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Tag Archives: CMS

Many Doctors Opting Out of Medicare

This NY Times article notes that many patients who become Medicare eligible are finding that the “insurance rug has been pulled out from under them.” More and more physicians are dropping Medicare and patients can’t find physicians to take care of them. “The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.” There is already a shortage of internists in the US and the ones that are available are unwilling to accept new Medicare patients. Universal coverage doesn’t mean much if no one takes your insurance. The more I think about this, the more I wonder whether this is exactly what the feds are looking for. They keep taking 15+% out of everyone’s paychecks to fund a Medicare system that fewer and fewer doctors participate in – until everyone pays a lot of money to end up with little or no access to medical care.

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University of Chicago's EMTALA violation

There’s suddenly a lot of conjecture flying about a patient who died in the University of Chicago’s emergency department a couple of months ago. Everyone that reads this blog had a heads up on the event way back on February 8. According to news reports, a 78-year-old man was brought to the emergency room by ambulance about 12:30 PM. He was put into a wheelchair in the waiting room, but was neither triaged nor logged in. At 4:15 PM, the patient’s daughter wheeled the patient to the triage nurse to ask about the delay. The triage nurse noted that the man wasn’t breathing and called a code, even though rigor mortis had already set in. Unfortunately, rigor mortis is one of those things that usually precludes a successful cardiac resuscitation. We don’t know anything about the man’s health or his complaints. All we know is that he was brought in by ambulance, sat in the waiting room for 4 hours (at least some of the time accompanied by his daughter), and was dead for a while (rigor mortis takes several hours to set in) before anyone noticed it. Be careful drawing conclusions without knowing all the information. The University of Chicago admitted that procedure wasn’t followed. In other words, given the recent adverse publicity at the University of Chicago, a couple of nurses had to take the fall for what happened. The University of Chicago posted a statement about the incident emphasizing the U of C’s commitment to quality and safety. Illinois State, the Medical Marijuana Advocates, and federal investigators are all looking into the incident. Some news reports stated that the feds have now cited the University of Chicago Hospital for an EMTALA violation. Then comes the big stick. CMS allegedly sent the University of Chicago a letter threatening to take away the University of Chicago’s Medicare funding. What an idle threat. If I were the CEO at the University of Chicago, and the feds told me they were considering whether to revoke the hospital’s Medicare funding, I’d give them a double dog dare to go right ahead. The Emergency Medical Treatment and Active Labor Act (“EMTALA” for short) only applies to “participating hospitals” – those hospitals that receive federal funding under Title 42 of the US Code. If the feds kick the University of Chicago out of the Medicare program and it no longer receives federal funding, then, just like free-standing emergency departments, the University of Chicago has no further duties under EMTALA. It wouldn’t have to provide a screening exam to patients. It wouldn’t have to provide stabilizing care to patients. If the patient doesn’t have insurance, the University of Chicago could essentially tell patients to “go to the county hospital.” It could even call an ambulance and have the ambulance transport the patient to another hospital. It could transfer patients to other hospitals without the transfer being “appropriate” under the EMTALA rules. EMTALA requires that hospitals accept transfer of patients if the hospital provides specialty services, so the receiving hospitals would be stuck taking any patients that University of Chicago decided to send them. Added bonus: the Joint Commission would no longer have any business in University of Chicago’s affairs. A termination from the Medicare program could be a blessing in disguise. Without being subject to EMTALA, the University of Chicago could technically engage in “patient dumping” and only accept patients with insurance. True, a hospital would lose the income from Medicare (which is the dominant player in the market), but maybe that shift to providing only funded care would make up some of the difference ...

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Emergency Care – Where's The Line?

