Archive for the ‘Policy’ Category
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.
VN:F [1.6.3_896] Rating: 8.8/10 (11 votes cast)
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!
VN:F [1.6.3_896] Rating: 8.5/10 (6 votes cast)
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
VN:F [1.6.3_896] Rating: 8.0/10 (7 votes cast)
Posted in Policy | 14 Comments »
Wednesday, October 28th, 2009
If you’re in the Fort Worth, Texas area and you call an ambulance for your influenza symptoms, your ride to the hospital may not have the red spinning lights on it.
In order to respond to the threefold increase in ambulance calls from patients with influenza-like symptoms, Medstar Ambulance Service is considering a change in policy where patients are evaluated after a call and then told that they “don’t need to go to the hospital.” If the patients still insist on transport, they won’t be taken to the hospital by ambulance. Instead, Medstar will arrange a taxi ride – and not necessarily to the hospital, either. Patients might get taken to an emergency clinic instead.
Oh, and when they’re discharged they’ll still have to find a ride home.
VN:F [1.6.3_896] Rating: 10.0/10 (13 votes cast)
Posted in Access to Care, Policy | 19 Comments »
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…)
VN:F [1.6.3_896] Rating: 8.0/10 (14 votes cast)
Posted in Access to Care, Medicare, Policy | 23 Comments »
Wednesday, September 16th, 2009
Emergency Physicians Monthly just published the results from a survey that it performed on health care reform. The results show something that most physicians already know.
ED physicians were asked how many tests they could have eliminated in an 8 hour shift without compromising the quality of care. Most said that they could eliminate at least 1 or 2 CT scans, and 27% said that they could eliminate more than 4 lab tests per shift. Two thirds of physicians responding to the survey estimated the potential cost savings at more than $500 per shift.
The survey also explores suggestions that emergency physicians have for improving health care, including creation of physician boards to determine the standard of care, tax rebates for charity care, copayments for all medical services, and implementing caps on non-economic damages in lawsuits.
Interesting read.
VN:F [1.6.3_896] Rating: 10.0/10 (4 votes cast)
Posted in Policy | 20 Comments »
Thursday, September 3rd, 2009
Below is a point-counterpoint that was published in this month’s EP Monthly print magazine.
Many thanks to Max Kennerly for putting up a valiant fight in a losing effort 
I will add links supporting facts for both arguments when I get a little more time.
Feel free to pick up in the comments section where we left off.
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Opening Argument
A 2006 American College of Surgeons report argued, “the single most important factor shaping the [emergency] surgical workforce today is declining reimbursement,” a euphemism for one of the most cutthroat industries in America. Last month, Bayonne Hospital Center sued Horizon Blue Cross Blue Shield for a parade of horribles, including Horizon calling patients in the ED, lying to them about their coverage, and instructing them to leave prior to screening or stabilization.
Against this backdrop, malpractice premiums are at a per-doctor thirty-year low, representing 0.45% of national health care expenditures. The impact of this particular cost should be ripe for economic review, but unbiased analysis is in short supply. The American Hospital Association, for example, conducts its studies through the Lewin Group, part of Ingenix, a UnitedHealth subsidiary that in January agreed to a $400 million settlement for providing phony data about physicians’ “usual and customary” fees so that UnitedHealth could short-change reimbursements. AHA studies unsurprisingly blame “lawyers” — but not “racketeering” — for physicians’ woes.
After a decade of declining premiums and paid patient claims in the 1990s, the stock market collapsed, causing insurers to raise premiums rapidly and prompting widespread reports of physicians forced to restrict services. In response, the General Accounting Office investigated the impact of malpractice premiums on access to care (in 2003, the height of the premium raises) by surveying five states with “reported malpractice-related problems” and four without. The GAO found no impact in the non-”problem” states. In the “problem” states, the GAO found “scattered” reductions by providers of ER on-call surgical coverage and newborn delivery services, most of whom also faulted “long-standing factors in addition to malpractice pressures,” like declining reimbursement. The GAO thus concluded most of the reports were “unsubstantiated” and that malpractice premiums “did not widely affect access to health care.” The same report found little evidence of “defensive medicine,” criticizing prior research, including a widely-reported Health & Human Services report, for transparently flawed assumptions.
> Such did little to stop a wave of malpractice “reform,” like in Texas, Georgia, South Carolina, Oklahoma, and Idaho, all of which capped noneconomic damages and eliminated joint and several liability, much as California did more than twenty years ago. Now that the stock market has stabilized and the tort reform has been in effect for several years, we have control and experimental groups in our laboratory of democracy.
The American College of Emergency Physicians’ 2009 Report Card on the State of Emergency Medicine is a revelation: of the ten states with an “A” or “B” grade for their “medical liability environment” (i.e., the most hostile to plaintiffs), six had an “F” for “access to emergency care” (the six “reform” states mentioned above), one had a “D,” two had a “C,” and one had a “B,” together averaging a “D-.” Conversely, the nine states with an “F” for “medical liability environment” earned the only “A,” had only one “F,” and averaged a “C” for “access to emergency care,” better than the national average of “D-.”
But, tort reformers say, there are other factors. That’s my point: the impact of malpractice premiums on access to care is so small that it appears *positive* because it is dwarfed by other factors such as the assault made on physicians’ income by companies like Aetna, Cigna and WellPoint, all of whom the AMA recently sued for also using the bogus Ingenix database. Physicians may feel premiums more directly, but they should not let loss aversion blind them of economic reality: the big change in the past generation has not been an increase in malpractice premiums or claims but rather an extraordinary decrease in reimbursement.
