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Tag Archives: Healthcare Access

Tax Incentives for Providing On-Call Care

Some states are having difficulty finding enough physicians to provide needed specialty care to patients who come to the emergency department. If a patient needs neurosurgery or trauma surgery and there is no one on staff that is able (or willing) to perform the necessary services, then the patient must be transferred to another facility. Sometimes the waits involved in arranging and performing the transfers can lead to bad outcomes for the patients involved. In a recent Healthcare Update, I mentioned an article about Oklahoma legislation providing tax credits to physicians to provide on-call care. A friend forwarded me an e-mail from ACEP that listed several states which are contemplating tax credits for on-call care. Hawaii has a bill that would provide physicians who provide at least 576 hours of on-call services per year with a tax credit totaling 5 percent of the physician’s liability premiums. For a policy premium of $30,000 per year, the credit would be $1,500. Another bill in Hawaii would waive medical licensing fees (usually several hundred dollars) for physicians who treat more than 20 percent Medicaid patients. Missouri considered a bill that would exempt Medicaid payments from a physician’s state income tax (currently 6%). Keep in mind that Medicaid reimbursements are generally low, so the benefit isn’t as significant as the bill would make it seem. In a chart I have from 2006, Missouri paid a whole $15 for managing a high complexity (life threatening) patient in the emergency department – the same as it paid for treating a kid with a runny nose. In the entire country in 2006, Missouri reimbursed the least for providing high complexity care in the emergency department. By 2008, the rates it paid were up to $20.23 for low complexity and $60.01 for detailed complexity patients – a little more than half of what Medicare paid for the same patients. Oklahoma’s Senate Bill 1604 would provide a $100 state tax credit per day for on-call emergency coverage in rural areas – to a maximum credit of $5000 per year. So what do you think? [poll id=”4″]

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Dialysis and the Right to Health Care

According to this Article from the Atlanta Journal Constitution, a court has ruled that at least some health care is not a right. In October, I linked to an article about how Grady Memorial Hospital in Atlanta was closing its dialysis clinics due to the significant financial burden. Grady has agreed to pay for the patients to receive dialysis at a private dialysis clinic until January 3, 2010, but after that, the patients are on their own. After Grady’s announcement, approximately 50 illegal immigrants sued to keep the clinic open, alleging that closing of the clinic “violated their constitutional right to the health care service” and that closing the clinic amounted to “medical abandonment.” The court held that the plaintiffs had neither a state nor a federal constitutional right to outpatient dialysis services and that Grady Memorial was not legally bound to provide those services. The attorney representing the patients stated that she realizes that some people don’t believe the patients are entitled to such care because they are illegal immigrants. “They are human beings, and we all have the right to live.” The attorney also stated that “these people are going to die without this.” The lawyer misrepresented the plight of the patients. Under current federal law, renal failure patients will always have access to hemodialysis, and that access will likely be more expensive than the current system that Grady uses. I called this one seven months ago. High levels of potassium in a dialysis patient is an emergency medical condition. Under federal EMTALA laws, hospitals are required to provide stabilizing treatment to anyone with an emergency medical condition that seeks medical care in an emergency department. All the patients have to do is call “911” and they will get door-to-door service to the hospital via ambulance, will get a bunch of expensive testing done to document their elevated potassium, will likely be admitted to the hospital, and will still get their dialysis. The situation raises a second question, though: Should we be providing uncompensated care to illegal aliens? I think that the answer should be “yes” – with an asterisk. If people are violating federal laws, they should suffer the same consequences as anyone else who violates any other federal law. In this case, provide the patients with dialysis, contact police, take the patients into custody, and then initiate deportation proceedings – or whatever other action is appropriate under federal law. If hospital personnel become aware that a patient has committed a crime, we already call police from the emergency department. A patient has a gunshot wound? We call the police to report it. A patient may be the victim of domestic abuse? We file a police report. A patient in a car accident has an elevated blood alcohol level? We notify the police. How hard would it be to contact the police to verify someone’s identity if a patient is unable or unwilling to provide a state-issued identification? Not only would doing so determine whether or not a person is in the country legally, but it would cut down significantly on health care fraudsters who obtain care in the emergency department using a fictitious name and fictitious address and then stiff the hospital for the bill. If we don’t want to enforce our laws, that’s fine. Then we need to stop complaining about providing care to those who violate the laws.

