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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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How To Meet Medicare AMI Thrombolytic Documentation Requirements

After learning that a colleague had to sit through a quality control hearing with hospital administrators and that the hospital was marked as “non-compliant” because a patient suffering a heart attack received thrombolytics at 32 minutes instead of within the 30 minute time frame required by Medicare, I did a little research on the Medicare documentation guidelines. I found a “Hospital OQR Specifications Manual” detailing the circumstances in which a hospital/physician will not be considered as being out of compliance when a delay in administering tPA occurs. According to Medicare, there has to be a reason documented by the treating physician why thrombolytics were not given in a timely manner. That reason for delay may not include any “system” reason such as equipment malfunction, issues relating to staff (such as delay in receiving medications from pharmacy or delay in nurse administering the medications), or any administrative issues. Documentation must clearly state that the thrombolytics were “held” or were “delayed” due to a non-system reason such as: Patient request for delay in treatment pending arrival of family members or pending consultation with personal physician Patient refusal of fibrinolytics Delay in treatment due to medical issues such as ruling out bleeding (such as controlling high or low blood pressure) Waiting for return of laboratory testing that may impact decision to give thrombolytics (such as elevated INR that may increase bleeding risk) Stabilizing patient condition (such as treating arrhythmias or starting IVs or intubating patient, etc.) Consulting with a specialist regarding patient’s condition or treatment (for example neurology or cardiology) Patient required CPR or advanced airway management within 30 minutes of arrival Examples of possible documentation might include “Thrombolytics delayed until patient’s surgical history could be obtained from different hospital” “Thrombolytics held until consult with cardiologist regarding PTCA” “Thrombolytics held pending discussion with surgeon regarding patient’s recent surgical procedure and bleeding risk” “Thrombolytics held at patient’s request until family members arrive” “Thrombolytics delayed due to discussion of risks, benefits, and alternatives to treatment with patient. After this discussion, patient agrees to thrombolytic therapy” “Thrombolytics initially held as EKG did not meet criteria. On repeat EKG, patient found to meet criteria for thrombolytics” “Thrombolytics delayed while patient’s low blood pressure/respiratory status stabilized.” I’m sure that you can come up with other acceptable documentation given the above guidelines. If any of these events occurred and may have delayed administration of tPA, Retavase, or other thrombolytics, make sure that you document the events so that you can ensure that you meet all Medicare guidelines … which will make you and your administrators much happier.

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Too Heavy to Fly

Medical care for the morbidly obese is back on the radar. Today this blog got several inbound clicks from a site where a bunch of apparent doctor haters have used one of my blog posts and the comments to the post as an example of how much the medical profession allegedly likes to bestow shame upon others. It seems that the discussion we had regarding whether it is ever acceptable to refuse medical care to morbidly obese patients was something that Ms. Marianne’s readers were cautioned that they may not be able to “stomach.” The author and most of the people who commented to her article seem to believe that they have the right to demand that any doctor at any time must provide any type of services to them that they demand. Whether or not the doctor is comfortable providing those services or whether the doctor even has the knowledge and training to provide those services is irrelevant. Any doctor who doesn’t agree to their demands is hated and publicly shamed. This doctor who chose not to treat patients weighing more than 200 pounds was one example of their wrath. I left a comment to Marianne’s rant back when she first posted it. I don’t remember the comment verbatim, but the gist of my comment was that there are specialists for a plethora of conditions who provide care to patients when other providers are uncomfortable caring for those conditions – HIV, diabetes, organ transplants, ophthalmology, etc. Why shouldn’t doctors be able to refer obese patients to other physicians more experienced in caring for obese patients? In addition, there is no “right” to force any person to provide you with any services against their will. The Thirteenth Amendment to the Constitution addressed that. Finally, I noted that when there is a bad outcome related to a patient’s obesity, one of the first things that a plaintiff’s attorney will allege is that the patient should have been referred somewhere else. My comment was never approved. Non-conforming, I suppose. Today there also happened to be an article in the NY Post – linked by the Drudge Report – about how a morbidly obese woman with multiple health problems traveled to Hungary for a month-long stay in their family vacation home. When she tried to board a flight back to New York to resume her medical treatment, the airline refused her because she had gained water weight and could not be safely strapped into three seats. The airline tried to make alternate arrangements for the patient’s travel back to the US, but those plans also fell through due to the patient’s size. There was no mention that the woman ever went to a hospital for care of her medical problems while trying to secure travel back to the US. Both the patient and her husband were quoted as saying that they “didn’t trust” doctors in Hungary. Nine days after first attempting to return to the US, the woman died. Difficult situation. Comments to the article were mixed. Some people blamed the patient for allowing herself to become so obese. Others blamed the airline because it was able to get the patient to Hungary and then left her stranded there. This case illustrates the point that I was trying to make in my previous post about providing medical care to morbidly obese patients. At some point, the safety and well-being of the patient and of others must be taken into account when deciding whether to provide care. These decisions are made all the time in medicine. A patient with severe lung disease may be ...

