Home / Healthcare Updates / Healthcare Update — 05-16-2011

Healthcare Update — 05-16-2011

Also see more updates at the Satellite Edition of this week’s update at ERStories.net

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The devil chased one patient off the roof of a two story building. The devil also possessed a 7 year old girl, so her brother pushed her down the stairs. Two patients were so uncontrollable that they had to be put in medically induced comas and admitted to the intensive care unit. Kansas emergency physician goes on high school lecture circuit to discuss the dangers of using “bath salts” to get high.

New survey on “insurance for all” in Massachusetts: More than half of primary care practices are closed to new patients, long wait times for appointments, many physicians won’t accept government “insurance,” making it difficult for patients to find access to medical care. Almost time to replicate this model nationwide.

Healthcare reform law reportedly will decrease costs by $24 billion/year while simultaneously increasing quality. Wait. LOOK! There’s the Easter Bunny wearing a diving helmet while riding the Loch Ness Monster … rodeo-style!

Doctor who at one time ran the nation’s largest distribution point for OxyContin convicted of 18 counts of illegal prescription drug distribution and found responsible in connection with four patient deaths. Now faces sentencing from 20 years to life in prison. And all of this was accomplished without creating new laws to criminalize the practice of medicine and pharmacy. Remarkable!

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Connecticut jury awards woman $10.5 million after anesthesiologist allegedly performed preoperative assessments and intraoperative monitoring in a negligent fashion.

Plaintiff awarded $2.8 million after injury to urethra during kidney stone removal and allegedly substandard post operative care.

We really can sue our way to better health care. Just ask ATLA mouthpiece Joanne Doroshow. Just FYI, she has officially become my new “Deborah Peel.”

Patients gone wild. Psychiatric patient in emergency department awaiting placement in psychiatric facility becomes agitated and combative. Police officer guarding him tries to subdue him with pepper spray and stun gun. Those don’t work, so police officer whips out gun and shoots patient in leg.
In other news, the Joint Commission has now declared guns a patient safety threat – except in Florida where any medical professional who talks about the subject will be thrown in jail.

I see your two days … and raise you ten years. Recent Virginia law requires those who assault emergency medical workers to serve minimum 2 days in jail. New Vermont law makes it a felony with minimum one year in prison for assaulting a health care worker while on the job. Repeat offenders can get up to a 10 year stint in the Greybar Motel. I pick Vermont.

Good insight into Medicare coersive forces and how they are applied to physicians … and how patients with Medicare are going to have more difficulty finding doctors to treat them.

Giving the phrase “don’t let the bedbugs bite” a whole new meaning. Bedbugs in Canada found to carry superbugs including MRSA and VRE.

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40 comments

  1. Bed bug story is scary. I travel frequently and the thought of this is disconcerting.

    More scary is that those of us paying attention knew what would happen to MA people’s access and quality, but you are not going to convince anyone who thinks this is a good idea of the truth.

  2. I battle Dolores “Floorshow” on Huffpo all the time ( guess who I am on there !). Must be Matt in drag.
    As for Medicare- how about we just all refuse to accept it ?

  3. “More than half of primary care practices are closed to new patients, long wait times for appointments…”

    Yeah, this is a good thing. It means that more people are going to their PCP’s for non-emergent and preventive care, rather than going without or going to the ER. That’s what you want them to do, isn’t it?

    The long wait times, and doctors’ ability to be choosy about which plans they accept, are due to the shortage of PCP’s. While this shortage is dire, it is also nationwide; you can’t blame it on MassHealth. And it has a simple solution: train more PCP’s.

    • Yeah; this isn’t a video game where you can just push the slider from “specialist” to “primary provider”.

    • “Can’t blame it on MassHealth” …
      Sorry, but I disagree.
      That’s like saying “sorry that the house collapsed because no one put in a foundation … can’t blame the general contractor.”
      If MassHealth knew that there was going to be a large demand for primary care physicians in its new health care system and it did nothing to even attempt to meet that demand, then we absolutely CAN blame MassHealth. Massachusetts took a chance by implementing a system that was destined to fail from the beginning. Now its citizens are paying the price.
      You’re right we need to train more PCPs. That takes 4 years of college, 4 years of medical school and 3 years of residency. Before that, you have to make it worthwhile to go $400,000 into debt to become a PCP. Cutting pay and increasing administrative hassles isn’t the way to go about doing so.
      The American public will get what the government pays for … and it isn’t going to be pretty.
      Boy am I glad I’m a doctor.

