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Archive for the ‘Policy’ Category

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.

Spidey Senses

Sunday, November 11th, 2012

This was one of the patients I submitted for Nurse K’s Dr. No BS contest. By my calculations, I was the unofficial winner in said contest, but I don’t want to brag.

The case involves what one of my old mentors used to call his “Spidey Senses“. Something just doesn’t seem quite right. You can’t figure it out, but something tells you that you need to dig deeper. Most of the time, the Spidey Senses are just a false alarm and you end up performing what some people deem an “unnecessary” test. Hey, even Spiderman wasn’t always right. But in a select few cases, listening to your Spidey Senses (and sometimes ordering “unnecessary” tests), can help to make an important diagnosis.
Psych wonks may use the term “cognitive dissonance” to describe the Spidey Senses. I’m leaving the post title as “Spidey Senses” because prolly no one would read a post about cognitive dissonance and because I couldn’t find a cognitive dissonance picture.

A 50-year-old man came in with R shoulder pain for about a week. He was already going to a pain clinic for low back pain, and that day he went to the pain clinic for a re-check of his shoulder pain. The doctor at the clinic prescribed him Neurontin for his shoulder pain and the patient came to the emergency department because “that stuff doesn’t work.”
He said that his shoulder pain was bothering him so much that now his right side was killing him, too. In fact, he wouldn’t lay back on the bed because of the pain. His wife sat next to him helping to support him while he was sitting as he slumped over to the right side and didn’t answer many questions because he was in too much pain. The patient’s wife did most of the talking.
I have to admit that my initial impression of this gent was tainted by the whole pain clinic story.
Maybe he was coughing from his pack-and-a-half day smoking habit and strained a muscle in his chest wall.
Pain from a gallbladder attack can cause referred pain to the right shoulder when the inflamed gallbladder irritates the diaphragm. Maybe he’s having biliary colic.
Maybe he had a pneumothorax.
Maybe he was doing something he shouldn’t have been doing and injured his shoulder, but he didn’t want to tell me.
But come on, now. Pain so bad you can’t even talk to the person trying to help you? Call me skeptical.

(more…)

Obama vs. Romney vs. Honey Boo Boo

Sunday, September 9th, 2012

By Birdstrike M.D.

 

Once again, our upcoming election will have great impact on future health care policy.  Obamacare will either be kept intact, repealed or altered.  This will have great impact on patients, physicians in general, and especially Emergency Physicians.  By whom they choose to lead us, the electorate will decide whether treatments are rationed or not, and if so, to what extent, by whom and on what basis.  They will decide whether doctors are free to choose what tests to order, and if so which ones, how many and for what reasons.  Also, they will influence physician salaries, by choosing the leaders who will determine Medicare and Medicaid reimbursement, which generally lead with reimbursement cuts that private insurers follow.  Our electorate will determine our malpractice liability by choosing our leaders who will either, strengthen, weaken or ignore tort reform.  They will influence which charting systems we are required, or not required to use, given that Obamacare has already written into law penalties for failure to implement electronic health record use.  By whom they choose to lead us, the electorate will influence how much we are, or are not burdened by regulations, and whether these regulations will be logic based, or cumbersome and irrational.

The choice of the electorate will affect which pay for performance measures we and our salaries are subject to.  Likely, they will also influence which form of patient satisfaction surveys we are or are not subject to.  Also influenced, will be our overall workload depending on whether patients are adequately insured, by which doctors and in which settings.  This will influence who is most, or the least burdened by the overall shortage of healthcare providers, and whether or not the millions of newly insured will end up in primary care physicians’ offices, shunted to emergency departments with growing wait times, seen in specialists’ offices or remain uncared for.  How informed, or uninformed our electorate is, particularly as it relates to health care policy, will affect the health of our patients, our livelihoods as physicians, not to mention the health of our families and ourselves as patients.

Since the end our nation’s two major party conventions, it caught the attention of several major news organizations that on any given night of the week of either the Republican or Democratic National Conventions, that both parties faced stiff competition for viewers from the new and controversial TV show on TLC called “Here Comes Honey Boo Boo,”  which TLC describes on its website as a show where a “six-year-old pageant sensation proves that she is more than just a beauty queen.” As said by the child’s own mother, June Shannon on ABC News, “We are a little redneckish, and we live in Georgia and that’s what people do in the country — get muddy and have fun with the family.”  In the first episode they take part in the “Redneck Games,” bob for pigs feet and take part in a “mud pit belly flop.”  Although fortunately the overall viewership of the conventions was greater according to ABC News, this show did draw more viewers than Fox News’s coverage of the Republican National Convention on at least one night and tied the ratings of the Democratic National Convention during Bill Clinton’s speech.  Does anyone know where Honey Boo Boo stands on health care?

Apparently, a large part of our electorate would prefer to watch a show like TLC’s “Here Comes Honey Boo Boo” over either convention.  Whether this is more of a reflection on our political parties, our electorate, our “Democracy” or (hopefully) none of the above, I am not sure.  However, two months before an election where we will choose a President, seat our entire House of Representative and 1/3 of the U.S. Senate, that will have a huge impact on future health care policy, I think it is worth discussing how informed or uninformed, and how engaged or apathetic our electorate is about the health care issues at hand.  Their decision will affect our patients, our health, our work environments, our salaries, and countless details of our health care system going forward.  It is our responsibility as physicians to educate the public on this part of their vote and its potential consequences.

Have we done our job as physicians to educate our patients, friends and co-workers on the issues at hand and how important this election is?  Have we come to grip ourselves, with how much this current election will affect the lives of our patients, our families, as well as every aspect of our profession?  If the answer to either question is no, then between now and Tuesday, November 6th 2012, we have a lot of work to do.

Which did you watch, the Republican Convention, Democratic Convention, or “Here Comes Honey Boo Boo”?

 

 

 

Choosing Wisely – Good Medical Practice or Prelude to Rationing?

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.

Unnecessary Testing

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.

Political Quote of the Day

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 … ;-)

 

Get Your Own X-ray

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?

Deregulation.

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.

The Expense of Saving Money

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.

Bye Bye Generic Vicodin

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.

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