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Is Bad Medical Care Better Than No Medical Care?

Doctor picture

In my past few shifts in the emergency department, I have seen the following patients who were seeking further care after being treated by other providers. One was a child who had been seen twice at an urgent care clinic. He had a fever of 103 degrees and wasn’t eating. The first time he went to the urgent care center, he was diagnosed with an ear infection. He was started on amoxicillin and sent home. He returned to the clinic 8 hours later because he still had the fever and still wasn’t eating. When the clinic provider looked in his mouth, he saw a red rash that appeared to be an allergic reaction. He was therefore changed from amoxicillin to Biaxin and started on Benadryl. The parents were concerned that his allergic reaction may get worse, so they left the urgent care clinic and came directly to the emergency department. When he came to the emergency department, he still had a fever, his ears looked fine, and he had the typical enanthem of herpangina. We stopped the antibiotics, stopped the Benadryl, gave the child some stronger pain medication, and had the parents feed him popsicles and cool liquids. Another patient had been in a bar fight several days prior. He had a cut on his knuckle and his knuckle was starting to hurt. He went to another emergency department and saw a provider who washed out the cut, started the patient on amoxicillin, and then put packing in the wound. When he came to our emergency department, we started IV antibiotics, removed the packing … from the joint … and sent the patient for surgery to clean out the infected joint and to repair the lacerated tendon. A third patient had been to both an urgent care clinic and an emergency department for evaluation of palpitations. The urgent care clinic diagnosed the patient with anxiety and discharged the patient with a prescription for Xanax. When the Xanax didn’t help and the palpitations were causing worsening shortness of breath, the patient went to an emergency department. There the patient was seen by a provider who performed an EKG and did a drug screen. The patient was told not to drink caffeine and given a refill for Xanax. When she came to our emergency department, an EKG showed Wolff Parkinson White syndrome. We got a copy of the EKG from the prior hospital and it showed the same thing. Their EKG even said “Ventricular pre-excitation, WPW pattern” on it. Finally was the patient in his 70s who was seen at another emergency department for evaluation of abdominal pain and no bowel movement for a couple of days. He had some lab tests done and the provider performed a rectal exam which showed that he had a lot of soft stool in his colon. So the patient received an enema and was discharged home with a diagnosis of constipation. He was told to take laxatives and eat more fiber. When he came to our emergency department by ambulance later that evening because he vomited the Milk of Magnesia, his abdomen was swollen and tympanitic. He had low blood pressure, no bowel sounds, and a sigmoid volvulus with an obstruction on x-ray. He also went straight to surgery. I understand that it is considered bad form to question the care of other practitioners. If another provider’s care is criticized, often the criticisms are met with allegations of elitism and hindsight bias followed by a plethora of anecdotes about how those commenting were able to catch some other provider’s mistakes. You don’t know which patients, ...

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Bloated Healthcare Costs: Are Emergency Physicians to Blame?

By Birdstrike M.D.   In an article entitled, ”Why the ER Admits Too Many Patients,” Dr. Michael Kirsch tries to explain that Emergency Department admissions are inflated due to Emergency Physicians acting in their own self-interest.  Many Emergency Physicians have read this and taken offense, feeling that his assertions point unfair blame on them for a significant portion of excesses in medical care and costs.  I share this visceral reaction in part, but such a reaction blurs some very important points worth examining.  Let’s give the benefit of the doubt for a moment, that the author may in fact be pointing the blame not at Emergency Physicians personally, but at a broken “system” instead. First, he claims that due to fears of potential lawsuits, Emergency Physicians when in doubt, cautiously err on the side of admitting a patient and ordering tests, rather than discharging them with minimal work up.  How any Emergency Physician can deny that this happens baffles me, as almost every one I’ve ever known will say in private they think about, and are motivated to avoid the threat of lawsuits (except for possibly a few in the handful of states with strong tort reform).  Physician surveys seem to support this, with at least one showing >90% of physicians across multiple specialties admitting to such.  This speaks to the greater issue of defensive medicine and the need for tort reform, and should not be seen as an indictment of Emergency Physicians.  Tort reform is an issue where the American people just plain need to decide.  Do they want to keep their cake uncut, or to eat it?  You absolutely cannot cling to the pipe dream of reducing unnecessary medical testing and expensive overly-cautious admissions while holding true to the good old-fashioned American past time of suing the pants off of a doctor who sends a patient home, only to have something unexpected go wrong.  Decide: Do you want, A-Doctors to send you home, cancel your test, and throw caution to the wind when you might be sick to save costs for the “greater system,” and give up the right to sue if something goes wrong, or, B-Do you want to retain the right to sue in court for hundreds of thousands of dollars (or even millions) if you have a bad outcome and have doctors admit you when in doubt and order every test (expensive or not) that they think they need to keep that from happening? You cannot have both A and B.   For the most part, and in most states in the land, the American people, their elected politicians and the plaintiff’s attorneys that support them, have already decided in favor of option B.  The right to sue has always come out on top (in most states) and there’s no sign that’s about to change any time soon.  To those who will respond with “science,” “data” and articles claiming the threat of medical malpractice doesn’t alter doctors’ practices or inflate healthcare costs, don’t bother.  Most physicians are not interested in hearing evidence or “data” to show oxygen isn’t needed for breathing, or that 2+2 isn’t 4, either.  There are some things we as doctors know to be self-evident.  To the extent that one blames such a drive to err on the side of admitting patients on a dysfunctional medical malpractice system, is the extent to which he is correct.  To the extent one points the finger specifically at Emergency Physicians, who have no choice in this day and age but to admit patients with the utmost of caution when in doubt, is the extent to which ...

