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Healthcare Updates

Links and commentary to healthcare news around the internet

Choosing Wisely – Good Medical Practice or Prelude to Rationing?

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.

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Good medical reads

For those medical practitioners that don’t usually read EP Monthly, there are always good articles from some of the top names in emergency medicine. Lately, there have been several articles published that are exceptionally good. Rick Bukata has a thought-provoking article about management of simple abscesses. Definitely worth a read. The bottom line is that most abscesses resolve just fine after they are lanced (medical terminology = Incision and Drainage or “I +D”). A majority of abscesses – 50 to 66% are due to MRSA (methicillin resistant staph aureus – a “superbug”). The organisms causing the abscesses were resistant to the antibiotics prescribed in some if the studies Rick cited, but the cure rates were still quite high – and were similar to those patients taking no antibiotics at all. Kind of interesting to consider that by giving antibiotics to patients with abscesses, we aren’t helping the patients and we could be increasing the prevalence of the same organisms we’re trying to eradicate. So why do doctors keep prescribing antibiotics to patients with abscesses? I’m going to venture a few guesses: 1. They don’t keep up with the literature. Old habits die hard. 2. Many patients expect them. If patients expect antibiotics and don’t get them, then they complain to administration or give us bad Press Ganey scores. This is one of those perverse situations in which outside influences can affect proper medical care. 3. If there is a bad outcome, attorneys and journalists will sensationalize the case and fault the doctor for not giving antibiotics. Call it defensive medicine. It is a lot easier to fault someone for doing nothing than to fault them for doing something – even if that something is of marginal benefit. Speaking about antibiotic use, an article from a few months ago by David Neuman (who works with Graham Walker and others over at theNNT.com – an excellent resource for clinicians) explores whether antibiotics are useful in preventing infections after mammalian bites and in treating “bronchitis”. Some of the results will surprise you, some of them shouldn’t surprise you. One interesting factoid: Out of 100 patients prescribed antibiotics for “bronchitis,” none receive any benefit and about three of them are harmed by the antibiotics themselves. I’d say that every one of the patients receiving antibiotics is harmed. They pay a lot of money for medicine that doesn’t do a thing to help them. News you can use about pediatric appendicitis from Ghazala Q. Sharieff, including scoring systems, ways to predict severity, and potential testing to use if ultrasound is equivocal.

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What Is Your Life Worth?

By BirdStrike M.D. “Good, it’s about time that these greedy doctors get smacked down for being the financial rapists that they are.  Medicine in this country is the biggest, most destructive SCAM going on today. Doctors think they are entitled to RIDICULOUS amounts of money for simple routine procedures.”- Johnathan Blaze August 27, 2012 at 4:54 pm It is generally agreed upon that the more one values a good or service, the more he or she is willing to pay for it.  Most will agree that shoes are important.  They keep your feet from bleeding and hurting when you walk on the street.  People seem happy to pay anywhere between $20-$150 for them.   Some will clamor to pay without complaint as much as $315 for sneakers that mimic those of their favorite basketball hero, or $865 for designer Manolo Blahnik “BB” Snakeskin Pumps.  Many place great value on a youthful physical appearance and sex appeal and will gladly pay up to $15,000 cash for a new pair of breasts with little if any sense of resentment for the doctor providing the service and metering the charge.  Having a car, most of us will agree is very important, and therefore paying around $30,000 is pretty average.  Though it seems that many are outraged at a Plastic Surgeon charging $12,000 to repair a fingertip, most people consider their limbs and appendages important, and being able to use them of significant value.  Therefore, it follows that a total cost of approximately $40,000 for a hip replacement tends be generally well accepted and frequently paid by insurance companies along with the physician portion of $1,505 (CMS CPT 27130.) So how much is your life worth to you?  Clearly it is worth more than a pair of shoes.  Are we still in agreement?  Certainly you would be more than happy to pay $20-$150 to have it saved, if you or your insurance company had the finances.  Is a human being’s life in total worth more than the $15,000 pair of augmented breasts on the human being?  I’m sure most would agree it is.  I’m sure as a society we must pay more than this for a human life saved, correct?  I’m sure we all similarly agree that the entire value of a human life saved is greater than the value of a “spare replacement part” such as a $40,000 hip.  We must certainly and gladly pay those who save our lives at least as much as we pay for sneakers, designer shoes, our cars or a spare hip, correct? No.  We don’t.  It’s not even close. In the field of Emergency Medicine, there are only a few situations where the physician can truly walk in a room and walk out a few minutes later absolutely certain he saved a life.  One is an emergency intubation (making a non-breathing person breath again) and another is cardioversion/defibrillation (restart a non-beating heart.)  It doesn’t always happen every day, but it is what Emergency Physicians and other critical care providers are paid to do.  To be an Emergency Physician is a paid position.  It is not a volunteer position.  It stands to reason that Emergency Physicians would be paid at least as much as for a life saved as for the aforementioned goods and services, correct?  Let’s break down what a true life-saver gets paid to save an entire life, not just the hip, the breasts, the fingertip or the shoes. What an Emergency Physician actually gets paid to save a life- 1)      Emergency intubation: $112  (CMS payment for CPT 31500) or, 2)      Cardioversion/Defibrillation: $131  (CMS payment for CPT ...