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Banning Bypass: Good Policy or Tempting Fate?

Remember this skit from I Love Lucy? Lucy and Ethel worked on an assembly line and were responsible for wrapping all of the chocolates that came down the conveyor belt. At first, things were easy, but as more and more chocolates came faster and faster, eventually Lucy and Ethel became overwhelmed and the whole process fell apart. The result was a classic comedic moment. In emergency medicine, things aren’t so funny. The chocolates are our patients. At times, patient flow is manageable. At other times, patient volume becomes so high that we have difficulty providing good medical care. When things get too busy, usually there is a relief valve called “bypass”. Hospitals have to meet certain criteria to go on bypass, but once a hospital declares bypass, no ambulances may bring additional patients, giving the emergency department time to stabilize patients already there and to open up beds to accept new patients. Massachusetts is pushing the envelope in medical care and, in January, created a statewide policy that hospitals could not go on bypass. According to this article from the Boston Globe, the law seems to be having its intended effect … for now. By refusing to allow hospitals to go on bypass, the state forces busy hospitals to keep accepting ambulance runs. It is then up to the hospitals to find a way to make room for the additional patients. Kind of like pushing a kid into the deep end of a swimming¬† pool and telling him that he better figure out a way to stay afloat. Hospitals are now opening up additional units and are hiring additional staff to get floor patients discharged earlier in the day. However, wait times haven’t changed much – still an average of about 5.5 hours for admitted patients and 2.5 hours for discharged patients since the rule went into effect. So is forcing hospitals to work at above capacity a good idea or not? Is necessity the mother of invention? Or will we start to see a bunch of hospitals floating to the surface at the deep end of the swimming pool? I seem to remember a lawsuit that stemmed from emergency department not providing prompt enough care to a celebrity …

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Healthcare Update 12-12-2009

Healthcare insurance does not equal healthcare access. Physicians are suing the state of Florida because more than 1.2 million children on Medicaid are not receiving access to critical medical care. Some children covered under Medicaid are unable to find any orthopedists willing to fix their broken bones. More than 750,000 children received no dental care because “reimbursement rates are among the lowest in the country” and 30% of Florida counties have fewer than two dental providers willing to treat Medicaid patients. A Florida official stated that “We have a system that is growing by-double digits, where providers are paid less and less each year. Access is limited, outcomes are not measured … I’d say that’s a bad system.” Oh, and Florida’s defense to the lawsuit? The plaintiffs don’t have legal standing to pursue the claims because “the Medicaid program promises money but not necessarily the delivery of health services.” Hey, but at least all the Medicaid patients have insurance. Wonder how much their insurance will be like the insurance proposed in this new health care bill … These insured patients still end up in the emergency department. Before state Medicaid cuts, many dentists would not accept Medicaid patients because of low reimbursement rates. After Michigan cut dental coverage to 400,000 Medicaid recipients, officials expect emergency departments visits to increase by 10%. One woman recently died from complications that went untreated due to loss of Medicaid dental benefits. Hey, but at least all the Medicaid patients have insurance. That’s what everyone needs from this health care bill. Insurance. One way NOT to get faster care: Threaten to kill the staff in the emergency department because they aren’t seeing your child quick enough. Grabbing the security guard by the throat and attacking the nurse won’t help either. Enjoy your stay in the Greybar Motel, ma’am. In other news, due to the throwdown given to the mom by the security guard during the incident, JCAHO is now mandating that hospitals remove all security personnel as a patient safety measure. Should hospitalists be performing pelvic exams on admitted patients if those pelvics have already been performed in the emergency department? Do women prefer males or females performing their pelvic exam? And who goes singing “come out come out wherever you are” to the cervix when performing a pelvic exam?? These answers and more at Happy Hospitalist’s blog. One lucky dude (or “dood” if you’re Nurse K). Man walks into emergency department feeling “sick and disoriented.” Shortly afterwards, his heart stopped beating and he collapsed. 47 minutes, 4,500 chest compressions and 8 defibrillator shocks later, he was back in the land of the living. Doctors kept him in a medically-induced coma and cooled his body with special cooling pads. Three days later, he woke up and started talking. Not many people survive codes and even fewer end up well enough to walk out of the hospital. Ohio balances budget on backs of patients. Ohio legislators recently imposed a “franchise fee” on hospitals amounting to 1.5% of all operating expenses (not a percentage of profits, mind you). That fee amounted to $19 million for one hospital and $22 million for another hospital. In order to balance their own budgets, now hospitals are cutting staff and cutting services. “More layoffs and service reductions will mean longer waits and higher costs for all patients.” Minnesota hospitals “shed jobs and services” as they brace for $43 million in revenue cuts when the state terminates some programs for indigent care. Such cuts would “tip this hospital over” and “would mean unacceptable deaths for patients who can’t get care” according to ...