For example, a 2003 AMA report found physicians lost $4.2 billion in annual revenue providing unreimbursed emergency care; compare that “declining reimbursement” in a single field to the $4.7 billion paid in 2008 to resolve *all* malpractice claims nationwide. The same AMA study said emergency physicians incurred an annual average of $138,300 in uncollectable fees, double the average insurance premium for specialists and nine times the average premium for primary care physicians. All in all, it seems an ounce or two of reimbursement would be worth a pound of tort reform.
-Max Kennerly
Counter Argument
Doctors fear malpractice liability. And why shouldn’t they? Last month a woman was awarded $60 million dollars after a cosmetic surgeon allegedly botched her thigh lift. Medical malpractice law firms proudly display news releases about their multimillion dollar malpractice verdicts against physicians.
Does malpractice liability affect access to medical care, though? Access to medical care is limited by two factors: Available providers and willing providers. The best vascular surgery program in the world can’t help you if there’s no surgeon available or if you’re 150 miles away when your aortic aneurysm ruptures. Similarly, an abundance of nearby neurosurgeons helps no one with a brain hemorrhage if none of those neurosurgeons is willing to perform brain surgery.
What factors affect whether a provider is available or willing to provide services?
Money undoubtedly affects access to care. Even though patients with Medicaid ostensibly have a means to pay for their care, they often have difficulty finding a physician to treat them because payments do not cover the costs of providing care. In this case, physicians may be available, but they are unwilling to provide care for the proposed payment. Conversely, patients with commercial insurance don’t seem to have such problems.
Liability also affects access to care. At first glance, it is easy to discount that effect. How could something that amounts to only 1.5% of total healthcare expenditures affect a physician’s willingness to provide care? The answer is that direct liability costs are only a small piece of the puzzle. Fear of liability creates a tremendous ripple effect. No physician wants to be at the receiving end of the next $60 million verdict. Residents in high-risk fields cite malpractice costs as by far the largest reason for leaving one state in favor of another. More than half of hospitals in medical liability crisis states have difficulty recruiting physicians, resulting in less physician coverage for their EDs. A survey of some Nevada Ob/Gyns showed that 60% planned to drop obstetrical coverage due to malpractice premium increases. Similarly, many Mississippi Ob/Gyns have dropped obstetrical care due to malpractice liability, leaving some counties with no obstetrical care at all. Trauma centers in several states have temporarily closed due to malpractice issues.
Texas tort reform shows that liability reduction can increase access to healthcare. Since tort reform was passed in Texas six years ago, the number of applications for physician licenses has increased dramatically. The number of emergency physicians has increased in 76 Texas counties – many of which were considered “underserved” for emergency care before tort reform. The number of malpractice insurers in Texas increased from 4 to more than 30 and insurance premiums dropped more than 40%. One Texas health system was able to spend $100 million extra dollars helping poor patients. That money had previously been held in reserves for legal defense fees and insurance premiums.
Some might try to draw conclusions by comparing metrics on ACEP’s Report Card. Doing so does not take into account multiple other factors affecting each metric. We cannot directly compare better access to higher liability any more than we can directly compare better access to colder climate. After all, states that scored worst in “access to care” were exclusively in the South and West United States – which generally have warmer climates.
Finally, defensive medicine costs our system up to $300 billion each year. Eliminating defensive medicine could provide each one of the 46 million uninsured patients in the US with $6500 in health care. Unfortunately, there is little tolerance for errors or misdiagnosis in medicine. While no lawyer will ever admit an expectation that medical care should be perfect, I still haven’t found a lawyer who will give me an example of a heart attack, a ruptured appendix, or a leaking cerebral aneurysm that it is OK to misdiagnose. Instead, doctors perform one low-yield test after another to “prove” that every haystack really doesn’t have a needle in it.
I respect Max and I respect his opinions. It just seems ironic that some of the strongest supporters of the notion that we can “sue our way to better health care” are those who stand to benefit the most from trying to do so.
-WhiteCoat
VN:F [1.6.3_896] Rating: 10.0/10 (4 votes cast)
Posted in Access to Care, Policy | 77 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.
Drug Testing Welfare Recipients
Saturday, November 28th, 2009From the steamy comment section of Nurse K’s blog comes IglooDoc’s link to an article showing how a state agency in Arizona is heading in the right direction in the war on drugs.
Effective Tuesday, the Arizona Department of Economic Security started performing urine drug testing on individuals whom officials had “reasonable cause” to suspect were using illegal drugs. Get caught using and you’ll lose your welfare check for a year.
Before you start applauding, the requirement has a lot of loopholes:
The test only happens when you reapply for assistance — it is not a random test.
When you do reapply, apparently “reasonable cause” is determined by peoples’ answers to a three question questionnaire. I’m bubbling over with anticipation to see how many people will answer “yes” to the “do you use illegal drugs” question.
If you are one of the unfortunate few to be selected to take the urine drug test, you have to submit your sample within ten days – by which time it is likely that, if you can control your habit for that long, most drugs will be out of your system anyway.
So the Arizona requirement is largely toothless, but at least it is a step in the right direction.
There was an e-mail going around not too long ago saying that if working people are subject to random drug tests while earning money at work, people who are earning money from welfare should be subject to the same random drug testing. Don’t want to give up your civil liberties and privacy to the contents of your bodily secretions? Then don’t take the money.
Now if only more state governments would get the hint.
Posted in News Commentary, Policy | 31 Comments »