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Nonemergent Complaints and Refusal of Care

Wednesday, February 29th, 2012

A few recent emergency department complaints:

1. “My husband is snoring too loud when he sleeps.” Husband shrugs his shoulders.
2. Nonverbal patient sent from nursing home for evaluation of “irregular heart rate.” History on the transfer papers includes chronic atrial fibrillation … which causes an irregular heart rate.
3. Patient sent by another physician for immediate surgical consultation to rule out necrotizing fasciitis. Physical exam had a 1 cm boil on the hand with a small amount of lymphangitis.

In retrospect, all of the complaints seem like relative non-emergencies.

Prospectively, how many of the visits would have been “nonemergent” to an average layperson?

How many of the visits would have been denied payment by the new Washington State law?

How many of the visits would have been augmented by additional findings to make the complaints more serious if the patients and physicians knew that they wouldn’t otherwise be paid for the visits?

1. Further history states that husband sometimes has apnea during his sleep. Physical examination shows he is overweight. Workup for acute exacerbation of “obesity hypoventilation syndrome“.
2. Call to the nursing home confirms that patient was moaning most of the day and that his heart rate was faster. Pressing on the patient’s chest causes her to moan. Patient worked up and admitted for chest pain and cardiac arrhythmia.
3. The patient is admitted for IV antibiotics because of the possibility of necrotizing fasciitis. Lymphangitis alone can be an admissible diagnosis.

So three patient presentations which would likely need little evaluation and could all be reasonably treated on an outpatient basis are also just as easily able to be classified as admissible diagnoses by highlighting certain aspects of the patient’s history and physical examination.

Washington State doesn’t want to pay for first degree burns? There looks like a small blister in the burn. That makes it a partial thickness burn. Let’s debride it. Increased costs.
Washington State doesn’t want to pay for pregnancy screenings? I’m betting that the women who want to be screened will now all have abdominal pain. Urinalysis. Pelvic exam. Ultrasound for those with positive pregnancy test. Costs increase significantly over a routine pregnancy test.
Washington State doesn’t want to pay forĀ “chronic tonsillitis”? Patients will state that their tonsils just started hurting a couple of days ago. Strep test. Maybe a CBC and a monospot. Costs increase.

When governments pay for certain outcomes and not for others, the governments are guaranteed to get the outcomes they pay for.

While some may assert that it is inappropriate to emphasize points in a patient’s history to make complaints seem worse, the fact is that workups are largely subjective and dependent on a physician’s risk tolerance. Some physicians, even most physicians, may say that a patient with a boil and minor lymphangitis may be treated as an outpatient with oral antibiotics. A small subset of the people treated as outpatients will get worse and likely have bad outcomes. The findings are likely MRSA and MRSA kills more than 30,000 people each year. Those providers who want to be extra thorough or who want to minimize the risks of patients having a bad outcome may do “extra” workups that are still medically appropriate.

Abuse of emergency services needs to be addressed, but cutting payment for nonemergency services when there is no disincentive to obtaining more costly services will only increase the demand for the more costly services. It’s all about the Benjamins.

Emergency care is about to become a bigger drag on Washington’s budget. Just watch.

 

 

Amanda Trujillo Update

Friday, February 17th, 2012

I haven’t dropped the mission with Amanda.

There have been a few technical problems, though.

Amanda is in the process of creating a timeline of events that have occurred since the incident. I have been piecing together responses from organizations that have responded to the issue and will add those to the timeline. Thus far, I am disappointed in some of the responses from the Arizona Board of Nursing. If you have more information about Amanda’s case, e-mail it to me.

I have also done some research on several of the people involved in the firing and investigation. I can’t post their names here, though.

I have also received multiple documents from several sources that I will also post.

The problem is that I have been asked not to post the material on this blog. There were several reasons for this request, and I agree with the reasons and have agreed not to post the material here as a result. One reason that was raised was that the problems that Amanda is facing do not involve emergency medicine physicians and do not involve emergency medicine in general. This was a problem that occurred with inpatient medicine and surgical informed consent. Emergency Physician’s Monthly magazine has a focus on emergency physicians. I agree with that.

I think that the issues involved in Amanda’s case cut across all aspects of medical care.