      • I moved to MA a couple years before RomneyCare was enacted and had trouble finding a PCP since most were closed to new patients. So the lack of PCP’s has nothing to do with RomneyCare, IMO.

        And what most people don’t know is that the state of MA had something called FreeCare that was in place before RomneyCare. So providers got paid (ER/PCP’s,/Specialists etc) for taking care of people who qualified for Free Care. And FreeCare paid pretty well and came out of the state’s budget. RomneyCare was a way to contain these costs by making these FreeCare patients have some personal responsibility and cutting payments to providers.

        So these patients were all getting care before RomneyCare – either by PCP’s or ED’s or by specialists. IMO, there hasn’t been this influx of patients wanting to see a doctor as has been reported in the press and used as ammo by those with opposing viewpoints. But I only practiced in MA for a couple years before and after the change, so I’m sure the pundits know more than me :-)

      • What saddens me is that you are right that we need more physicians, and especially primary care, but at least part of the problem is that there are not enough medical schools, and not enough potentially GOOD doctors are able to get into the ones that exist.
        Complaints about low pay don’t convince me that that is the reason for the lack of PCP’s — as a teacher with a Master’s Degree, I never made a fraction of what a PCP makes, and I worked 60-hour weeks, and worked during the summer too (surprise!!).
        So I truly believe it’s the restriction of access to medical school that is the problem, not the pay scale. I WISH I could have made what a PCP makes!

      • natalie

        the difference is that you, as a teacher, do not have to worry about malpractice, huge continuing med education requirements, and the paperwork which makes being a PCP a thankless, hard job. As a specialist (though in er), I would never even consider being a PCP unless the compensation far exceeded what I make now. thats exceeded, by a large amount.

      • I believe and hope Natalie is correct. Most people who are going into primary care, like teachers, are motivated by factors other than economics. Otherwise, like Hawk, they go into some other field. I think the big problem attracting folks to the field are the endless insurance hassles, the lifestyle sacrifices, and the tedium and difficulty of taking care of chronic disease – endlessly pulling pulmonary patients or congestive heart failure folks through repeated exacerbations, trying to save limbs on diabetics with foot ulcers, caring for people with complications from degenerative neurological conditions, strokes, etc. After a while you feel like Sisyphus rolling a rock up a hill in hell and it can be quite frustrating. Medical students see this and avoid the field. In the ER you may have the stress of whether to give TPA for a stroke, but you don’t have to take care of a hemiplegic aphasic patient with recurrent decompensations due to aspiration for months and years afterwards. Much less trying to support the family who try to manage this kind of patient at home, who by the way are the true unsung heroes of our “health care system”.

        A few comments which will probably irritate a lot of people:
        The average worker, who in my state makes less than $40,000 a year, has little sympathy for the economic woes of a profession whose lowest paying members make more than $100K. I think they sympathize with the hassles, stress and malpractice worries but the salary? Not a chance.

        A big problem in the country is lack of affordable insurance for a big part of the population. I’m talking about the unemployed who can’t find work and can’t afford the cost of a private plan or cobra extension or people with pre-existing conditions, such as the kid who has inflammatory bowel disease or diabetes and suddenly gets too old to be covered under her parents’ plan. All I’ve seen on this blog are complaints about the government’s plan to try to rectify this, with no practical solutions proposed otherwise. It’s easy to criticize – how about proposing a workable alternative?

        To Throckmorton, there may be some doctors working at the VA who come in at 8:30 and leave early, but I personally know many who work long hours in an attempt to get the system to work for the patients and you shouldn’t stereotype an entire group. One thing you can’t accuse them of is creative documentation to upgrade the bill or ordering unnecessary tests and procedures to augment their income (which, by the way, I think is a rare occurrence anywhere but is a frequent criticism of fee for service medicine). Your comment is as tasteless as anything Matt has ever posted about doctors.

  4. “Medicare As A Coercive Force” says…

    “Turning private pay into public information is not something that would sit well for most professionals.”

    du-WHA? He’s really saying that it would be a bad thing to require that doctors publish what they charge instead of fumfering about how “it’s up to insurance negotiaton” and “can’t really say until I see the service” and suchlike?

    • That’s not what he said nor what the bill says.
      According to the bill doctors and other health entities would have to publically report how much they were paid by Medicare for the year/month/etc.
      People, being woefully ignorant of how business works, would translate that to income and think all doctors are rich. They would forget to take out the 50-60% or more overhead.

