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Tag Archives: Healthcare Access

How Payments Affect Care

When an unconscious intoxicated multiple trauma patient was brought to the ED, we did a bunch of CT scans to look for injuries. Fortunately there wasn’t anything life-threatening. He was admitted and was later discharged in good condition. I then got a memo from the hospital several days later stating that Medicare would not pay for the CT scan of the patient’s cervical spine. There is a list of diagnosis codes for which Medicare will reimburse hospitals for performing a CT scan of the cervical spine. That list is contained below. If one of the selected codes is not on the patient’s final diagnosis list, then Medicare tells the hospital “tough luck” and pays the hospital nothing for the scan. As part of Medicare’s Conditions of Participation, the patient may not be charged for the exam unless the patient specifically agrees to the charges. When Medicare doesn’t pay, almost always the hospital gets stuck holding the bag. If a patient is a victim of multiple trauma and is unconscious, CT scans of the cervical spine are more likely to show significant injury. This study showed that in multiple trauma patients, CT scans picked up on 98.5% of fractures while cervical x-rays only picked up 43% of fractures. It is uncommon to pick up ligamentous injuries on x-rays or CT scans – generally need an MRI for those. If physicians choose to do a CT scan on an unconscious or poorly responsive patient, according to the “permissible” diagnosis codes, in most cases hospitals have to hope that either an injury or some type of cancer shows up on the CT scan. Otherwise, the CT scan won’t be reimbursed and the hospital eats the cost. What are the other options in multitrauma patients? We could just do only x-rays of the cervical spine, and, if negative, tell patients that everything is OK because the government won’t pay for CT scans unless you meet certain criteria. The 57% of patients with cervical spine fractures missed on x-rays will have all their medical needs met under the new health care reform measures anyway. Or, while bleeding to death and strapped to a backboard wondering if they’re going to live or die, we could give patients an ABN form to sign. “Medicare might not pay for this test, if Medicare doesn’t pay for this test, do you agree to pay the cost of the test yourself — assuming that you live, of course?” We could always perform x-rays on everyone’s necks first and make up notice some “abnormality on radiological or other exam of the musculoskeletal system” to justify the CT scan. That will be a 793.7 to all you CPT coders. We could just say that notice that the patient winced in pain when the neck was palpated – causing “cervicalgia.” That’s CPT code 723.1. Or we can just practice good medicine and let the hospitals get shafted by the system. Of course, if hospitals get shafted enough by the system, they end up closing or reducing services. Then access to care suffers. You get what you pay for. Do a search for “hospital bankruptcy closures” and see how often it happens. Here are a few examples. CT scan payments are just one example of the cat and mouse game that constantly goes on between those providing the services and those “paying” for the services. It is also an example of the “Golden Rule” – he who has the gold makes the rules. Things aren’t going to get better.

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Effects of Saving Money

In 2008, St. Johns Hospital and Mary Immaculate Hospital in Queens had a total of 119,883 outpatient department visits. In February 2009, the two hospitals went bankrupt and closed. In June 2009, the New York City Office of Policy Management published a paper showing that once St. Johns and Mary Immaculate Hospitals closed their doors, the patients that previously went to those hospitals didn’t just vanish. Instead, the patients flocked to other nearby hospitals which were already operating at capacity. Guess what happened? Those nearby hospitals – such as Jamaica Hospital in Queens, are now “overwhelmed.” According to the report, Jamaica Hospital’s daily census went up 50% — from 350 visits per day to “well over” 500 visits per day. On May 27, 2009, Jamaica Hospital had 663 visits – more than double its usual number. Other area hospitals such as Elmhurst Hospital, Queens Hospital Center and New York Hospital Queens noted increases of at least “an extra 100 patients a day.” The number of patients being boarded in the Emergency Department of nearby hospitals also “soared.” Jamaica Hospital, Queens Hospital Center, and Long Island Jewish Hospital all noted dramatic increases in the numbers of patients being boarded in their EDs. One emergency physician with twenty years of experience was quoted as saying “the state of emergency medicine in the borough of Queens is the worst I’ve seen it in my career.” At the heart of the hospital closures was funding. New York City was subsidizing St. Johns Hospital and Mary Immaculate Hospital to the tune of $61 million over the years leading up to the hospital closures. The City was unable to sustain that commitment. Without the city’s support, the hospitals went bankrupt. Availability of ambulance services is also now in question. When St. Johns and Mary Immaculate hospitals closed, the ambulance services operated by the hospitals also ceased operations. None of the remaining hospitals was interested in providing ambulance services to the area served by Mary Immaculate Hospital, so ambulance service in that area was temporarily taken over by New York City Fire Department EMS. NY City is cutting the budget for the EMS service by $3 million which will result less ambulance availability. One mother noted that it took 25 minutes for an ambulance to reach her home after her son had a seizure. A $60 million Medicaid reimbursement reduction anticipated in the near future will likely result in even less care being available. Whatever health care reform package that is chosen will necessarily involve an attempt to cut this nation’s health care costs. This country simply can’t sustain its current level of health care spending. But we need to be very judicious in where spending cuts are made. Many hospitals are not “rolling in the dough.” Cut funding for health care too much and we risk further hospital closures. The decrease in the quality and availability of care in Queens, NY is just one example of the impact hospital closures can have on the medical care in a community. Remember this point in the health care debate: We can talk all we want about providing health care insurance to everyone in this country. Health care insurance means nothing if there is no one available to provide the care for you.