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Press Ganey’s Latest Business Model: Eavesdropping

Eavesdropping Person

A reader provided me with a report showing that in addition to the “let’s get hospital administrators to rely on invalid patient satisfaction statistics” business, Press Ganey is also in the “let’s eavesdrop on what are supposed to be private physician patient conversations” business. People acting on Press Ganey’s behalf are supposedly showing up in hospitals to evaluate the hospital settings … and snoop through patient’s protected health information in the hospital … and even eavesdrop on what are supposed to be private conversations between patients and their physicians in restricted areas. Below are some excerpts from the report I received which are transcribed for web searching purposes. Press Ganey apparently printed its report on dark paper in an attempt to make the report difficult to copy. Transcription: Sitting against the wall by the printer there is a sheet of patient labels with PHI that anyone can see when walking down the hallway. ED was very busy with all days [sic] occupied. The ED received three ambulance patients almost simultaneously while I was there. A new patient arrived via EMS. Initially, when the doctor and nurse went into the room, no one pulled the curtain for privacy. After the doctor exited the room, the nurse then pulled the curtain. During this interaction, the doctor explained what he was doing throughout the process and asked the patient’s permission, saying for example “can I listen to your heart and lungs?” A patient who was brought in via ambulance for alcohol abuse was very belligerent with the nurse. The patient told the nurse “don’t put one of those gowns on me.” The nurse said he wouldn’t put one on now, but would need to later. Then the nurse tried to put the patient in a gown again. The patient stated it was too cold to get undressed. The nurse offered warm blanket. Patient cursed and said to call administration down to the emergency department. The patient told the nurse to f*** you.” The nurse addressed the patient’s comments but in doing so also said the word “f***.” The nurse was doing a decent job of handling a very difficult patient but I did not think was appropriate occurs even if in addressing the patient comments. The patients who had arrived in the waiting room during my observations starting at 1703 were all still sitting in the waiting room I exited the emergency department. This included a teenage boy who was triaged at 1714, an infant boy, and another woman. Were these patients ever rounded on? I observed the patient being called back to a treatment room. The patient was called be a very loud overhead paid for number 4621 to come to the front desk. “Number 4621 to the front desk please.” You could hear the phone tone after the message until the receiver was hung up. The patient assigned number 4621 went to the front desk. The patient family waited to be addressed, and while they were standing at the desk, they paged the patient again. This process was very impersonal. How are patients who have disabilities assisted? The person creating this report appears to have little knowledge about hospital procedures, about emergency department flow, or about legal issues. Your correct response to a patient who is repeatedly verbally abusive to you and for whom you have no choice but to stabilize and treat should be … And when an emergency department is full and gets three ambulance runs in a row, the first thing on the overworked staff’s mind should be to go out in the emergency department waiting room and ...