      • You take public funds, that information should be available publicly. It is for anyone else who takes taxpayer money except in cases of national security.

      • The charge sheet for my clinic has our U&C fees for every service we offer posted on it.

    • JustADoc and Matt are both right.
      Rather than publishing a doctor’s total earnings, though, Medicare should instead publish how much it pays physicians per patient visit and how many patients each physician is being paid to treat.
      That would give a more realistic view of what doctors are earning in comparison to other professions.
      Then maybe doctors start publishing how much extra time they waste calling Medicare to get Medicare to reverse “denials” for legitimate claims.

      • Medicare already has a publicly available Fee Schedule (it’s on the HHS website) which lists the Medicare rates for the various CPT codes.

        Now, granted, it’s a bit hard to find on the HHS site unless you know where you’re looking, plus I doubt most patients understand what CPT codes are.

        Our state also has it’s Medicare Fee schedules publicly available online too

  5. “And it has a simple solution: train more PCP’s.”

    Who the heck wants to be a PCP these days? Same training (costs upward of 50k a year), less money and all the woes of the US healthcare system. There’s a reason the number of medical students entering family practice training dropped by 50% between 1997 and 2005.

    It’s gonna take more medical schools to open, mega incentives (federally subsidized tuition?) and a drop in applicant standards.

    • Yes, of course we will need to incentivize people to become PCP’s. I prefer simply paying them more (or paying specialists less), but if it’s politically easier to do federally subsidized tuition or what-have-you, that would work too.

      If we need an increase in the overall number of doctors, then yes, we will need more medical schools. That’s okay; we know how to build medical schools. Although some would argue that having PCP’s provide preventive and ongoing care is so much more efficient than doing that sort of thing in the ED, that we could treat more patients with the same number of doctors. That would be okay too.

      You can pick at this all day, but any efficient healthcare system is going to need more PCP docs. So unless you’re going to argue that it’s impossible to make more PCP docs, or you’re going to propose a healthcare system that treats everybody with the same number of PCP docs, I don’t see what such nit-picking is going to accomplish.

      • Poor choice of words — I shouldn’t have written that your objections were “nit-picking”. Just that the shortage of PCP’s is not the fault of MassHealth, it’s a problem under any healthcare system we choose to implement, and we know the solution.

      • Knowing the government, they will prefer to cut everyone’s pay and raise no ones.
        Unionize , anyone ????

      • Huey…
        I think of my BIL who is a neurosurgeon. He will never stay if he must be forced to give more services away than he already does.
        It would be nice if there were more access to schools. I would make a darn good nurse, but can’t get in because they keep cutting what is offered.
        And my BIL as a specialist will suffer.
        On the dark side, the gov’t could end up forcing who MUST choose medicine as a profession as opposed to those who feel “called” and there will be no turning back. Scary, indeed.

    • Again, if you know there is a shortage of primary care physicians to begin with, then building a system that depends on access to primary care physicians isn’t a very good idea, is it?

      • It’s not a good idea only if a better idea exists. So when the good folks at Google finally bring us a working RoboDoc(tm), I will agree with you that depending on PCP’s is a bad idea. Until then, they’re the best option we’ve got.

  6. The govt wwlcomes the Primary Doc shortage – great opportunity to push NP’s to the forefront. They’ve already set the groundwork with the term “Healthcare Provider.” Enter Dr. Nurse – Your primary care provider. Be afraid … be very afraid.

    • I agree. It’s simple math- Doctor- 4 years college + 4 years medical school + minimum 3 years residency = 11 years.. For a surgeon its 13 years minimum.

      NP- 4 years college + 2 years NP school = 6 years. Its almost half of the training. And NP school is not residency. They are not “meat in the seat” the same way residents are. They rarely function independently during their rotations and this makes a big difference. There is a lot more at stake when you are responsible for actually writing orders and dealing with problems instead of shadowing those that do.

      And before someone chimes in that they had rotations where they were “meat in the seat” it’s still a lot less training because the 2 years is classroom plus rotations. Also- NP school covers a variety of rotations- it’s not two straight years of practicing inside a specialty the same way residents do.

      I am not saying that NPs/PAs don’t have their place in healthcare- they do- under the guidance and supervision of a residency trained physician. But NPs are pushing that envelope to practice independently. For now, its mostly in primary care but the snowball has started rolling and it won’t be long until they insist that they are qualified enough to work in ED and critical care specialties totally unsupervised.

