t finished yet. I expect that it will be over with in the next few months, but I’ll have to wait and see about that.

The discussion centered around medical records, which were one of the issues in my lawsuit.

The other doctor believed that what people write in the chart plays a big part in whether a doctor is successfully sued. In other words, the doctor believed that medical providers largely have the ability to document themselves out of a lawsuit.

I, on the other hand, asserted that charting generally does more harm than good. Sure, a well documented chart may make a doctor look more thorough and conscientious, but in the end if a diagnosis is missed, experts and jurors will work backwards from the diagnosis to determine all of the things that a doctor should have done to arrive at the diagnosis. If it’s a difficult diagnosis, documentation *may* save you. But if it is a disease where a patient manifested a couple of symptoms – even if those symptoms were nonspecific – documentation won’t do much. Electronic charting also provides a LOT more information, so it gives plaintiff attorneys more opportunity to show inconsistencies within a patient’s complaints, review of systems, and physical examination. Create an inconsistency by checking the wrong box or accidentally clicking “yes” instead of “no” and you look like either a careless schlubb who couldn’t be bothered to do an accurate exam or you look like someone who’s documenting an exam you didn’t perform in order to bill more money.

Then I started thinking. You know where that leads.

Suppose that a patient came to the emergency department with chest pain. He has a couple of risk factors for heart disease. His chest pain wasn’t classic cardiac pain, but he had chest pain. His EKG didn’t show any acute changes, but sometimes they don’t when someone has angina. His blood tests were normal, but again, blood tests often are normal when someone has angina. The pain gets better, so the emergency physician sends the patient home with a diagnosis of “chest pain” and instructs the patient to follow up with his doctor. But the patient doesn’t live that long. He dies that night from a heart attack.

Of course there’s going to be a lawsuit because a patient died from a heart attack after going to the emergency department with chest pain. I’m not going to argue whether or not the physician should have been sued. I didn’t give enough information in this example for anyone to make that determination.

My question is this: Given this scenario, is there anything about the chest pain patient’s history or physical exam that the physician could write in the chart to lessen the likelihood that he would be sued? If you were jurors, what types of things would sway your opinion (if anything) and make you decide that the doctor shouldn’t be liable for missing a heart attack in a patient complaining of chest pain? If the medical professionals were acting as expert witnesses, what documentation (if any) would make it more likely for you to conclude that the doctor complied with the standard of care?

I’ll let you know my thoughts once I read some comments.

CMS One Way Data Transparency

Thursday, January 23rd, 2014

1-23-2014 8-42-19 PMAccording to an article on the CMS Blog, in 60 days the government plans to begin disclosing information regarding payments it has made to individual physicians. In order to receive the information, there has to be a FOIA request and each request will be evaluated on a “case by case basis” which means it is unlikely that they plan to just give their entire payment database over to the first person who makes an inquiry. However, the CMS blog states that the government is planning to publicly disseminate aggregate information regarding payment information.

The AMA, all of the State Medical Societies, and a few dozen specialty societies all oppose the idea (.pdf file), alleging that privacy rights of the physicians would be violated, that releasing raw data would result in “inaccurate and misleading information,” and that releasing information such as a physician’s National Provider Identifier would subject the physicians to identity fraud.
On the other hand, watchdog groups such as the “Council for Affordable Health Coverage” believe that all of the data regarding physician payments should be on a publicly accessible database rather than being disseminated on a case-by-case basis.

CMS responded to the medical establishment’s concerns by stating that before releasing individual data, it will consider the “importance of protecting physicians’ privacy and ensuring the accuracy of any data released as well as appropriate protections to limit potential misuse of the information.”

To me, this should be a no-brainer. If any entity does business with the government – not just physicians – disclosure of what services are being performed and what payments are being made should be a right to every citizen.  Remember that whole bit about establishing a constitution on behalf of “We the People”? Remember Abraham Lincoln’s dream of a government of the people, by the people, and for the people? People are the government. If We the People are paying for services through taxes then there is always an overwhelming public interest in seeing how much We the People are paying. If those providing services to the government don’t like it, then do business somewhere else.