If a patient hasn’t received informed consent or doesn’t understand the informed consent, to me, that’s not a “floor medicine” issue, that is an issue that affects patients in every aspect of medical care – including emergency medicine.

If a staff physician had a temper tantrum in front of patients and staff and is otherwise disruptive, to me, that is not just a floor medicine issue. Disruptive physicians affect every aspect of medical care. They make other staff afraid to do their jobs for fear of the next tantrum or … of losing their jobs. If physicians are disruptive on the medical floors, they will be disruptive in the operating rooms and disruptive in the emergency departments as well. Most hospitals have a code of conduct that must be followed. That code must be followed everywhere, including the emergency department. This is a team sport.

If a nurse has gone outside the scope of her nursing license, that isn’t a floor medicine issue, to me, that is another issue that affects every aspect of medical care – including emergency medicine.

If a hospital trumps up charges against a medical provider due to political pressures, that tendency doesn’t stop with floor nursing, with nursing in general, or even with physicians. Inappropriate administrators should be investigated just as much as inappropriate medical staff.

If a state nursing board has to hide its review of a nurse’s actions and has to threaten a nurse’s licensure for disclosing facts about the investigation, to me, that is facially suspect and flirts with constitutional due process violations. The same issues could happen just as easily to an emergency medicine nurse and I have first hand knowledge of similar things happen to emergency medicine physicians.

So, yes, Amanda is a floor nurse and this issue did not happen in the emergency department. However, the underlying procedures involved with this case transcend specialties. When medical professionals stop questioning the process, we lose as a profession, not as a specialty and not as a class or providers. When we stop investigating the potential for nepotism and conflicts of interest to assure that any disciplinary process is fair, everyone loses.

I still don’t have enough information to conclude one way or another whether what Amanda did was correct. But the fact that the parties investigating her actions won’t release any information and have allegedly threatened Amanda in order to prevent her from disclosing the allegations against her and the investigations involved makes me wonder what those parties are hiding.

In order to pursue this issue and to help other bloggers in the process, I am starting another independent blog. I’m not leaving EP Monthly, but I am going to independently publish information on this other blog about Amanda’s case. I’m also going to provide an open platform to other medical bloggers who want to blog – either anonymously or in their own name. We’ll compile our stories and write about random unidentifiable patient scenarios so that there can be no claims of “HIPAA violations” by administrators, lawyers, or anyone else. De-identified information is not and has never been subject to HIPAA laws [see 45 CFR 164.502(d)].

Want to blog? Drop me an e-mail at whitecoatrants (at) Google’s e-mail service dot com and I’ll sign you up.

I have paid for the domain and hosting and am just waiting for the hosting service to confirm everything. And after the SOPA fiasco, I’m not using GoDaddy, either.

UPDATE:

Medbloggers.org is registered and will soon be live.

 

 

Open Mic Weekend

Saturday, January 28th, 2012

Haven’t had an Open Mic in a couple of months.

Leave questions, opinions, and any other medically-related comments below and I will try to get to them Monday night.

Remember, no personal attacks.

Why Bundling Payments Won’t Reduce Costs — Part 3

Saturday, December 31st, 2011

If you haven’t read parts 1 and 2 of this manifesto, please do so here and here before reading further.

How will bundled payments affect the incentives for each of the players in the medical market?

For patients, a change to bundled payments will probably have little effect upon monetary issues or fears. Demand for medical care will increase. With millions of additional patients being added to Medicaid roles, and with government “paying” the costs, there will still be little disincentive for patients to seek comprehensive care. In addition, patients who are forced to purchase insurance through health care reform will want to get something for their money.

