Archive for the ‘Policy’ Category
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.
Posted in Access to Care, Medicare, Policy | 26 Comments »
Wednesday, July 21st, 2010
 The parent of a patient that we saw in our ED last night upset staff members.
One of her three children was out riding a bicycle without shoes and her foot got cut on the pedal of the bicycle. As we were cleansing and sewing up the laceration, the mother promised to take the children to get ice cream after we were done.
I discussed follow up instructions with the mother and she asked whether her child would be in pain. I told her that there might be some pain, but that Motrin should take care of it. She asked me if I planned to write a prescription and I told her that the over the counter Motrin would be fine. Then she got a little more assertive.
“We have Medicaid. I want you to write a prescription so we don’t have to pay for it.”
“You can get a bottle of liquid Motrin at the Dollar Store … if she even develops any pain.”
“I don’t have a dollar to spend at the Dollar Store.”
That ticked me off.
“But you’ve been promising your children that you would take them out to get ice cream when we were finished. You have money to buy ice cream but you don’t have money to buy medicine?”
“Are you going to write my child … the prescription … or not?”
“No, I think you’ll be able to get everything she needs over the counter.”
The nurse came to get me out of another patient’s room and told me that the mother was causing a scene in the hallway because I wouldn’t give her child a prescription for Motrin.
I wasn’t willing to argue with the mother any more, so I wrote the child a prescription for Motrin – 20 milliliters – which is a little more than a tablespoon – and which would cover the patient for two doses in case she did have any pain. The mom smiled, thanked the nurse, then left.
The thing that got so many staff members irritated was that the whole family was well-dressed, the mother had an iPhone and gold jewelry, and the kids were all eating stuff from the vending machine while they were waiting to be seen.
So we got into a discussion.
One nurse said that a patient in the grocery store was offering to pay for peoples’ groceries with food stamps if the people would give her the cash afterwards. A second nurse mentioned how she frequently saw people purchasing junk food in the grocery stores with food stamps then ringing up a second order with cases of beer and cigarettes that they purchased with cash. Our unit secretary noted how one of the patients who frequently comes to the emergency department with back pain and who is on public aid drives a Cadillac Escalade.
What possessions are reasonable for patients on public aid? What measures should be taken to make sure they aren’t gaming the system? Should we even care?
All I know is that this little girl’s mother really put a damper on the shift for a lot of the people who were working in the ED that night – to pay for the woman’s iPhone data package and that tablespoon of Motrin for her child.
Posted in Patient Encounters, Policy | 97 Comments »
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.
Posted in Access to Care, Defensive Medicine, Funding Crisis, Health care reform, Medicare, Policy | 43 Comments »
Monday, March 15th, 2010
I read this article and was going to put it in the next healthcare update, but decided to make it a separate post.
Immediate organ donation from the emergency department.
You’re involved in a serious car crash, the trauma team attempts to save you, but you end up dying. Instead of your body getting whisked off to the morgue, they take you to the operating room and harvest your organs.
Ethically, will doctors be doing their best to save patients, or will they be sizing up trauma victims to see which ones would make good organ donors? One ethicist in the article calls the concept “ghoulish.”
This is a tough call, but I lean more to the side of providing more organs.
That’s what I would want for someone else if I was the trauma victim.
Posted in Policy | 35 Comments »
Friday, January 8th, 2010
On one hand, times like these try mens’ souls.
On the other hand, times like these can show you the goodness in people’s hearts and the desperation that some patients face with medical illness.
As the number of rural health clinics has fallen from 500 to 316 in Texas, here’s a story about a small group of docs who do their best to care for patients in rural Texas. They even have a van packed with portable medical supplies that they use to perform house calls on patients too frail to make the trips into town.
The story is both somber and heartwarming.
Then there is another story about a group called Remote Area Medical that organizes events to provide free medical care to uninsured and underinsured patients.
In Tennessee, the lines for free health care begin the night before the doors open. A school serves as the venue. Bleachers are full of patients waiting for care. Patients get evaluated and treated in classrooms. Dental chairs fill the gymnasium floor.
Most patients either need to see a dentist or an eye doctor. But as the dentists evaluate patients, they note that some have medical problems that must be addressed first. One has a blood pressure of 200/120.
Insurance doesn’t do much for patients who cannot afford – or who are unwilling to purchase – medications. Many patients who are “unable” to afford basic prescriptions for as little as $4 a month have packs of cigarettes sticking out of their shirt pockets.
In two days, the volunteer staff evaluated 701 patients, extracted 852 teeth, performed 345 eye exams, and provided 87 medical exams. The total cost of the “free” care provided in two days amounted to $138,370.
Think things will change with the current health care bill? Think again. Dental and vision care are not covered for adults under the current House or Senate bills.
As the article states, “to fix health care inequities, expanding insurance alone may not be enough.”
“May” not be enough? Try “will” not be enough.
“Insurance” doesn’t equal access and it doesn’t equal health care.
Never has. Never will.
Posted in Insurance, Policy | 59 Comments »
Friday, November 20th, 2009
The director of our group was called to the administrative offices to explain why our Press Ganey scores had dropped eight percentage points. A slightly larger than normal proportion of patients rated us as “good” rather than “excellent” for the past couple of months. Now the hospital wants answers.