With very few exceptions, We the People should be able to see a full and detailed accounting of all government income and expenditures – not just aggregate physician payments.

That’s where CMS’ whole “we’re disclosing physician payments to prevent fraud and abuse” argument falls apart.

Payments to individual doctors are going to be disclosed. Also, any payments or “transfers of value” physicians receive from pharmaceutical companies or medical device manufacturers is also on a government database.

What isn’t going to be disclosed?

  • It isn’t clear whether CMS will release payments to physicians per individual procedure or per individual office visit. My guess is that it won’t. So you won’t know whether your doctor works 4 hours a day twice a week or 12 hours a day for seven days a week to get the payments that CMS is disclosing. You won’t know the overhead in the doctor’s office or the amount of the payments on the doctor’s student loans or the thousands of dollars each month that the doctor pays in malpractice premiums. CMS won’t tell you to divide their “payment” by at least one third to account for taxes that the doctor pays. CMS will just provide you with a number so that everyone can shake their heads at how unfair it is that medical providers are being paid so much
  • It also isn’t clear whether CMS will break down payments to hospitals by specific ICD-9 or CPT codes. To be fair, CMS has published aggregate data for payments to hospitals for the top 100 DRGs, but those payments are several years out of date, in the aggregate, and only involve “average covered charges” and “average total payments” but do not itemize what CMS pays the hospitals for specific services. The aggregate payments include intangible variables such as “teaching,  disproportionate share, capital, and outlier payments” so it is impossible to compare “apples with apples” using the data.
  • And CMS definitely won’t divulge information about patients. The Federal Register Notice (.pdf file) signed by CMS administrator Marilyn Tavenner and approved by Kathleen Sebelius, the Secretary of the Department of Health and Human Services specifically states that “in all cases, we are committed to protecting the privacy of Medicare beneficiaries.” Those superusers and drug seekers who run up the health care tab on the public dime are protected from scrutiny.

On one hand, CMS alleges that it wants to create transparency to avoid fraud, but on the other hand it releases only select data.

Where is the data on how often CMS has denied payments to physicians or to healthcare organizations for services that were provided?
Where is the data showing why those payments were denied?
Where is the data showing how often the denials were reversed and how much extra time that CMS was able to avoid paying for legitimate services by inappropriately denying payments?
Where is the data on the average length of a phone call it takes to contact CMS regarding an inappropriate denial?
The fact is that we don’t get the “transparency” when we look back at CMS.
It’s a one-way mirror.

If we’re really interested in combating fraud, why can’t we get FOIA requests for aggregate payments made on behalf of patients? We don’t need to know what the payments are for and public agencies delivering social security or welfare benefits are not covered by HIPAA privacy rules, so don’t even go there.
Shouldn’t it be my right to see how much of my tax dollars are being paid to the guy on disability down the road with the souped-up Escalade who goes on vacation more than I do and who is out on the golf course all day? Or is it that fraud only of “public interest” when it is committed by medical providers?

CMS is taking this approach for one reason – to vilify medical providers.

With 37% unemployment in this country, medical providers are an easy target. Publish data that inflame a large proportion of the population, allege that medical providers are being “greedy” for not accepting pay cuts, then use that negative public opinion as a means to justify cutting payments and creating even more laws and regulations that make the practice of medicine even less appealing. When you’ve driven enough providers out of health care so that there isn’t sufficient access to all the aging baby boomers and newly-minted Medicaid patients, you can blame that on the medical providers, too. How dare we not provide care to our fellow citizens.

I’m all for transparency, but there needs to be global transparency, not a bunch of smoke and mirrors labeled as “transparency” and used as a means to an end.
You want to publish the data? Publish all of the data.

Come to think of it, maybe we can create public databases of all the payments and perks to all government officials. How much in “transfer of value” has Kathleen Sebelius received since she entered office? Business trips? Meals? Office supplies? Travel?