Bundled services will obviously benefit the insurers. Otherwise there would be no incentive to move to such a model. For insurers, bundled payments will increase profits. Much of the uncertainty involving payments for medical care disappears with bundled payments. If a patient with a heart attack develops a complication requiring prolonged hospitalization, in the current system the insurers bear the costs of treating that complication. Switch to a bundled payment model and the providers bear the risk of medical complications or outlier patients. Whether a patient is in a hospital for six hours or six months, the payment to the hospital for one diagnosis will be the same. The theory is that the threat of paying for complications will “encourage” hospitals to take steps to avoid those complications. In other words, a threat of financial liability will improve the quality of care. Kind of like suing our way to better health care … and we all know how well that has worked. For now, the point is that bundled payments increase profits for insurers by decreasing uncertainty in the payments that must be made to providers. As providers decrease costs, then the insurers will gradually decrease the bundled payments while gradually increasing the premiums that every person in the United States will be required to pay under health care reform. Profits go up.
Demand for insurance will go up under health care reform because there is a mandate that everyone purchase insurance. Insurers will encourage people to buy into their plans. More subscribers plus relatively fixed costs equals more profits.
The financial risk that insurers fear in the current medical payment model is largely erased by a bundled payment model. While insurers may be forced to accept all patients – even those with pre-existing conditions – bundled payments diffuse the risk that the insurer must accept. Even though some patients may be hospitalized more often than others, the insurers know that they will only have to pay a fixed cost for the hospitalization.
There will also be a decrease in the legal risks to insurance companies with a bundled payment model. Insurers will be less liable for refusing care. They pay the providers one fee and the providers are then forced to decide what care is and is not “necessary.” Also look for our government to create additional legal protections for insurers as health care reform becomes implemented over the next few years.

Probably the largest effect of bundled payments will be felt by providers of medical care.
For providers, bundled payments will create an incentive to provide less care. Currently, extremely ill patients create profit through utilization of costly medical services. More services = more payments. When providers are paid one price for a given diagnosis, regardless of the severity of the illness, then the incentive will be to accept a large bundled payment and provide the least expensive medical care possible. This will happen in several ways.
First, providers will want to make patients look sicker so that the bundled payments will be larger. Bundled payments for a patient suffering from pneumonia will be much more than a bundled payment for a patient with a chest cold. Patients in respiratory failure will command an even higher bundled payment. Therefore, the incentive will be for providers to label patients with serious illnesses in order to receive higher bundled payments. Just like payments for catheter-related sepsis caused a significant decrease in the reported incidence of catheter-related sepsis (but an increase in other types of sepsis), increase in bundled payments for more serious illnesses will cause an increase in the reported incidence of serious illnesses. The problem is that those serious illnesses will get reported to the Medical Information Bureau and will follow a patient for the rest of the patient’s life.
Second, there will be less utilization of costly medical services. Look for invasive procedures to decrease. Providers will start pointing to medical studies saying that such procedures are not proven effective. Costly antibiotics and other costly medications will be off limits. Consultations will be less available.
Third, providers will begin avoiding patients who are more likely to suffer adverse consequences. Ideally, bundled payments will provide appropriate reimbursement for an “average” patient. Healthy patients will utilize less resources and therefore increase profitability for a given bundled payment. Young healthy patients who may need a day or two in the hospital for their pneumonia will be readily admitted as there will be a high likelihood of profitability with the ensuing bundled payment. Pneumonia patients with diabetes or with HIV who will likely need long admissions and expensive medications will become hot potatoes. Community hospitals will find reasons to transfer high utilizers to other facilities. Perhaps they need an endocrinology consultation. Perhaps they need an infectious disease specialist. Bundled payments will create an incentive to avoid treating obese patients, cancer patients, and other patients with chronic diseases. Financial solvency will be difficult to maintain with bundled payments and chronically or seriously ill patients.
Demand for services from providers will increase, since some patients will not be receiving the level of care to which they are currently accustomed. Patients may go from provider to provider trying to get the care that they desire.
I’m not sure how the fear issue will play out with medical providers. In the current system, fear is mitigated by providing more services. However, in a bundled payment system, providing more services will quickly erase profits and may lead to financial insolvency. How will medical providers adapt? My guess is that there will be less services and more studies and medical testimony showing why providing fewer services is within the standard of care. There will also be a backlash against hospitals if patients die because they didn’t receive what was retrospectively deemed to be “necessary” care. I also think that at some point there will be a revolt against regulatory agencies that create guidelines which increase expense without improving outcomes.

