Archive for the ‘Policy’ Category
Saturday, September 8th, 2012
EP Monthly has an important Pro-Con debate between ACEP President David Seaberg and EP Monthly founder Mark Plaster about the “Choosing Wisely” program.
Choosing Wisely is being pushed by the ABIM Foundation as a way to get specialty societies to label certain tests as “unnecessary” or of questionable benefit.
I side with Dr. Seaberg in this argument.
I disagree with the concept some people advance that we need to essentially “do it to ourselves before someone else does it to us” (see the comment to Dr. Seaberg’s position). Reasoning like this is how physicians and patients have lost much of the control of the house of medicine. Read through the news and look at the emphasis on reducing the amount of “unnecessary” care. Just last week, the Washington Times published an article about how the Institute of Medicine stated that we waste $750 billion each year in health care. How could anyone disagree with reducing that which is “unnecessary”? It’s a great sound bite. But as Dr. Plaster notes in his article, the devil is in the details.
How do we define “unnecessary”? A pregnancy test in a male patient is “unnecessary.” No way to justify its use. But other tests which seem to have little clinical utility may be deemed “necessary” for non-clinical reasons. A CT scan may only infrequently show the etiology of a patient’s syncope, but some doctors may believe the CT scans are “necessary” to avoid accusations of improperly evaluating a patient or to prevent being sued for missing a rare neurologic cause of a patient’s syncope. If we want to decrease the amount of “unnecessary” testing, we need to address all of the reasons that such testing is performed. Why doesn’t Choosing Wisely change the preamble of its campaign to include: “The following tests are medically unnecessary and no type of professional or legal liability should ever be imposed upon physicians for failing to order or perform them …”?
I question whether the ties that several ABIM foundation trustees have to the Obama administration (hat tip to A Line of Sight) will affect the mission of this project.
Finally, many of the groups listing “unnecessary” testing in the Choosing Wisely campaign are making their directives at other specialties. Radiologists are telling emergency physicians not to order so many CT scans. Neurologists are telling emergency physicians not to order CT scans for migraine headaches. Unless those specialists are going to come to the emergency department, evaluate the patients, and follow their own recommendations, they have no business telling other specialties what to do. Easy to point fingers when you have no skin in the game.
We need to reduce the amount of testing performed in this country, but I still think that the best way to do so is through deregulation and free market principles. If patients want to pay for a test with little clinical validity, they should be able to do so. They should be able to have the test done ten times if they want to pay for it.
Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing.
In this respect, I predict that Choosing Wisely just won’t work for its intended purpose and it will likely be used as a first step toward rationing care – especially care that ends up with “normal” results.
Wednesday, August 22nd, 2012
Real patient encounter …
A 22 year old guy comes to the registration grabbing his chest. He’s having palpitations and chest pain.
He’s a pack a day smoker, has no family history of heart disease, and was out late the prior evening partying. So when he woke up, he was dragging a little. He had to be at his construction job in an hour, so he drank a “Monster” energy drink. When he got to work, he still felt tired, so he drank another “Monster” energy drink. That’s when the palpitations and chest pain started. He was anxious and felt a little short of breath, too.
The EKG from triage showed a mild sinus tachycardia of 106. No arrhythmia. No ischemia. His physical exam was completely normal except for his anxiety and his elevated pulse. He got an aspirin and some Ativan.
A half hour later, he wasn’t feeling any better even though his pulse was in the 80s.
Now everything points at this guy being acute “Monster” caffeine overdose. It was suggested that he be discharged with a prescription for Ativan and an order to lay off the caffeine. But because he was still symptomatic, he got an entirely unnecessary cardiac workup. His second EKG was normal sinus rhythm and still showed no ischemia. His CBC, chemistries, cardiac enzymes, and urine drug test were all normal.
Oh, and his chest x-ray showed a complete collapse of his left lung.
The problem with labeling testing “unnecessary” – even though the tests may be normal most of the time, they aren’t normal all of the time.
Where do we draw the line between what is and is not “unnecessary”?
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
Thursday, July 26th, 2012
“Maybe we should have started with you at the very beginning, talked to the physicians before they started writing a 2,000-plus-page bill that many of them [politicans] didn’t read, yet passed.”