Betcha those numbers would put payments provided to most medical providers to shame.

Alarm Fatigue

Wednesday, May 1st, 2013

Alarm Clock (Copy)For those of you who don’t know what alarm fatigue is, think of a car alarm. The first time you hear it going off, you run to your window to see who’s breaking into a car. Maybe you run to the window the second time and the third time, too. By the tenth time the alarm goes off, you’re thinking that the alarm is broken and someone needs to get that fixed. After about thirty false alarms, you’re feeling like going out there and busting up the car yourself – especially if the car alarm wakes you when you’re asleep.

So alarms can be good, but if there are too many “false positives” – in other words if they go off too much when nothing is wrong – people tend to become tired of listening to them and eventually ignore the alarms.  On the other hand, if there are too many “false negatives” – meaning that they don’t go off when something is wrong – then the alarms aren’t fulfilling their purpose.

The same problem holds true for multiple types of alarms. Think about virus alerts on your computer. If they are set to alert you about everything, the first few times you freak out, then, after investigating, you dismiss them. If they alerts keep occurring too often, eventually you figure out a way to disable them. If the alarms don’t alert you when a virus is trying to hack into your computer … then what good is it to have the software?

With electronic medical records, medical providers are often alerted to multiple types of medical problems with each patient. No recent tetanus shot. Haven’t asked whether the patient is abused at home. No allergy information available yet. Time that patient was first evaluated not entered. Did you review vital signs? The list seems endless sometimes. Some of these alerts are useful. Most just serve to document some government mandated question that we must answer in order to receive payment for billing or to look like we provide better care on some database that only hospital administrators and reporters ever look at.

It was busy as heck during a shift and I kept getting knocked off task by alarms which are supposed to be helping us. A patient is having an acute heart attack. I try to put in orders for basic treatments and labs. Once I get logged into the patient’s chart, that takes a minute or so. Then, before the system will accept the orders, I get the alerts.
“No medical allergy information had been entered for this patient. Medication orders will be canceled.” The only button to hit is “OK” on that screen. Well, he’s a new patient. So I have to spend another few minutes clicking through a dozen or so screens to tell the computer that the patient has an allergy to sulfa drugs (causing him to have an upset stomach) and to iodine (which gave him a “warm” feeling when he received dye for a CT scan once).

Phew. Close call.

Then I spend another few minutes re-entering all of the medications I want the patient to receive. I have to enter all the medications by hand now instead of clicking on the boxes since the computer system won’t let me enter the same “order set” twice on the same patient.

First, let’s give the patient some aspirin. Everyone knows that’s an important treatment for patients having a heart attack.

Whoops.

Sulfa Allergy Aspirin

Alarm. Now I have to go through a few more screens and enter my password to confirm that I dare to give aspirin to a patient who gets an upset stomach when he takes sulfa medications. Where the connection is … GOK.

Well, I’ve dodged that bullet. Now let’s start an IV so that we can give him some IV fluids and have access to give him other medications if he needs them.

Whoops.

Iodine Allergy Saline

Alarm. Now I have to go through more screens and enter my password to confirm that I dare to give salt water to a patient who felt warm after receiving CT scan dye. Where the connection is … GOK. Salt water contains three things: sodium, chloride, and water.

Now that I’ve averted that disaster … oh yeah, the patient has a history of GI bleeds and was pretty anemic last time he was admitted to the hospital. Let’s get a type and screen on him too, just in case he needs blood.

“Reflex order: Blood transfusion.
“How many units of blood will patient receive?” Um … zero. We’re just doing the preliminary stuff if he should need blood.
“Should patient receive Lasix with blood?” Um … no. We’re not transfusing him yet.
Nevermind. Cancel the blood. Cancel. Cancel. Cancel. Yes, I’m sure I want to do that. Confirm.

OK, now let’s … wait a minute. Where was I? Oh yeah. Trying to take care of the patient having a HEART ATTACK.