Bundled payments will also have several other effects:
First, the system will get gamed. Big time. If insurers are going to make a large bundled payment for a given diagnosis, expect more of those diagnoses to be made. Patients who previously were sent home with “walking pneumonia” will be admitted because admissions for “pneumonia” generate more money. The admission may only be “overnight,” but it will still generate that bundled payment. Outpatient diseases will suddenly require inpatient management – if that inpatient management is what generates the bundled payments.
Second, bundled payments will allow insurers to vilify medical providers. In the current system, insurers are the bad guys when they refuse to authorize or to pay for medical care. By bundling payments, insurers will be able to blame medical providers for not providing more services because those services are included in the bundled payment. Patients will then direct their anger toward providers when the patients don’t get the medical services that they want.
Finally, bundling payments will also cause fighting between providers. How do physician consultants get paid when the hospital receives the bundled payment for the patient’s illness? The pie is only so big and anyone that provides services is going to want a piece. Hospitals are already trying to minimize this problem by purchasing physician medical practices. When physicians are employees and paid by the hospitals, the hospitals get to keep the bundled payments. Otherwise, let the fights begin.
What happens if a patient goes to an emergency department with a pneumonia and needs to be transferred? Who gets the bundled payment? What if a patient is hospitalized for a hip fracture and then develops a pneumonia while in the hospital? Who gets the bundled payment? Will the payments be split? If so, how much? I posed these questions to a friend who works at CMS. Her response was that the providers would have to create agreements regarding payments for services. Of course, providing a prospective division of payments for every possible type of care would be impossible, so the providers will be left fighting over who gets what payments and how much. When providers fight with each other, nothing good happens. Divide and conquer.

Bundling payments will protect insurers, increase insurer profits, and decrease the willingness of providers to care for seriously ill patients. When the only variable for payments from insurers is how many times a diagnosis is made, the diagnoses will be made more frequently and will result in an increase in the number of “bundled” payments.
Bundling payments will also cause rifts between medical providers that will ultimately detract from the medical care provided to patients.

Stay tuned for Part 4 where I discuss solutions that will reduce costs.

Duty Calls

Monday, December 12th, 2011

Had intended to finish the second half of the bundled payment post, but in my other job, I had a somewhat unexpected … umm … need that had to be filled Friday through tomorrow. Because of that, I haven’t been online very much.

Got a posts lined up to auto-publish, but may not be online again for a little while.

Thanks for the patience.

 

Dear Diary

Saturday, December 3rd, 2011

This week was rather rough.

Things in the ol’ emergency department have been busy lately. Lots of people seem to have minor problems that don’t need “emergency” care, but they have nowhere else to turn. I’ve had several patients come in just asking for medicine refills or asking to have their medications switched to something on WalMart’s $4 list. Kind of a difficult position to be in. On one hand, several people have a sentiment not to “feed the bears” because then the “bears” will keep coming back for more prescriptions. On the other hand, what are the patients supposed to do? Sometimes, I wish we could put legislators into the shoes of these patients.

Got behind in some work I needed to do because of emergency department shifts. Planned to catch up on everything yesterday. Woke up and had to drive two kids to school because they missed the bus. Then got home and the house smelled like someone hadn’t flushed the toilet. Went to check the toilets and they were clean. Then went to the basement to check the toilet. Someone had flushed. Unfortunately, the pump in the ejector pit had burned out, causing toilet contents to back up into the basement. Oh, and as a cherry on the top of this sewage sundae, someone also threw out a half-eaten apple in the bathroom garbage can. That apple had turned brown, had partially liquefied, and the non-liquefied portion had grown a white beard. I was going to post a picture, but between the smell in the basement and the looks of that apple, I damn near barfed.
Fortunately, I had a hand pump that I purchased a few months ago the last time that the ejector pump failed. I was able to pump about three gallons of sewage out of the pit and then the ever expanding smelly puddle started to recede.
Removed the old pump. Went to Home Depot to get a new pump and some PVC pipe. Got home. Damn. Forgot a plastic connector to reattach the pump to the sewer line. Drove all the way back to Home Depot for a 83 cent piece of plastic. Bought two of them just in case. Got home and got the new pump installed and working. Took most of the day to do all the cleaning and disinfecting.
So much for getting work done.
Oh, and if one more person says anything similar to “sh*t happens” and then laughs about it thinking they’re witty, they’ll be coughing up teeth … or maybe coughing up a brown bearded apple. I think I’m going to put that into a garbage can in the garage and see if it grows into a Tim Burton character.

The two youngest girls finally got to be in their stage play. They happened to be the best two performers in the show – not that I’m biased or anything. It did my heart good watching them enjoy themselves on stage … all three shows.