- Republican Rep. Scott Tipton, commenting about the Affordable Care Act during a House Small Business Committee meeting last week which showed how “physicians have reached a tipping point” due to overregulation by Congress and insurance companies.
Dr. Louis McIntyre does a very good job at putting things into perspective during the included video interview. Not bad for an orthopedist …
Friday, July 20th, 2012
GruntDoc had a post that illustrates a point I have been trying to make for quite some time.
The post is simple enough.
It starts out with a Twitter post by a physician named Brett (@EMDocBrett) noting “Ottawa Ankle Rules? People follow them? I try to explain to pts but really, they [just] want an [x-ray].”
For those of you not familiar with the Ottawa Ankle Rules, they are a way to predict with high accuracy whether a patient does not have an ankle fracture. In other words, if you don’t meet the criteria in the Rules, it is almost certain that you don’t have an ankle fracture.
GruntDoc relayed a story about how, through use of the Ottawa Ankle Rules, he was able to substantially cut down on the number of ankle x-rays at a clinic where he worked. He was proud of the impact he made … until he learned that all the corpsmen drove to the local emergency department to get their x-rays anyway.
Then he cited the scholarly Nick Genes (also at @nickgenes) who once said “Canadians get exams, Americans get x-rays.”
What’s the simple solution to the problem of everyone wanting ankle x-rays when no injury is present?
If people want to have an x-ray, they should be able to walk into any radiology facility and have an x-ray without a doctor’s prescription. Why are we requiring doctors to be the “middlemen” between patients and testing? Common knowledge that if a patient goes to a doctor demanding an x-ray, the patient will get an x-ray. Press Ganey has made it likely that you will get what you want in the emergency department even if it is medically inappropriate. And if one doctor doesn’t write a prescription for an x-ray, then, just as they did with GruntDoc, the patients will just go somewhere else to get their x-ray done.
Allowing patients to get their own x-rays would cut down on the number of doctor visits and emergency department visits significantly. How many patients go to the doctor solely because they want a prescription to have an x-ray done?
Allowing patients to get their own x-rays would also cut down on medical liability. If patients get an x-ray without their doctor knowing about it, then the doctor doesn’t have to worry about following up on the study or the results. If the patient wants to discuss the results with the doctor, they make an appointment. Otherwise — just like if you choose to fix the brakes on your car — if something goes wrong, you’re on your own.
Deregulation would also mean that patients have to pay out of pocket for the x-ray.
Patients would then be faced with a dilemma: Do I pay $100 for an ankle x-ray, do I just follow those Ottawa Ankle Rules and save the $100, or do I go get a professional opinion from the doctor?
Let’s say that the patient decides to go purchase an x-ray. It’s normal. After a few normal ankle x-rays, then patients may be a little more hesitant to get radiated next time they twist their ankle. Now what? See a doctor for an exam? Go pay for an MRI?
Let’s pay $1000 for an MRI and interpretation. Or perhaps we save money on the radiologist’s interpretation and we look up MRI ankle interpretation on the internet. Now what?
Want to discuss what to do with the results? Your family doc can probably get you in to the office in a day or two. Or … our emergency department doors are open 24/7. We don’t interpret MRIs, but we can place your ankle in a splint and refer you to an orthopedist.
Want to reconstruct your lateral collateral ligaments on your own? You’re empowered to make that choice.
Just do an internet search.
You can even x-ray your ankle when you’re done to see how you did.
Friday, June 22nd, 2012
Our state government, just like every state government, is trying to save money.
One of the largest targets for this attempt at savings is the health care system, since health care is one of the largest expenses in any state budget.
In order to save money, the state government has several options: It can raise revenues, cut services, or cut payments. But unless these options are well-thought out, the attempt at saving money may have the opposite effect. Which brings me to the topic of this post.
In the emergency department, there are certain patients who we see on a regular basis. Some are present so frequently that they should literally have their mail forwarded to the hospital. Others, upon investigation, rotate from hospital to hospital and doctor to doctor for some type of secondary gain. And some are attempting to survive in a system that can be stacked against them.