In creating a “safe” environment for patients, the medical records have delayed me from providing necessary and time-sensitive care to a patient.
Now imagine going through the same or similar scenario multiple times each shift. Every shift.

Ready to go bust up someone’s car yet?

 

Proving a Negative

Thursday, April 11th, 2013

Skull Medical book [morguefile.com]A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem.

Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms.

The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier.
No old records in the computer.
I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any.
I asked her to show me her drivers license. Nope. Didn’t have that, either.
I was quickly developing an opinion that this was a snipe hunt.

Snipe hunts like this are an example of another conundrum that many physicians face.

We are often expected to prove a negative.

Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible - don't comment with all your weight loss feats] that any patient could lose 50 pounds in a month.

But what if …?

What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for?
What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities?

Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem.

I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready.

A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups?

And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation.

I’m going to be eating my words if she comes back next month weighing 80 pounds.

Increased Workload = Increased Medical Errors?

Friday, March 1st, 2013

They throw around that lame 98,000 preventable deaths per year statistic, but the survey is still quite telling.

More than one third of 890 hospitalists surveyed stated that their workload exceeded safe levels on at least a weekly basis.

As a result of this increased workload, 22% of doctors stated that they had delayed admissions or discharges, 10% stated that they had failed to promptly note/follow up/act on a critical lab value or radiology report, and 7% stated that they had made a treatment or medication error.

In addition, 22% of doctors believed that they had ordered potentially unnecessary testing, 12% believed that the quality of care they provided had worsened, and 5% said that it was possible/likely/or definite that a patient died due to the increased workload.

As more and more doctors become employees of hospitals, I wonder how long it will take before hospital CEOs and administrators start being named in malpractice lawsuits (no malpractice caps on non-physicians, folks) for inadequately staffing the hospitals.

Healthcare insurance but no healthcare access

Wednesday, February 13th, 2013

Lucy VanPelt The Doctor is INCalifornia doesn’t have enough doctors to provide healthcare to newly “insured” patients under the UnAffordable Care Act.

California state senator Ed Hernandez asks “”What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?”

Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years?

The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients.

California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together.

Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not?

If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money.
If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur.

These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea.

Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea.
We all should be part of a team, but not everyone is able to play quarterback.
I predict that these types of policies, if implemented, will ultimately increase the demand for physicians.

Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care.

But remember that everyone will be insured, so things will be OK.

In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists, and possibly even Lucy VanPelt expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted on KevinMD’s site a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.”

You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.

I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be [independently] treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.

Social Media Fair Play

Wednesday, February 6th, 2013

JustADoc commented about a Yahoo News story concerning an obstetrician who posted a mini-rant on Facebook about one of her patients always being late. The obstetrician’s post said

“I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?”

After the post became widely distributed, some people called for the doctor to be fired. Others defended her as a good physician.

The hospital assured all their concerned patients that the hospital would “reinforce their high employee standards.”

The Yahoo news story created a fake retort from the obstetrician’s hospital (I looked up the hospital’s Facebook page to make sure it was a fake retort) saying

Mercy Hospital St. Louis Facebook

When I look back at my post last week about State Medical Board investigations for what are deemed to be inappropriate online posts, I started thinking.

If people agree that doctors’ livelihoods and the money and time they spent on their medical educations should be threatened because of a potentially offensive statement, shouldn’t that be the standard for everyone else as well?

An offensive statement is made by a hospital, investigate the administrative staff. Maybe fire them and blackball them from further jobs in hospital administration.
Politicians make an offensive statement, investigate them, too. Maybe they get fired and prevented from working as a politician. Same for CEOs, federal workers, journalists, editors, public employees, judges, lawyers … everybody.
Anyone receiving government assistance gets the same treatment. Make any offensive statements and you get investigated. If the statements are offensive enough, you’re on your own. You are no longer eligible for government assistance.

Sound outrageous?

I agree … in all cases.