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Medical Malpractice and Access to Care

Below is a point-counterpoint that was published in this month’s EP Monthly print magazine. Many thanks to Max Kennerly for putting up a valiant fight in a losing effort ;-) I will add links supporting facts for both arguments when I get a little more time. Feel free to pick up in the comments section where we left off. ———————————————————————— Opening Argument A 2006 American College of Surgeons report argued, “the single most  important factor shaping the [emergency] surgical workforce today is  declining reimbursement,” a euphemism for one of the most cutthroat  industries in America. Last month, Bayonne Hospital Center sued Horizon Blue  Cross Blue Shield for a parade of horribles, including Horizon calling  patients in the ED, lying to them about their coverage, and instructing them  to leave prior to screening or stabilization. Against this backdrop, malpractice premiums are at a per-doctor  thirty-year low, representing 0.45% of national health care expenditures.   The impact of this particular cost should be ripe for economic review, but  unbiased analysis is in short supply. The American Hospital Association, for  example, conducts its studies through the Lewin Group, part of Ingenix, a  UnitedHealth subsidiary that in January agreed to a $400 million settlement  for providing phony data about physicians’ “usual and customary” fees so  that UnitedHealth could short-change reimbursements. AHA studies  unsurprisingly blame “lawyers” — but not “racketeering” — for physicians’  woes. After a decade of declining premiums and paid patient claims in the 1990s,  the stock market collapsed, causing insurers to raise premiums rapidly and  prompting widespread reports of physicians forced to restrict services. In  response, the General Accounting Office investigated the impact of  malpractice premiums on access to care (in 2003, the height of the premium  raises) by surveying five states with “reported malpractice-related  problems” and four without. The GAO found no impact in the non-“problem”  states. In the “problem” states, the GAO found “scattered” reductions by  providers of ER on-call surgical coverage and newborn delivery services,  most of whom also faulted “long-standing factors in addition to malpractice  pressures,” like declining reimbursement.  The GAO thus concluded most of  the reports were “unsubstantiated” and that malpractice premiums “did not  widely affect access to health care.” The same report found little evidence  of “defensive medicine,” criticizing prior research, including a  widely-reported Health & Human Services report, for transparently flawed  assumptions. > Such did little to stop a wave of malpractice “reform,” like in Texas,  Georgia, South Carolina, Oklahoma, and Idaho, all of which capped  noneconomic damages and eliminated joint and several liability, much as  California did more than twenty years ago. Now that the stock market has  stabilized and the tort reform has been in effect for several years, we have  control and experimental groups in our laboratory of democracy. The American College of Emergency Physicians’ 2009 Report Card on the State  of Emergency Medicine is a revelation: of the ten states with an “A” or “B”  grade for their “medical liability environment” (i.e., the most hostile to  plaintiffs), six had an “F” for “access to emergency care” (the six  “reform” states mentioned above), one had a “D,” two had a “C,” and one had  a “B,” together averaging a “D-.” Conversely, the nine states with an “F”  for “medical liability environment” earned the only “A,” had only one “F,”  and averaged a “C” for “access to emergency care,” better than the national  average of “D-.” But, tort reformers say, there are other factors. That’s my point: the  impact of malpractice premiums on access to care is so small that it appears  *positive* because it is dwarfed by other factors such as the ...