      I know there are shortages in primary care and someone has to fill them- I just don’t think that letting NPs and PAs slide into them instead of a physician is the answer.

      And I haven’t even addressed the whole “Doctor” thing with NPs…another rant for another day…

      • The NP boom has been a big boom to our bottom line. We are now consulted for things that we have no business seeing; things that normally would have been taken care of by a patients internist of family doc. Instead, the patients see the NP, get billed, then get sent to a specialist for another bill. It has also been a boom to our lab and radiology departments as we see more and more studies ordered for dubious reasons.

  7. I’m certainly not arguing that we don’t need more PCPs (or a substitute – NPs, PAs etc.) All that I’m saying is that there is going to change in one way or another; the question remains – what is that change going to be?

    Cutting specialists salaries may bring more PCCs in (although probably not substantially; I truly believe that most doctors are NOT in medicine for the money) But we will also have issues with specialists. There are already horrible issues with, lets say urologists – it’s been found they cluster in urban areas and that numbers are dwindling.

    It seems that the only solution is to not to pull numbers from specialists, but to generate new PCCs independently. The big issue with this though, as I said before, is the sacrifice of quality.

    • The only change that the government is going to implement right now is to cut costs. That can be accomplished in one of two ways – either decrease payments to providers or decrease access to care (i.e. rationing).
      Cutting payments to providers accomplishes both goals. More providers get fed up with the red tape, the low payments, and the long hours, so they leave. Fewer potential providers want to go into the system. Increased amounts of patients seek care from fewer providers amounts to longer waits for care. Therefore less money is getting paid to the providers and fewer patients are taking money from the system because they are unable to find the care and have to wait longer to obtain that care if they do find it.
      Government takes same amount of money from your paycheck for 40+ years to pay for care but provides you with less and less access to care when it is time for you to take back what you put into the system.

      Just like those who purchase other products: Quality will always be available for those willing to pay for it.

      • I thought this whole reform was to make healthcare accessible to more people. This seems a few degrees off of that orientation.

      • Also – I do believe that medical schools have been popping up at historically steep rates. Could be interesting to look into.

  8. How would salaries for physicians change among PCPs, specialists, etc. if they found a different payment model – hourly billing for example?

    • Doubt that such a system would be able to be implemented.
      Current payment system is too entrenched in people’s minds and most people don’t appreciate the cost of providing medical services.
      Multiple specialists managing a single patient’s inpatient and outpatient care and getting paid on an hourly basis would drive costs so high that most people couldn’t afford the care anyway.

      • Then isn’t all this pissing in the wind? From tort reform to bitching about patient satisfaction scores to complaining about MassCare?

        If the payment model doesn’t change to something other than fee for service, we’re just headed toward single payer. The only question is how fast we get there.

      • I didn’t mean fee for service, I meant third party payment.

      • I would love to see attorney’s pay scale set by Medicare !

      • Why? I don’t understand your need to, rather than fix your own situation, bring others down. How does that help you?

      • I think that billing hourly could work. I think a shift in how insurance is approached could make a huge difference.
        Most people, most years, spent less than $3000 on their health care. Yet we spend much more than that on health insurance and health care once you count employer and employee premimums/copays/deductibles/coinsurance.

        On average, people in the US spend about $8000/yr on healthcare with only $1600/yr actually paying doctors and that $1600 appears to include labs/x-rays/etc as well.

        Of course those numbers tend to be skewed to the older years.

        I have alwayws argued that I am relatively cheap. For the overwhelming majority of 0-60 year olds they and I and the country would be better off if insurance was not involved for my services. Doctors spend an inordinate amount of overhead trying to collect that $1600. If that money wasn’t spent we would be happy to collect only $1100 as we would still take home the exact same amount and have much less hassle for it. The public would be happier as their insurance would cost less. It costs just as much time and effort to process a $68 bill as it does a $1894 bill. And there are a LOT more $68 bills.

        I don’t have numbers or estimates, but just lowering the huge costs associated with processing all these small claims on the doctors and insurance companies and patients sides would save 10s if not even low 100s of billions out of the $500 billion paid to doctors and clinics.

        This could be done by removing doctors and clinics from insurance. Or at least removing FPs/internists/Peds who very very rarely generate a bill(or least actually collect) above $150 for the visit itself.

      • Misery loves company…..

      • Matt:

        There already is data on other ways to pay docs. The easiest is to look at the VA. There you are paid a salary. You start your first surgical case about 830 and no matter what you are home by 3 regardless of how ong patients have to wait.

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