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Physician Bodyguards and Government Policies

Surgery

Chinese hospitals recruiting 1500 “guardian angels” to protect doctors from violent patient attacks. Patients who are angry about the Chinese healthcare system, medical expenses, long waiting times, and uncaring doctors have become more violent over the years, with violent attacks occurring every two weeks on average – according to state media – which in reality means that it probably occurs a lot more frequently than twice a month. Now China is starting a campaign to get volunteer students, medical staff and other patients to intervene when patients are upset with physicians. Apparently China views non-physicians as being more expendable when patients become upset and brandish cutlery. At least we have concealed carry laws in the US … for now. Interesting that according to the article, China has created a culture in which “doctors are in crisis” and in which “medical practice in China is a high-risk job.” Now China is vowing to “root out corruption in the healthcare system” – to save all the patients from the evil and corrupt medical providers. In reality, China’s policies have created many of the problems it seeks to “root out”, but state-run media likely won’t put that in print, either. After reading through the article, think about what it happening in the US right now. Doctor rating sites and patient satisfaction take precedence over proper medical care. Patients are forced to purchase government-mandated “insurance” that in many cases doesn’t pay for the cost of care and that many doctors will therefore not accept as payment. Losing money every time that you provide medical care to patients – while paying off student loans, paying office overhead and salaries, paying malpractice insurance premiums, and paying licensure fees – is just not a sustainable business plan. As a result, patients pay a lot of money for government insurance but they often have difficulty finding medical care when they need it. Federal agencies, in order to improve “transparency,” publish a list of how much money the federal government is paying physicians so that it can make physicians look like overpaid whiners when they complain about their workload and the regulatory burdens of a medical practice … but the same federal agencies refuse to publish statistics about patients who abuse the system (“privacy rights” apparently outweigh the public’s right to know about illegal acts) and the same government hides data about maltreatment of patients in its own facilities. “Transparency” indeed. Regulations related to the provision of medical care rise exponentially and educational costs to become a physician steadily increase while payments for medical services steadily decline. The pervasive media message is what a lousy job physicians are doing. Increased malpractice. Unnecessary testing. Missed diagnoses. Malpractice verdict after malpractice verdict. Hundreds of thousands of deaths each year from hospital errors. A well-respected profession is now becoming despised. By systematically making the practice of medicine more difficult and less appealing, the United States is slowly creating a crisis similar to that which China is experiencing now. The more insidious problem is that it takes at least 10 years and sometimes up to 14 years to educate and train a new physician. Cause the best and brightest students to shy away from medicine while older physicians retire or die off and in 5-10 years there will be an even larger crisis that will be impossible to immediately solve. At that point, it may no longer be an issue of which doctor you will choose to treat your medical problems, but instead a question of which doctor will choose to accept you as a patient. Then who will the government and President Obama ...

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Hospital CEOs Earn Tens of Thousands of Dollars From Patient Satisfaction

Million Dollar Bill

Dan Diamond (@ddiamond) tweeted this slide from a lecture by Harvard’s Ashish K. Jha at this year’s Association for Healthcare Journalist’s Annual Meeting in Denver. The slide shows how CEO incomes are affected by different variables and contains a few interesting tidbits of information. First, hospital CEOs earn around $600,000. Far more than most physicians. Second, hospital CEO salaries are not significantly affected by multiple different, yet seemingly important factors, including “quality” scores, the number of patients who die in their hospitals, the number of readmissions to their hospital, or the amount of charity care they provide. Logically, it would seem that the payment system would want to incentivize hospital administrators to work on those topics: Improve quality scores, decrease hospital deaths, decrease readmissions, increase charity care. But payments systems apparently don’t work that way. Want to know the thing that affects a hospital CEO’s salary the most? Patient Satisfaction. Highly favorable patient satisfaction scores add an average of $51,000 to the income of hospital CEOs. When your CEO threatens your job because your satisfaction scores aren’t high enough, when your CEO relies upon the statistically insignificant data reported by companies like Press Ganey, and when your CEO ignores studies showing that highly satisfied patients are more likely to die and suffer adverse consequences, now you know why your CEO may be making those decisions. Plaintiff attorneys are crazy for not raising this issue in medical malpractice lawsuits. Companies provide invalid statistics to hospital CEOs. Hospital CEOs knowingly rely upon invalid statistics to influence medical care. Tie patient harm to the CEO’s decisions (and motives) and you have another defendant with deep pockets who isn’t subject to a malpractice insurance cap. Oh, and by the way, Press Ganey’s ratings over at Glassdoor – despite the obviously fake positive reviews – is still an abysmal 2.7 out of 5, with only 39% of employees willing to recommend this company to a friend. If doctors had those types of ratings, they would be fired immediately. Why is CEO Patrick Ryan still around?