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The Demise of American Health Care

A couple of news headlines paint a bleak picture about the future of healthcare in this country. First are some comments made by US Republican Senator George LeMieux. During a news briefing (video here), LeMieux expressed a concern that Obama’s healthcare plan would amount to “Medicaid for the masses” and would put all Americans on a government run or government controlled health care. The Palm Beach Post News also ran a story regarding a speech given by Senator LeMieux where he stated that the cost of the bill over the next 10 years was grossly understated due to “funny math”. He estimated the true cost of the bill to be more than $2.5 billion over 10 years rather than the projected $849 million. LeMieux stated that in order to decrease costs, the bill intends to cut Medicare spending by more than $500 billion – through $400 billion in cuts to home health providers, hospitals, hospices and others while decreasing subsidies to Medicare recipients by more than $100 billion. My favorite quote from the article is the following: “If we really want to provide health care for Americans, why shouldn’t we give them the tools to go out into the marketplace and be a consumer, which we know will end up driving down costs.” Another free market advocate. I love it. As our legislatures plans to significantly cut spending on the Medicare program, today several Massachusetts hospitals are filing a lawsuit against the state of Massachusetts because the current reimbursements from Medicare and Medicaid are already too low. According to this article in the Boston Herald, Massachusetts currently reimburses hospitals for only 40% to 86% of the costs of providing care. Because at least 63% of patients going to these hospitals have Medicare or Medicaid, the low payments are pushing many hospitals “to the brink of financial ruin.” The state countered by stating that it recently increased payment to the hospitals by 10 percent. Unfortunately even a 10% increase still leaves hospital payments at 44% to 95% of the cost of providing care – still below the break even point. No business can stay afloat when the costs of doing business exceed revenues. Recall that in 2006, Massachusetts was the same state that established a mandate that every person in the state have health insurance … similar to the mandate proposed in the current US health care bill. Also recall how, since this Massachusetts mandate was created, the number of visits to Massachusetts emergency departments increased 7 percent and how the cost of caring for patients in Massachusetts emergency departments increased 17 percent – due to the lack of primary care providers in the state. Oh yeah, and in a survey last year, only 2% of graduating medical students in the country plan to go into primary care internal medicine. So the plan in Massachusetts to insure all of its state residents has resulted in almost every state resident having insurance … and in more people having trouble finding care. The greater number of insured patients increases the costs of providing care to those patients. Then, to control costs, the government cuts or maintains ridiculously low payment schedules to providers – to the point that the providers are having difficulty staying in business. Welcome, ladies and gentlemen, to your new national health care system. The current health care bill plans to cut Medicare spending by $500 billion. Medicare plans to cut physician reimbursement by 21% next month. What good will your new health insurance be few providers are willing or able to provide care for you? The biggest myth of this ...

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No Spinning Lights For YOU!

If you’re in the Fort Worth, Texas area and you call an ambulance for your influenza symptoms, your ride to the hospital may not have the red spinning lights on it. In order to respond to the threefold increase in ambulance calls from patients with influenza-like symptoms, Medstar Ambulance Service is considering a change in policy where patients are evaluated after a call and then told that they “don’t need to go to the hospital.” If the patients still insist on transport, they won’t be taken to the hospital by ambulance. Instead, Medstar will arrange a taxi ride – and not necessarily to the hospital, either. Patients might get taken to an emergency clinic instead. Oh, and when they’re discharged they’ll still have to find a ride home.

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