It was one such patient’s fourth visit to the emergency department in two weeks. Each time she had difficulty breathing. She had a long history of asthma and has been hospitalized several times for asthma in the past. During one of those hospitalizations, she had been on a continuous albuterol nebulizer for an hour. She developed supraventricular tachycardia (a fast heart rate) which was presumed to be from too much albuterol and one doctor emphatically told her that she was thereafter “allergic” to albuterol and that the next time she ever used albuterol she would most certainly die.
Therein lies problem #1. A fast heart rate is not an “allergy” to albuterol any more than diarrhea is an “allergy” to antibiotics. A fast heart rate is a documented side effect of using albuterol. But the seed had been planted in the patient’s head.From that point forward, the patient was only able to use Xopenex.
Xopenex is structurally very similar to albuterol. In theory, Xopenex has fewer cardiac side effects than albuterol, but from a practical standpoint, there isn’t much difference in side effects between the two. Rapid heart rate is also listed as a documented side effect of Xopenex.
For a long time, the patient received her prescriptions for Xopenex for free from the state. Then the state decided to save money. It stopped paying for Xopenex for people on public aid. Albuterol was now the only approved rescue medication for patients with asthma.
But since the patient was “allergic” to albuterol, there was no way for her to pay for the “only” medication that she could take. And her doctor left the state because of increasing taxes and decreasing reimbursement for seeing Medicaid patients.
So when she had an asthma attack, the patient simply came to the emergency department. She informed the staff that she was allergic to albuterol and so the respiratory department had to find some Xopenex to use in the emergency department. She felt better after a couple of treatments and was discharged with a prescription for steriods and a Xopenex inhaler, but she never filled the Xopenex because she could not afford it. She was also referred to the county hospital for specialty care, but the trip was long and the waiting list for appointments was longer, so she never made an appointment.
So during the spring months, we sometimes see Joanne Doroshow several times per week. She fills her prednisone prescriptions and sporadically fills other prescriptions for maintenance medications, but she still ends up in the emergency department every time that she feels “tight.”
The amount of money that the state saves in withholding Xopenex from Joanne is more than surpassed by all of the money that the state must pay for her emergency department visits. In its attempts to save money, the state ends up owing more money.
The same scenario applies to patients with dental pain and to patients with other chronic medical conditions. When infrastructure and primary care are cut in cost saving attempts, the patients will still need medical care, and they go to whatever providers are available to provide that care.
The emergency department “safety net” will be there — until payment cuts cause the hospitals to close — but the care isn’t cheap.
Friday, June 15th, 2012
Let the wailing and gnashing of teeth begin.
Vicodin pills are about to get a lot more expensive.
You see, according to this Abbott Vicodin Announcement (.pdf file), Abbott Labs is very concerned about the Tylenol content in its combination pain medications. After all, too much acetaminophen per dose in prescription medications may cause “severe liver injury from acetaminophen overdosing.”
In bowing to pressure from the FDA, Abbott decided to stop making the combination pills containing hydrocodone with 325 mg Tylenol or more and decided to start producing all of its combination pills with 300 mg Tylenol, instead.
Phew. I’m glad they took care of that. I’m sure that the extra 25 mg of acetaminophen in the current formulation was just causing an untenable overload of all the liver transplant centers throughout the country.
The other thing that creating a new formulation and discontinuing the current formulation does is create a new patent on the medication. Which will undoubtedly mean that, much like how the cost of colchicine went from 10 cents per pill to $5 per pill, the cost of brand name Vicodin will soon skyrocket as the medication goes “non-generic”.
Since states don’t like spending a lot of money on medical care, it is also likely that the “safer” brand name Vicodin will no longer be covered under state insurance plans. I’m sure there will still be generic versions of hydrocodone/acetaminophen available along with Oxycontin and Tylenol with codeine — until the remaining manufacturers also create their own “safer” versions of the medications.
For now, any time that a physician writes a prescription for the brand “Vicodin”, patients are going to not only have pain in their body, but they will also have pain in their wallets. I’m predicting $2.50/pill price point.
Look for lots more hassles to both pharmacists and to the doctors writing the prescriptions.