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“Illegal” Limits on Emergency Department Use

Sunrise over Frozen Field (Copy)

According to an article in the Miami Herald, Florida is “illegally” limiting Medicaid patients to six emergency department visits per year. Federal officials call such arbitrary limits illegal and says that the limits would not be in a patient’s best interests. CMS intends to withhold a portion of Florida’s Medicaid funding as a result. Another article on ThinkProgress.org comments on how unfair and inappropriate the limits would be, especially since only a “sliver of the poorest Florida residents” are eligible for Medicaid. The total population in Floirda is 19.5 million. The number of Florida residents eligible for Medicaid is 3.3 million. That’s 17% of Florida residents eligible for Medicaid. Add to that another 3.1 million Florida residents who have Medicare benefits (although there is likely some overlap with patients who have both Medicare and Medicaid) and you’re looking at one third of Florida’s population that receive medical care from the government. Some fricking “sliver.” Aside from the misinformation that reporter Sy Mukherjee is perpetuating, the story raised several additional issues with me. First, if acts that are not in a patient’s “best interests” violate the Social Security Act, then how did Obamacare pass muster? Not enough doctors in the system: not in a patient’s best interests. Outlawing established insurance plans: not in a patient’s best interests. Byzantine registration process: not in a patient’s best interests. Inappropriate Healthcare.gov web site security: not in a patient’s best interests. Second, I was surprised by the number of people commenting on the articles who deemed Gov. Rick Scott’s attempts to limit excessive emergency department use as: intended to harm poor people “DEATH PANELS,” a form of fascism a form of criminal Naziism preventing “Medicaid patients from receiving legitimate treatment” There were also multiple ad hominem attacks tossed at Gov. Rick Scott for taking steps to shore up the state’s budget. Want a couple of easy ways to solve this problem? Get rid of the rationing. All it will do is incite people whose services may be rationed. Change must come from within. First, publish the names (pictures?) of the top 50 ED users each month/each quarter/each year in the newspapers and on websites throughout the state. Announce that this list will be published in advance so patients are given fair notice. Don’t have to publish any medical data or the hospitals involved – just publish the number of visits the patient made and the costs involved in providing care for each patient. Post the lists in the waiting rooms of the hospital emergency departments. If the public is paying for the care of these individuals, the public has a right to know who is receiving the public’s money. Sunlight is the best disinfectant. Then, require mandatory co-pays for all emergency department visits … regardless of the medical problem … regardless of the urgency. Other patients don’t get free health care just because they’re having an emergency. Why should we create a privileged class of patients who receive all their medical care at no cost? Everyone should pay something for their medical care. Non-urgent cases still pay a co-pay, receive a screening exam and then must be discharged to a federal health clinic for follow up care. Not enough federal health clinics? That’s not in a patient’s best interests. The federal government is violating the Social Security Act. If the patient doesn’t have money for the co-pay, deduct the costs of the copay from any future forms of government assistance that the patient may obtain each month. Controversial? Sure. Effective? Absolutely. If you don’t agree with me, give me some better ideas on how to ...

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Medicaid Emergency Department Reimbursement Rates