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Healthcare Update — 09-02-2012

Deadly amoeba found in home drinking water. Initially, two patients who died from Naegleria fowleri meningoencephalitis were thought to have contracted the disease from using Neti pots. Now investigations show that the amoeba was found in the patients’ home plumbing systems. JCAHO soon will require only bottled JCAHO-approved spring water in all hospital plumbing systems. For patient safety, of course. Pediatric emergency department injuries go up in the back-to-school months. More broken bones and head injuries from falling off playground equipment allegedly to blame … although those injuries shouldn’t just occur when school begins. This guy just gets it … insurance and health care aren’t synonymous. Who needs Medicaid? Former Utah emergency department tech “headed” to trial after being caught performing oral sex on an unconscious male patient. Faces between 5 years and life in prison. Don’t write me nasty comments, either — it was in the title of the article.

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Healthcare Update — 08-27-2012

And we think doctors have it bad … Woman sues Santa Monica City Hall for $1.7 BILLION because the town’s newly-installed parking meters and their wireless signals have caused her tinnitus, ear infections, and muscle tightness. Hat tip to Walter Olson at Overlawyeredfor the link. New Orleans jury awards plaintiff $24 million after infusion pump malfunctions and gives 3 year old child overdose of epinephrine. Former patient advocate at Chicago-area Alexian Brothers Behavioral Health Hospital fired, then tries to get even. Steals hospital stationery and takes three patient files, then sends letters to the patients on the hospital stationery telling them that their “electroshock treatments were insufficient” and “recommending frontal lobotomies.” Tried to embarrass hospital, but ends up in the Greybar Motel for forgery and can get up to 5 years in the Greybar Extended Stay Inn for each of three counts. Pregnant patient awarded $117 million after being severely injured in ambulance crash when driver took eyes off road to pick up company-issued GPS tracking device.

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Healthcare Update — 08-20-2012

Sharks beginning to smell blood in the water. Pradaxa lawsuits piling up and likely will result in giant class action suit. One law firm has 70 employees dedicated to Pradaxa litigation alone and the attorney can’t even remember the name of the client the reporter called to ask him about. Looks like the yolk’s on you. Widely quoted study on how egg yolks are as dangerous as smoking cigarettes was based on a self-reported lifetime history of smoking and egg-eating. The study didn’t take any other variables into account. A doctor who reviewed the data stated ““This is very poor quality research that should not influence patient’s dietary choices.” I love reading stories like this. Patient comes back to thank ED staff that saved her life. Brings flowers for nurses and a sheet cake for the staff. New Jersey hospital in dispute with Aetna over bills for patient services. When Aetna doesn’t pay in full, the hospital sends bills for the difference to the patients. Aetna then turns around and tells patient not to pay the bills. And the bills are expensive.

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