Wednesday, May 9th, 2012
Any patient who demands a ZeePack for a runny nose, who wants amoxicillin for sinus congestion, or who wants Levaquin to “keep this bronchitis from developing into pneumonia” needs to read this Bloomberg article.
We are heading toward a situation where people die from infections that no antibiotics can treat. The article discussed one infant in a pediatric ICU that died because the infection that the child developed was resistant to all antibiotics used for treatment. Six similar incidents occurred during the course of 16 months. Estimates are that 100 million people in India have been colonized with organisms carrying the genetic mutation. Medical tourism in India is decreasing as a result.
Even the director of the CDC cites the situation an example of why we have to limit antibiotic prescriptions: “We are looking at the specter of untreatable illness.”
Oh, and remember how the Centers for Medicare and Medicaid Services assert that if hospitals don’t give antibiotics to every single pneumonia patient within 6 hours of arrival – even though a large proportion of pneumonias are viral in nature – that the hospitals are falling outside of “quality” guidelines? Our government’s own “quality” guidelines may be contributing to the looming microbial Armageddon in this country.
Tuesday, May 8th, 2012
FDA decides whether to allow patients to purchase prescription medications over the counter for many common ailments.
This idea is controversial.
On one hand, deregulation would remove one of the largest barriers to receiving treatment for some conditions – the doctor’s visit. If no doctor’s visit is necessary to receive necessary blood pressure medications or diabetes medications, then patients don’t have to wait for an appointment and the patient/government doesn’t have to pay for the doctor’s visit. The move would also purportedly cost patients more money for their prescriptions because insurance companies (including Medicaid) don’t pay for over the counter medications. Therefore the costs for medications that go over the counter would be shifted to the patients who purchase the medications.
But on the other side, I’m sure that patients will “Bing” what medications they think they need, and the proposed plan would require patients to answer questions online or at a kiosk and then get input from a pharmacist before the prescriptions could be purchased. So there really isn’t unfettered access to the selected prescription medications.
According to the article, the American Pharmacists Association is embracing the concept while many doctors’ groups are opposing the idea. Pharmacists believe that their increasing role in a patient’s medical care will be a good thing while physicians see many of their “bread and butter” patients skipping appointments and instead going to the pharmacy kiosk.
Some of the conjectures about such a policy should be addressed.
Will prescription costs for patients go up? If patients have to pay out-of-pocket, then perhaps they would be paying more money for prescriptions, but I doubt that the amount of money would be much more than the copay they were previously paying. I imagine that most of the medications considered for over the counter use would be generic medications from the notorious “$4 list,” so the financial burden on a vast majority of patients would not be great.
However, there are certain medications that have no alternatives. Consider colchicine, vancomycin, and Plavix. Medications similar to these would continue to command a higher price. If patients need such medications or desire name brand medications, then they will keep going to the doctor in order to get their designer medications for a $20 copay.
However, medications that do have a generic or over the counter equivalent will see downward pressure on their pricing. Who in their right mind would buy a $300/month name brand medication when the $4 generics (or a combination of $4 generics) work just as well? So pharmaceutical manufacturers would have to justify the price of their expensive medications or would have to lower the price until patients felt that the price justified the benefits over generic medications. That’s free market at work.
Will the public be in imminent danger if they are allowed to self-prescribe? I doubt it. The Angry Pharmacist has a different take on the matter (read the post from behind a blast shield because it is rife with f-bombs). He believes that patients who take some medications need to be medically monitored for adverse effects from the medications. For example, patients who take ACE inhibitors may have deterioration in their kidney function from the medication and may even develop renal failure. If patients are worried about the effects on their kidneys, they can see their doctors for such testing. There are also some online labs that will provide direct-to-patient testing. But if we consider the renal function example, we can also look at Mexico where patients can purchase many medications over the counter. The rates of chronic kidney disease are no higher in Mexico where people can purchase ACE inhibitors over the counter than they are in the US where people cannot purchase ACE inhibitors over the counter. Maybe the adverse effects of medications are balanced by fewer people developing hypertension-related kidney disease because they are controlling their blood pressure. Lots of potential explanations, but we won’t know the real cause and effect without specifically studying the issues. Perhaps this isn’t the most accurate indicator of adverse effects from medications, but comparing health issues in the two countries may show that some of the health concerns raised against this policy are overblown.