Medicare Reimbursement by State

Ever wondered how much doctors get paid for taking care of Medicaid patients? I came across some data compiled for Medicaid reimbursement for emergency department visits from 2011. You can download the .pdf file here. There was also some information from 2008 and the rates hadn’t changed much. For each category, the payments are broken down into CPT codes depending on intensity of service. A 99281 code is essentially a nurse visit – no doctor involvement and hardly ever used A 99282 is a simple case with no or minimal physical exam – such as an asymptomatic patient needing a medication refill or perhaps a simple sunburn. A 99283 is a straightforward case with little medical decisionmaking such as an ear infection, a strep throat, or a UTI A 99284 case requires more decisionmaking with some lab tests being ordered. Perhaps a patient with a sprained ankle, a patient with minor abdominal pain, or a patient with asthma needing nebulizer treatments. A 99285 is a case requiring high medical decisionmaking, multiple tests, and likely hospital admission. Consider cardiac chest pain, severe abdominal pain, suicidal patients, patients with low blood pressure, etc A 99291 is a “critical care” code, meaning that the patients are in danger of dying or having severe health issues. Consider patients requiring CPR, multiple drug overdoses, uncontrolled psychiatric patients, patients with arrhythmias, etc. Finally 99292 is an “extended critical care code” meaning that if a doctor spends more than 90 minutes stabilizing a patient, then the doctor gets paid this amount in addition to the 99291 amount. What does this data show you? Based on their payments to physicians, New York and New Jersey seem to put very little value on the lives of their citizens. They’ll pay doctors as little as $58 to save your life and spend up to an hour and a half keeping you alive. Malpractice insurance costs more than that. Hell, parking your car in a garage in the Greater NY area to go to work in the hospital costs more than that. Rhode Island is even worse. It pays emergency physicians a whopping $29 to provide up to 90 minutes of critical care. Michigan and Wisconsin are also on the list of pathetic payors. When patients who get their new Medicaid “insurance” cards under Obamacare wonder why they can’t find anyone to provide them care, the fact that many states pay doctors less than the cost of caring for Medicaid patients would be one of the reasons for this lack of access. Remember: Healthcare insurance doesn’t guarantee you access to medical care any more than automobile insurance guarantees you access to a car.

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Why Patient “Satisfaction” Could Be Making You Sick

Ratings - Poor

By  Birdstrike MD All patients should be treated with professionalism and respect.  We all want our patients leaving our care happy, healthy and satisfied, if at all possible.  However, sometimes patients don’t leave an Emergency Department very happy or satisfied.  Sometimes the doctor could have prevented it, but many if not most times, such dissatisfaction has little if anything to do with what the treating physician did, or didn’t do.  The reasons for a patient being dissatisfied with a particular healthcare encounter can be very complex.  It’s not so simple as to just include a line in a survey such as, “Were you satisfied with your doctor?”  Who should be held responsible for the results of these surveys, is where the crux of this debate lies. So why are Hospitals obsessed with “patient satisfaction”? It’s the same reason Walmart puts greeters at the front door (the ED), not the back door (in-patient floors) and the same reason the Government collects taxes and not sea shells: Money.  The question we really need to be asking is: Why is the obsession with patient satisfaction in the ED so soul-crushing to those that work there?  1-Lack of Control A patient pulls into the ED parking lot.  The lot is full.  He doesn’t feel well, he’s in a hurry and having to search for a parking spot irritates him.  The wait to see a doctor is long, too long.  Once finally in his room, he sees a drop of blood on the floor from the previous patient.  He’s disgusted.  Despite great care by the doctor, it biases his overall view of the experience.  As much as he tries to remain objective, the patient satisfaction score suffers.  The patient gives a “1 star out of 5″ review after discharge, but writes in the comments, “Doctor and nurse were great, though!”  The tabulated score remains 1/5, or “FAIL.”  The doctor gets pulled aside at her next group meeting and is told she’s on watch due to low scores.  She’s never been fired from a job in her life, but now her job is in jeopardy, over something which she has no control. A patient leaves an ED satisfied.  He gets a patient satisfaction survey and throws it aside.  He has no need for it.  The visit went great.  It’s his preferred hospital for anytime he gets in a bar fight and needs to be sewed up.  He got in, got his knuckles stitched, and got a free Sierra mist and a meal tray.  On his way out the door, he tweets, “#CityGeneralERrocks!” on his smart phone to the world’s prospective ER “customers.”  Six weeks later, all has healed well, and there’s barely a scar.  Then, the bill comes.  “!&@!?#€!!!,” he thinks.  “$920?  Screw that place!”  He grabs the survey and nukes the hospital, doctor and nurse all with the lowest score possible.  He writes in the comments, “I would have rated you a ‘negative infinity’ if the scale went that low!” You can save a life, walk out of the trauma bay drained but proud, and be pulled aside and told that on last months survey, you didn’t get a patient a coffee “like they do at the car dealership.”  You are told, “Get those scores up.  Administration is watching.”  It translates into, “You suck.”  It’s not that big of a deal, right?  Maybe you should brush it off, but you are human.  You haven’t “evolved” to the “new way” yet.  You’ve heard of ER doctors losing their group contracts and therefore their jobs over things like this.  It bothers you. There’s a complete and utter ...

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