Oldest daughter is still having trouble with the bullies at school. In the past few weeks, not only have they gotten her last friend to turn on her, they also spread rumors about a teacher who has been helping her and now the teacher had to go to a private school board meeting to defend herself. I get frustrated watching her get depressed, but I also let her know we’re all there for her. May be filing legal papers against these miscreants.

Son goes to his first wrestling tournament tomorrow. He’s nervous because he gained 5 pounds from last year. Still, he can do 75 pull-ups and 100 pushups a night, so I think he’s ready to put some shoulders to the mat.

While decorating for Christmas, found out that the puppy doesn’t like any type of Christmas decorations. Stuffed animals are violently unstuffed. Garland vomit spots are in several areas of the house.

Found out I’m probably going to need more surgery. Running out of things to cut on in this body. Sucks getting old.

My wife and I try to go out of our way to help others. Over the past month, we both helped a family whose mother was dying from cancer. My wife went to their home and did home medical visits. I helped them fill out medical paperwork and power of attorney papers. The patient died this past week. We got a wonderful thank you note from the family. Totally unexpected, but much appreciated. Little things like that make such a big difference in our lives.

Finally, we went to our kid’s school for a Santa Workshop today. Kids go around to a bunch of tables and pick out all kinds of “low priced” gifts that they can wrap and give to their family members. Low price as in $10 for ratty stuffed animals or cheap costume jewelry. It was like an overpriced rummage sale. And it kind of ticked me off because it had a table just for gifts to “aunts and uncles” with $6 plastic screwdrivers that say “greatest uncle” and $8 ratty reminder boards that say “greatest aunt” on them. All the kids felt obligated to purchase gifts for everyone. Did get to have a lot of fun wrapping everything, though. Not one of them can keep a secret, either. My wife knew all of her gifts within about 10 minutes of our arrival home.

Gotta go, diary. Weigh-ins end at 7AM tomorrow morning, which means I’ll need to stop for an extra large coffee before we get on the road.

 

Events at Scientific Assembly

Monday, October 17th, 2011

GruntDoc, ShadowFax, Nick Genes, Graham Walker and others are all tweeting highlights from ACEP’s Scientific Assembly.

If you’re interested, read the tweets here – or meet them at the bar tonight.

Open Mic Weekend

Saturday, September 17th, 2011

I got the message.

OK, everyone, what’s on your mind?

Leave questions, comments, opinions, and any other medically-related comments below and I will get to them on Monday or Tuesday.

Remember, no personal attacks.

EMR Survey

Monday, September 5th, 2011

I was asked to post a short survey for those of you who use electronic medical records.

How does EMR use affect quality and delivery of health care that you provide? There are a total of about 20 questions and it should take you 2-3 minutes to answer them. The results will be published in a couple of weeks.

If you’d like to provide input, the link is below.

http://www.softwareadvice.com/articles/medical/benefits-of-emr-software-survey-1081611/

Hurricane Safety, Part Deux

Saturday, August 27th, 2011

Hurricane Irene is beginning its trek up the East Coast. The damage from the storm is predicted to be horrific.

Any of you self-righteous attorneys from New Orleans want to post a comment prospectively telling all the hospitals everything that they need to do in order to avoid being sued for an “inadequate response” to this natural disaster? Any experts in disaster preparedness want to chime in?

Anyone?

Bueller?

Bueller?

[crickets]

Yeah. Didn’t think so.

Yet when some patient gets a fleck of dust in their eye from the 120 mile an hour winds after the storm has passed, based on the recent $25 million settlement from Katrina lawsuits, I’m betting that the attorneys will be falling over each other to file lawsuits to retrospectively tell everyone what the hospital did wrong in preventing said speck of dust to become airborne and lodge in the patient’s cornea, though. God forbid that a hospital’s backup generator breaks down. Just sign a check.

While I’m at it …

Any person living east of the Mississippi River is hereby put on notice that a hurricane is coming. You need to take adequate measures to protect yourself from any potential injury or death from the hurricane. This may include moving yourself out of any hospital within 300 miles of the hurricane and relocating yourself in a hospital west of the Mississippi River.

Is that enough to prevent people from suing?

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