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My Interview With Mass

Mass left some questions in the comment section that I thought were insightful and added to the discussion about health care policy. So I’m treating them like an interview. 1) I’d like to know how Dr Whitecoat is an “Independent Voice for Emergency Physicians”? Does that mean that all or most independent ER docs are conservatives or Republicans or anti-HR 3200? It would seem so as there are plenty of references in his blog to the loaded phrase “socialized medicine” as well as (at times indirect) links to groups like CAHI (the health insurance lobby) or the NCPPR (a conservative lobby) or to other conservative blogs. Either admit you’re a proud conservative or give some left-leaning blogs and groups some links. First, I’m not, nor have I ever asserted, the “Independent Voice for Emergency Physicians”. That phrase refers to the magazine Emergency Physicians’ Monthly, and you won’t find a better forum in emergency medicine for emergency physicians to express their views. You could even submit an article and have it published if it was germane to the practice of emergency medicine. Dis me, but don’t dis the mag. I actually had to go look up conservative versus liberal qualities on a web site before I could respond to your challenge. I’d have to agree that if I had to choose between personal responsibility and government intervention, I’d pick the former. However, the news is replete with stories about how people and businesses, when left to their own dealings with the public, take advantage of others. Government intervention is necessary to establish and enforce rules by which everyone must abide. 2) How would WC doc define “socialized medicine”? Are patients in the VA system, or those who have Medicare or Medicaid part of such a system? Does it matter that Medicare patients have higher satisfaction than other insured patients? I would submit that if WhiteCoat Doc would term universal healthcare as “socialized medicine,” then I can call the present system, “Darwinian every-man-for-himself medicine.” Unwieldy, but accurate. Socialized medicine = publicly funded health care. Period. I don’t think that anyone can draw a line between “socialized” medicine and “single payer” medicine (in which government pays, but does not participate in delivery of care). The “golden rule” always applies – he who has the gold makes the rules. Look at the Medicare system now. The government pays for care, but conditions payment on a plethora of byzantine rules. Fail to follow the rules – even if you provide the care – and you don’t get paid. Technically, even though the government is not “providing” the care, it is orchestrating the care – sometimes on an “ubermicromanagment” level. Many people are content with Medicare because they get what they want at no current cost to them. Don’t forget that most people receiving Medicare have paid into the system through payroll deduction for all of their lives. I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”. Being “insured” by Medicare doesn’t mean much if no providers accept it. Our Medicaid crisis right now is what Medicare will look like 10 years from now unless the system changes. 3) Is this blog written from the perspective of a professional concerned about his income, independence, status, the overall health of his patients, or some mix of these? While I too am a physician, I don’t believe that physicians’ and patients’ interests always go hand-in-hand. There is no shame in defending our incomes and status – let’s just not ...

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More Analysis of Healthcare Reform Bill

I put the blog on autopilot while I was away for a few days. I was a little surprised by the reactions to the Health Reform Bill post. My intent in posting that e-mail was to generate discussion and encourage everyone to actually read what our elected officials are putting forth as the law controlling our health care for the foreseeable future. I had planned to do a point-by-point analysis, but didn’t have the time before I left, so I picked the end-of-life issue to comment because the comments made by the person who created the e-mail sounded inflammatory. They were.  It seems as if the mere fact that I posted the e-mail meant to most people that I ratified all of the contents. Not true. However, some of the comments were still on point.  Had hoped that others would analyze the wording similar to what I did with the  end-of-life issue. Oh well. For those who did look at the bill and post specific comments, I want to address them. “Page 22: Mandates audits of all employers that self-insure! (Section 142(b))” Here’s the exact text: COMPLIANCE EXAMINATION AND AUDITS (A) IN GENERAL – The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance. The language “shall” is a mandate, it is not permissive. The wording of the remainder of the sentence is poor, but it appears that the mandate requires the commissioner to conduct audits of whether qualified health benefits plans are complying with federal requirements. Unlike Shadowfax’s assertion, the wording does not “require[] ‘random compliance audits and targeted audits in response to complaints.'” Instead, the plain language states that the mandated audits “MAY INCLUDE” random compliance audits and targeted audits. The language does not limit the audits to those vehicles and states nothing about the degree or extent of the audits. Little different, don’tcha think? Since Shadowfax also picked out the “All non-US citizens, legal or not, will be provided with free health care services” statement, let’s look at that one, too. Section 401 changes Chapter 1 Subchapter A of the Internal Revenue Code to impose a 2.5% tax on a portion of the adjusted gross income any individual who does not have acceptable health care coverage. The exact language is ‘(a) Tax Imposed- In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of– ‘(1) the taxpayer’s modified adjusted gross income for the taxable year, over ‘(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer. Section 6012(a)(1) of the IRS Code is here and it makes no mention of what the “gross income specified” should be, so I am unclear how the 2.5% tax will be computed. However, the language of the Act creates exceptions for certain classes of people who have to pay this tax. Those exceptions include (2) NONRESIDENT ALIENS- Subsection (a) shall not apply to any individual who is a nonresident alien AND (5) a “RELIGIOUS CONSCIENCE EXEMPTION” where individuals do not have to pay such tax if their religious tenets make them conscientiously opposed to receiving benefits of any private or public insurance. Another part of the Act, Section 246, states SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS. Nothing in this subtitle shall allow Federal payments for affordability credits [note: See Section 241] on behalf ...

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Charity Care Tax Exemptions

Was talking with a colleague about health care reform this weekend and an interesting question came up. If exemption from federal income and/or state property taxes for non-profit hospitals is based upon providing “charity care” to their surrounding communities, how will hospitals qualify for income tax and property tax exemptions if health care coverage becomes “universal” and there is no longer a need for “charity care”? With declining revenues, requiring hospitals to pay income and property taxes would probably bankrupt some smaller institutions and inner-city hospitals. We weren’t the first ones to consider the issue – a good discussion is here. Still, there aren’t any answers out there.

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