Art Kellermann Rand Rant

Saturday, January 26th, 2013

One of the posts in my Twitter feed was a re-tweet of something asserted by Dr. Art Kellermann (@ArtKellermannMD). Dr. Kellermann is a distinguished physician. He is the Director and VP of Rand Health. At one point he was a professor at Emory University, but apparently does not practice emergency medicine any more.
Dr. Kellermann’s tweet said the following:

Kellerman Quote

Dr. Kellermann’s tweet references an editorial article that he wrote in the Annals of Emergency Medicine titled “Waiting Room Medicine: Has It Really Come to This? The article was from 2010, so I’m not sure what prompted him to tweet about it in 2013, but nevertheless, the article at least seemed pertinent … until I read it.

The assertion in Dr. Kellermann’s tweet was a quote from his article and was reportedly supported by a 2001 brochure created by the UK Department of Health (.pdf file). The context of Dr. Kellermann’s assertion in the article he wrote is as follows:

The ED is more than a clinical setting; it is a “room with a view” of the best and worst of modern health care. In the United Kingdom, a crowded ED is considered a telltale sign of a poorly managed hospital. If that perspective ever takes hold on this side of the Atlantic, things will change. Until then, it is up to us.

Things will change if our perspective changes. Until then, change is up to us.

What a feel-good nonsensical assertion of nothingness.

(more…)

Pressure to Admit

Monday, December 3rd, 2012

We were away for the weekend, but in a restaurant, I caught glimpses of this segment on 60 Minutes called “The Cost of Admission.” Couldn’t hear the conversations in the restaurant, but luckily CBS posted the entire report online. If you didn’t see it, you really need to watch the video and/or read the transcript.

In summary, 60 Minutes spent a year investigating irregularities in hospital admissions. Administrators at Health Management Associates and at EMCARE (one of the national emergency medicine contract groups) were accused of putting pressure on emergency physicians to admit at least 20% of patients that came to hospital emergency departments.  For Medicare patients, the “benchmark” for admissions at one hospital was allegedly 50%. The 60 Minutes expose also included spreadsheets showing comparisons of different physicians’ admission practices and text from e-mails saying such things as “I have been told to replace you if your numbers do not improve.”

HMA held a conference call disputing the allegations and stating that they “take all allegations regarding compliance very seriously.” HMA allegedly had outside experts review the data (not the medical records?) and the experts determined that “the data simply do not support the allegations.”

Now HMA is being investigated by the US Department of Justice for Medicare fraud. I predict that HMA will make a large settlement with the government to drop all charges (without admitting wrongdoing, of course) and that things will return to business as usual shortly thereafter.

With things like this, I can’t really blame patients for thinking that medical care is “all about the Benjamins.”

Patient satisfaction metrics are creating quite similar incentives with physicians. How long will it be before people wake up and see how much fraud that the satisfaction scores are causing?

What About MEN?

Tuesday, November 13th, 2012

Retired emergency physician/family physician writes letter to editor of Minnesota newspaper stating that insurance should pay for birth control for all women because otherwise rich women could afford to pay for birth control and poor women would be forced to have unwanted children or “back-alley abortions.

I’m not really sure how someone too poor to purchase birth control is going to be able to purchase insurance so that they receive free birth control via a government mandate, I’m also not sure how people too poor to purchase birth control are going to be able to afford to pay for a “back-alley abortion” on such limited income.

That’s OK. No one ever said that mandates have to make sense or have logically justifiable reasoning to support them.

He’s missing the simple solution to this problem.

Everyone should just be able to pick up as many condoms as they want at any federal building for free. Go drop off your mail, grab a handful of condoms. If government is going to mandate it, the government should pay for it.

Think about it: No worry about adverse side effects from “the pill.” No discrimination against males who don’t get to share in the free handouts. Plus, consider the added bonus of decreasing the spread of sexually transmitted diseases.

If they were smart, they could even sell political campaign ad space on the packaging. Then again, if that happened, people might get confused and think that the pictures are showing where to put the condoms.

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