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Tag Archives: Healthcare Access

Healthcare Update — 12-02-2010

Also see the satellite edition of this week’s update over at ER Stories. Problems with Canadian health systems getting worse. “We’re trying to get a Size 13 foot into a Size 8 shoe.” Emergency department overcrowding increasing due to lack of available beds. The president of the Edmonton Emergency Physicians Association described the situation as a “potential catastrophic collapse” of emergency medicine. Edmonton plans to decrease hospital emergency department crowding by moving patients out of the emergency departments sooner once the hospitals meet certain criteria such as the ED being 110% full or there are more than 35% boarding patients in the emergency department. Five times this past year, Dr. Raj Sherman’s 73-year-old father almost died after waiting hours on a stretcher in an ambulance parked outside the hospital waiting for a bed. As a parliamentary assistant on health, he decided he had had enough and blasted the government, the Alberta Health Services chairman, the former health minister, and Premier Ed Stelmach. As a result of his statements, he has been fired from his government position. California emergency physicians sue to keep the state from cutting reimbursement – and win. Medicaid insurance versus Medicaid access. Yes, they have insurance, but one patient had to drive 2.5 hours to see an orthopedist that would accept her insurance. He fitted her with a brace and sent the patient for physical therapy. Now the “insurance” won’t pay for the brace. Plans that are running Medicaid managed care plans are viewed as “managing costs, not managing the care.” When patients can’t get the care they need, where will they end up? Emergency department waiting rooms. Six California hospitals fined because employees inappropriately accessed patients’ medical information. How do we change the system to prevent this from reoccurring? Malpractice judgments and settlements in the news: $16.2 million Chicago settlement for neurosurgical injury after patient sustains a brainstem herniation. $6 million Wisconsin settlement in birth injury case where patient born with cerebral palsy. Largest verdict in Belize history for child who was delivered 2 weeks early due to miscalculation in gestational age and premature Caesarian section. Maine preparing to repeal its universal health care plan due to funding issues. The Governor elect states that the state has paid $160 million to cover 3,400 eligible residents. The outgoing governor disagrees with the numbers. Girlvet has another intriguing post about those warning labels on cigarettes. If cigarette packs are required to have graphic pictures on them, why aren’t beer cans required to have graphic pictures of DWI accidents? Why doesn’t McDonalds have to put graphic pictures of obese people on their bags? A real life “Catch Me If You Can.” Fake doctor works in Fayetteville, NC emergency department for 3 weeks before getting caught. SWAT team descends on hospital as Florida gunman fires shots in hospital cafeteria and then barricades himself inside hospital room. Canadian man has diabetic “seizure” while visiting his wife and newborn daughter. Instead of bringing him to the emergency department, the hospital calls an ambulance and paramedics bring the man to the emergency department where he is later released. Now there’s the little matter of that $400 ambulance fee that he’s being charged – even though he never set foot in an ambulance. One reason that some medical providers are reluctant to disclose errors: 25% of patients stated that they would file a medical malpractice lawsuit if they were told about a medical error. Many actions considered “medical errors” have no effect on patient outcomes. Giving a medication five minutes after the time it was ordered is a medical “error”. Giving ice chips to ...

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More Visits, Less Availability

A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth. Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics. Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government. The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession. Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons),  homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents. In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007. Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program. With the increase in visits, there are longer waits and less availability of medical care. Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years. The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures. Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what? I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.

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Government Declares War on Doctors

I was going to include this article in the rest of the Healthcare Update, but pulled it out and made it a separate post after reading this related article in the Christian Science Monitor – “Justice Department declares war on doctors” Five orthopedists sued for antitrust violations and settle case. Workers compensation in Idaho wasn’t paying enough, so these orthopedists allegedly colluded to refuse to treat any workers compensation patients until the state raised the rates that were being paid. In addition, several of the physicians allegedly threatened to stop seeing Blue Cross Blue Shield patients because Blue Cross payments were insufficient. Orthopedists across Idaho even published articles in the newspapers regarding the Blue Cross dispute. Now, as a result of the settlement, the orthopedists won’t be able do this same thing in the future. Other documents from the antitrust case are contained here. The assistant attorney general stated that “The orthopedists who participated in these group boycotts denied medical care to Idaho workers and caused higher prices for orthopedic services.” No word on when this brainiac is going to file suit against all the state and government hospitals that deny care and cause higher medical prices. Oh. Forgot. States and insurance companies are exempt from antitrust actions, so no one can sue them for colluding to deny care. I think I’ve discovered how patients will be guaranteed care under the new health care proposal. If too many doctors stop seeing Medicare and/or Medicaid patients because the reimbursement is too low, the Justice Department will just step up its antitrust enforcements. Watch what happens to speed and quality of care then …

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Florida Verdict May Threaten EMS Availability

Ambulance service held liable for failing to “do what was necessary” before accepting emergency transport of pregnant patient. I mentioned this case in a previous Healthcare Update. A child was born at 25 weeks gestation – 15 weeks premature – and was not breathing. Babies born at this age have a viability of 50-70%. In other words, up to half of children born at this age of gestation die. The family called 911. The paramedics arrived, performed CPR on the child, and brought the child back to life. I know a lot of physicians who would have difficulty resuscitating such a premature infant. These paramedics should have been commended as heroes for saving this child’s life. Instead, they were sued and found liable for $10 million. The plaintiff attorney stated that “the paramedic should have evaluated her before they transported her.” In its verdict, the jury found that the ambulance company “was negligent by accepting the transport task” and the company showed “reckless disregard” in rendering its services. So instead of getting to the mother as soon as possible, getting the baby out, performing CPR, and saving his life, the attorney apparently believes that the paramedics were supposed to diddle around arguing about whether or not to transport the mother to a hospital. Good idea. Let’s write that requirement into all future Florida EMS protocols. We can call it the “Kelley Amendment” – named after Bob Kelley, the plaintiff’s attorney in the case. After the verdict, the ambulance company may soon have to determine whether it can stay in business. A past-president of the American Ambulance Association is quoted as saying “EMTs and paramedics will go on the call until lawsuits like this break the bank and they can’t go anymore. That is $10 million that comes out of the ability to provide care, and the community will suffer because of that cost.” As I’ve asked in the past … which is more important – perfect care or available care? Jurors in Florida’s Volusia County seem to have made their decision. It will be interesting to see whether the jurors’ decision to award an additional $10 million to someone who had the benefit of excellent care yet who experienced a bad outcome will affect the future availability of emergency transport in Volusia County and other Florida counties. My guess is that few EMTs will want to work in Volusia County any more. Regardless of the verdict, you EMTs are still heroes in my book. UPDATE May 23, 2010 Additional facts about the case (and commentary) from the Editor in Chief of JEMS

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Dr. WhiteCoat Goes to Washington

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference. I attended some excellent lectures about leadership. Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions. I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional. I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for. There were other lectures about how health care reform fell short and some possible options for the future. One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference. And I went to legislators’ offices. The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff. I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input. I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer ...

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I may end up eating my words about this. We’ll see. James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him. I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now. A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster. Now the stakes just went up. The Senate blocked the latest legislation to extend the deadlines for the pay cut. Pay cuts will take effect on Monday. Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years. So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand. Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care. Initially, that may be true. Then what happens? First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them. Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need. If a lot of physicians opt out of Medicare, the health care system will turn chaotic. ...

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