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The Supreme Curve Ball

The Supreme Court decision on the Affordable Healthcare Act threw us a curve ball. Many people who predicted the outcome of the ruling swung and missed – including me. The Court agreed with the government’s argument that the individual mandate contained in the Affordable Care Act was not a tax … for purposes of the Anti-Injunction Act (which would have prevented a lawsuit regarding assessment or collection of the mandate and forced those bringing suit to sue for a refund after paying it). At the same time, the Court declared that the individual mandate contained in the Act was a tax … for purposes of validating and enforcing the mandate. To me that’s a stretch. That’s like legal argument defending a dog bite lawsuit by simultaneously alleging that (1) I don’t have a dog, (2) you weren’t bitten, and (3) my dog didn’t bite you. President Obama has declared the Supreme Court decision as a “victory” but this victory is largely Pyrrhic. The Supreme Court’s decision will become a rally cry for the 41% of Americans who believe the law should be overturned and the 27% of Americans who believe the mandate should be overturned. Romney’s campaign will emphasize Romney’s commitment to repeal the law – whether or not he truly intends to do so. While some argue that “President Romney” wouldn’t have the ability to repeal the law, President Obama’s decision not to enforce our country’s immigration laws shows that an executive order refusing to enforce laws can have the same effect as repealing a law. A dog with no teeth can’t bite you. In addition, President Obama and all the legislators who supported the ACA have essentially approved the largest tax increase in US history … in an election year. How many voters will be happy at the thought of a new and expanding tax that coerces us to purchase a commercial product which we may not even be able to use? The growing public backlash in this regard is probably the reason that the White House is backpedaling and stating that the mandate really isn’t a tax … even though the same White House stated that the mandate was a tax in the media and during oral arguments on the issue. The mandate stands because it is a tax and now President Obama and our legislators have to live with the consequences of their decision. In case you were wondering, here are how each of the House members and the Senators voted on ACA. But many people will think that the tax … er, um … penalty is OK because our government is going to provide us with insurance. Millions of more patients will be INSURED! If you’ve read WhiteCoat’s Call Room on a regular basis, you know why this is such a false and empty promise. Insurance amounts to a series of promises. First there is a promise that, in exchange for a premium payment, someone else will pay for your medical care. Then there is a promise that someone else will provide your medical care. Finally, there is a promise that you will be provided with the medical care you need when you need it. While the government wishes to expand the number of patients who receive our government-mandated “insurance”, many states are planning to restrict the eligibility for the “insurance” that our government wishes to provide to us. In other words, states don’t want to pay for your insurance. A House Ways and Means survey showed that 71 of the Forbes 100 companies could save a total of $28.6 billion in 2014 by dropping health care coverage for their employees. The Affordable Care Act ...

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