The University of Chicago case is getting a lot of press and is polarizing the people on either side of the argument about Dontae Adams’ care. Read about it at one of my previous posts, at ShadowFax’s place, over at Kevin’s blog, or at Scalpel’s blog. The Chicago Tribune is getting a lot of play out of the controversy. It has published several articles already and just put up another one last night. Just by the sheer number of people writing about the topic, you should be able to tell that the outcome of this topic is going to help define how medical care will be provided in the future. On one side of this issue is Dontae Adams and his mother. Dontae happened to be in the wrong place at the wrong time. He was bitten in the mouth by a pit bull and had a large cut on his lip. It is obvious that he needed medical care. Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program. Stop here for a minute. If you read through the comment boards at the Chicago Tribune web site, they are rife with people who criticize indigent/uninsured patients who may or may not be citizens of this country for “clogging up the emergency department” by going there for “routine” care. It’s easy to look down on someone is viewed as “abusing the system.” So let me ask you this: Suppose you lost your job tomorrow and had no insurance. Suppose you had to take a minimum wage job at WalMart to keep food on the table for your kids and you weren’t eligible for health insurance. What would you do for medical care? If you called a random doctor’s office and told them you needed an appointment for “routine” care and could only pay a small amount of cash, what are the chances that you’d get seen that same day? What are the chances that you’d be seen at all? Our family has good insurance, my daughter needs to see a specialist, and the earliest appointment is 4 months away. Let’s say you’re living on a fixed income and want to pay for your doctor’s visits in cash. How can you afford to spend well over a hundred dollars for a single doctor’s office visit? Ah, but there are free clinics all over the place, right? In the rural hospital where I moonlight, the closest free clinic is about 40 miles away and has very strict criteria on who it will treat at no cost. Cook County, IL, where the University of Chicago is located, is in the midst of a budget crunch and has closed down many free clinics. See articles HERE, HERE, and HERE. There’s also an issue of whether or not the care some people seek in the emergency department is “necessary.” Clearly, much of the care that emergency physicians provide is not “emergent.” But I can say that because I have had eight years of medical training plus all the continuing medical education each year. Going to the emergency department to get an excuse for missing work, or trying to get a three day government-paid babysitter for grandma so you can leave on a trip is one thing, but in general, we have to give the benefit of the doubt to the patients. Back to Dontae. According to federal EMTALA laws, patients must receive a medical ...

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Why I'm A Bad Doctor – Part 2

It isn’t just the patients who think I’m a bad doctor. Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous. For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ. I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site. In other words, Medicare thinks I’m a bad doctor. Let me tell you about the patients I screwed up on. The first patient was a gentleman in his 70’s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction. According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (“clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine. Now I’m faced with a choice: A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him. -OR- B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window. If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov‘s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!” If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines. I chose “B.” According to HospitalCompare.hhs.gov, my decision made me a bad doctor. The second patient was an elderly lady who came to the hospital with leg pain and weakness. She was in a lot of pain. We did some testing and she ended up having a blown disc in her back that was pressing on a nerve root. She was admitted and had surgery. Five days after she was admitted, she ended up having a heart attack while she was recuperating on the medical floor. According to the quality indicators at “HospitalCompare”, if a patient has a heart attack and does not have contraindications to receiving aspirin or beta blockers, the patient must receive aspirin and beta blockers within 24 hours of their arrival in the hospital. The brainiacs at Medicare who run this HospitalCompare site expect that I put on my Amazing Kreskin glasses, bust out the crystal ball, and predict with 100% certainty which patients I admit will ...

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VA Never Events

Here’s a conundrum for a VA Hospital. According to this article in the Oregonian, the widow of a patient who fell to his death from the roof of a Veterans Affairs Medical Center is suing the hospital and the doctors for $4.5 million. The federal government has already stated that a patient death associated with a fall while being cared for in a healthcare facility is a “never event.” I wonder whether the widow’s attorney will use the federal government’s new classifications of never events as proof that the government hospital was negligent. After all, if the government states, in effect, that such events should “never” happen, shouldn’t the occurrence of such an event be used as prima facie evidence of the government hospital’s negligence in this matter? Strict liability. Hello, summary judgment.

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The Future Under Socialized Medicine?

According to a Yahoo News article (similar article in the Washington Post) a medical records software upgrade in the VA Hospital computer system put the lives of all hospitalized veterans at risk late last year. According to the article, the “computer glitch” caused patients to get the wrong medications, to receive the wrong doses of medications, to experience delays in treatment, and to receive blood thinning medications for longer than the doctor had ordered them. The VA was quick to point out that it was not aware of any patient injuries from the “computer glitch,” but the article noted that the VA also tried to “keep the problems quiet” and didn’t initially notify the patients involved in the mix-up. The article also quotes Dr. Bart Harmon, a former Pentagon chief medical information officer, as saying that “the VA’s problems could become more common as more hospitals and doctors’ offices move toward electronic records.” The VA system currently includes 153 medical centers and cares for 5.5 million patients. What’s going to happen if a similar system becomes responsible for 5756 hospitals and more than 1 billion patient care visits every year under “socialized medicine”? Giving unnecessary infusions, delaying care, and trying to “keep problems quiet” aren’t included on the quality indicators list the the government’s “Hospital Compare” web site. Oh – I forgot. It doesn’t matter. The government won’t put its own hospitals up there for everyone to compare, anyway.

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