It wouldn’t be so bad if the hoops we had to jump through were rationally related to the care that we are providing. They aren’t. The things that are useful measures such as “quality of care” and “medical decisionmaking” are intangibles that can’t be measured and plugged into a spreadsheet. Try it. Describe what “quality care” is and then figure a way to quantify it.
Is quality care adhering to published guidelines? What if there aren’t any guidelines for your patient’s situation?
Does quality care amount to less complications than the other practitioners in your specialty?If so, then a large percentage of physicians will cherry-pick healthy patients who are less likely to suffer complications. What happens to doctors who care for the severely ill patients?
Maybe quality of care is equivalent to low cost. If we use that definition, then we’re going to be creating an incentive for doctors not to order “unnecessary tests” and not to find diseases. The old saying goes “if you don’t go fishing, you won’t catch any fish.”
It is nearly impossible to come up with a quantifiable definition of “quality care.”
So what happens? In some specialties, we allow our worth as physicians to be measured based on data that can be quantified: Our ability to make patients happy. When speaking specifically about emergency medicine, the measurements don’t start there, though. First, the system throws patients into situations that tend to make people mad or frustrated — in need of medical care and forced to wait, sometimes for an excessively long time, with a bunch of other people who are also in need of medical care — THEN we start measuring physician worth.
Sometimes patient happiness isn’t related in any way to the physician’s care, but the staff gets blamed anyway.
There are the creature comfort complaints like “the room was too cold” or “the food was horrible.” Patients may get blankets, but sometimes decreased satisfaction scores still carry over to the provider side of the survey.
Then there’s the “I saw my doctor the next day and he said that you should have given me antibiotics for my cold.” Great. The follow up doc is both a backstabber and an idiot. Doesn’t matter that the patient would have gotten better even if the doctor prescribed soap suds enemas because nothing is going to make a viral infection go away except time. Nevertheless, the physician providing medically appropriate care gets lower marks because of another doctor’s inappropriate medical treatment.
There are other examples, but you get the picture. The best similarity I can come up with is using a ruler to measure how cold it is outside. The instrument you’re using has little bearing on what you’re trying to measure.
Then I did some studying and found out additional information about patient satisfaction surveys in general.
To get an adequate sample size, for 1000 patients, you need about 280 respondents to have a 5% margin of error and you need 400 respondents to have a 1% margin of error. That’s between a 28% response rate and a 40% response rate for statistically valid data. Larger sample sizes need less response rates, but these numbers are just to give a general idea. Know what the response rate for a well-known patient satisfaction survey company is? Between 8% and 10%.
Then there’s the statistical term called “standard deviation.” The bell curve for any data set can vary. If 10% of people taking a test each got grades of 10, 20, 30, 40, 50, 60, 70, 80, 90, and 100, then the bell curve would be very flat and wide like a sprawling hill. If 10% got grades of 45, 80% got grades of 50 and 10% got grades of 55, then the bell curve would be very steep and narrow like the Washington Monument. The steeper that the bell curve, the less variation in the data. Often patient satisfaction data has a very steep and narrow bell curve. Therefore a small change in the data from one facility – such as a few more people than usual rating you as “good” rather than as “excellent” – can have a profound and potentially misleading effect on where your facility falls on the bell curve.
So I’ve decided to create a survey of my own … about the surveys.
Please pass along the link to your friends and colleagues. I’m looking for input from patients, administrators, and health care professionals. The more input, the better the results. There are at most about 20 questions, so it shouldn’t take more than 5 minutes to complete.
I’ll publish the updated results on this site weekly for the next few weeks.
By the way, please make sure that your answers are accurate since you’ll be asked different questions based upon what answers you give. I want to try to make the results as reliable as possible.
THANKS!
Posted in Policy, Random Thoughts | 17 Comments »
Friday, November 13th, 2009
 Now the Joint Commission has some competition from another medical professional society.
According to this LA Times article, the board of the American Marijuana Advocates, er, um the AMA, has put forth a statement that one of its goals is to “conduct clinical research, develop cannabis-based medicines and devise alternative ways to deliver the drug.”
The article quotes the AMA as stating that
“Despite more than 30 years of clinical research, only a small number of randomized, controlled trials have been conducted on smoked cannabis,” and these trials were “insufficient to satisfy the current standards for a prescription drug product.”
The AMA also published a disclaimer that stated “This should not be viewed as an endorsement of state-based medical cannabis programs, the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for a prescription drug product.”
Which leaves the whole issue not making sense. If they don’t endorse medical cannabis or legalization of marijuana, then why is their goal to “conduct clinical research, develop cannabis-based medicines and devise alternative ways to deliver the drug”? Do they want to do research in to “non medical cannabis” and “illegal drugs”?
In other news … the AMA Board also unanimously voted that batting one’s head with a sneaker could possibly be a sound way to gauge the effects of marijuana on one’s brain and that Mr. Hand was a real jerk when he stole Spicoli’s pizza in Fast Times at Ridgemont High.
Hat tip to the Volokh Conspiracy
Posted in Policy | 14 Comments »
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The topic of unnecessary medical testing comes up all the time in the health care reform debate and is a recurrent theme in news headlines.
Deconstructing Socialized Medicine?
Monday, July 26th, 2010Socialized 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.
Posted in Health care reform, Medicare, News Commentary, Policy | 6 Comments »