Will pharmacists be happy with this policy? Decidedly not. If patients are allowed to purchase prescription medications over the counter, pharmacists all over the country are going to have another very significant and time-consuming task added to their laundry list of things to do while simultaneously being expected by their employers to fill prescriptions at the rate of no less than two per minute. Consider the intent of this policy. What the government is trying to do is shift patients from a paid physician service to an unpaid pharmacist service. Pharmacists are going to be doing a lot of extra work for which they will receive no extra compensation. And … if the patient does develop a serious side effect from over the counter medications provided at a pharmacist’s advice, then the patient (or the family of the dead patient) will have only the pharmacist or the pharmacy to blame because no physician was involved in prescribing the medication. Pharmacy malpractice insurance premiums are about to go up. The Angry Pharmacist notes that there is no one to sue in Mexico if there is a bad reaction to a drug. Do pharmacists really want the target painted on their backs?
This is a case in which I think pharmacists should be careful about what they ask for.
So what’s the right answer?
Deregulation. We shouldn’t stop with medications, either. We also need to deregulate radiologic testing, lab testing, and many medical devices as well.
Under this proposed policy, there shouldn’t be any input required from medical providers before patients purchase a medication, either. If patients want to ask about a medication before purchasing it, that’s fine. Patients don’t need pharmacist input to purchase vitamins, ibuprofen, Tylenol, Prilosec, or Claritin, so why should patients require pharmacist input before they purchase blood pressure medications? Just as with current over the counter medications, the onus should be on patients to research the side effects and interactions of medications before taking them. For that matter, why should patients need a doctor’s permission to get a CBC, have their cholesterol checked, or get an x-ray of an injured ankle? All that the regulations are doing is causing a barrier to access. Very few people are refused x-rays if they go to a doctor and really want them.
There should be some limits on what can be purchased over the counter, though. Controlled substances and antibiotics are a couple of examples of things that should still be off limits to the general public. In fact, so many physicians inappropriately prescribe antibiotics that I think antibiotics should be a controlled substance and that physicians should lose their ability to prescribe antibiotics if they demonstrate a disregard for proper prescribing practices. Coughs, runny noses, and simple toothaches do not require antibiotics, doc. We need to practice 21st century medicine.
So let patients purchase most medications over the counter. Yes, medical providers will still have to be Vicodin police and ZeePack police. For the rest of the medications, have at it. There will inevitably be some adverse outcomes and even deaths from wrong doses and from medication reactions. When these adverse outcomes occur, patients will gradually begin to see the value in the services that pharmacists and physicians provide.
We’re there to try to watch out for your interests, we’re not there to keep you from getting care and treatment that you truly need.
If you don’t believe me, you should be able to go and purchase medications yourself, knowing that you alone are responsible for any adverse outcomes that come from using the medications you purchase.
I think that is a fair trade-off.
Cross-posted at Kevin MD here with additional commenters.
Wednesday, March 28th, 2012
Just got word that several additional medications have been added to the national list of “drug shortages”. Doctors better start learning more about wilderness medicine at this rate.
I can see the management of our next unstable patient now …
[Call comes in on telemetry line]
“We’re coming to you with a 44 year old male hypotensive and unresponsive. Short transport time.”
[15 minutes later, the crew arrives]
“Sorry it took so long, our ambulance ran out of gas because we couldn’t afford to fill the tank due to the high gas prices and low Medicare/Medicaid reimbursements. We had to call for assist with transport from the Amish Ambulance Service with its horse and buggy. By the way, do you know where I can get a broom and a very large shovel?”
[Patient is hooked up to the monitor. Wide complex bradycardia. Pressure 60/40. Dialysis graft is noticed in his arm.]
“Dialysis patient. He may be acidotic and hyperkalemic. Give him an amp of bicarb STAT.”
“Sorry doc, we’re out. There’s a national shortage.”
“Keep that fluid bolus going. Let’s start some Levophed on him to raise his blood pressure.”
“Sorry, doc. We don’t have any of that either. National shortage.”
“Well let’s at least give him some Vancomycin in case he’s septic.”
“I’d like to, but I can’t. That’s on national shortage, too.”
“Well, he’s not responding very well. At least let’s get him intubated. Can someone push some Rocuronium?”
“Don’t have that, either. National shortage.”
“Nope. That’s out, too.”
“Nope. National shortage.”
[patient now loses his pulse]
“He’s CODING! Start CPR. Give him an amp of epinephrine, STAT.”
“Sorry, doc. National shortage. Don’t have any.”
“OoooKayyy. Give him an amp of atropine, then.”
“Don’t you know that atropine isn’t part of ACLS protocol any more? Besides, we don’t have any and there’s a national shortage of atropine, too.”
[patient is unable to be resuscitated and dies]
Six weeks later, the doctor receives a letter from the Arizona State Nursing Board [for those who don't regularly follow this blog, this is parody -- background here] informing him that he is being investigated for failure to properly manage the patient and failure to properly look out for the patient’s best interests, too. He must submit to a psychiatric evaluation, must submit to a genetic test to assess his future intellectual capacity, and must submit to a hearing in front of the whole nursing board to explain himself or else his name will be posted somewhere on the Arizona State Nursing Board’s web site and he will never be allowed to be a nurse in Arizona.
“I think I’m going to be sick.”
“Hope not. We’re out of Zofran, too. National shortage.”
[fade to black]
Good thing I had extra coffee and some old jumper cables laying around to jolt my heart back into a normal rhythm after seeing the Instalanche! Thanks, Glenn!
Wednesday, March 21st, 2012
I’ve performed conscious sedation dozens of times. Never had a problem. Not once.
For some unforeseen reason, our hospital has now decided that there are multiple additional hoops through which physicians must jump in order to be credentialed to perform conscious sedation. We have to be certified in ACLS. We have to sit through a course on conscious sedation so that we know the difference between light/moderate/heavy sedation and general anesthesia. Then we have to take a test on the medications we prescribe to make sure that we know that the medications may … make patients drowsy. There are several “pre-procedure” forms that we have to complete to determine how difficult a patient may be to intubate … if intubation is needed. And, while the patients are in their sedated state, there is a six page form that the physicians must complete – in addition to another several page form that the nurses must complete. Looking through all the additional proposed paperwork, I’m not really sure how there will be time to do the procedures when all of the paperwork is required to be filled out and medical care will obviously just get in the way.
Yup. Conscious sedation just became a whole lot “safer.”
But I just don’t think that the paperwork is appropriate, and I think the overwhelming focus on paperwork is bad medicine. Because of that, I withdrew my privileges for performing conscious sedation. I’m not the only doctor who has done so, either.
Now, if patients need conscious sedation performed while I’m working, the hospital has decided that I am no longer competent to perform the procedure.
From this point forward, patients who need conscious sedation in the emergency department will get an anesthesiology consult and the anesthesiologist can
deal with the hassles if every last one of the multitude of checkboxes hasn’t been completed make sure that the conscious sedation is performed properly. That will cost substantially more money be safer.
And from this point forward, if the anesthesiologist is busy in the operating room (which is likely during the day) or is gone for the day (which is likely at night) and can’t come to administer the same medications that emergency physicians administer all the time, the patient will have to be admitted and the procedure will need to be performed in the operating room. That will be even more
expensive and time consuming safe.
Patients with dislocations or other painful conditions who need procedures performed will have to wait. I’m competent to give them IV pain medications (we’ll see how long that lasts), but just not IV sedation. Patients who need IV sedation will need to speak to the anesthesia specialists. I’d like to help and I’m able to help, but I’m just no longer certified to help. Everyone is just looking out for your safety.
Now the Medical Marijuana Advocates (nee “the Joint Commission”) has further justified its existence because it can now REVIEW the stack of charting required for every patient that has received conscious sedation and
threaten the hospital with decredentialing if every last check box on every last form hasn’t been completed correctly make sure that things are safe. It might even be able to create a booklet to describe how to pass inspection for said paperwork which will cost $595 per year be made available to hospitals. Hospitals will then be able to hire advanced consultants to look over all the paperwork and make sure it is complete before JCAHO comes to visit.
But patients will be “safer” …
at least on paper.
Isn’t that all that matters?