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Tag Archives: Healthcare Access

Healthcare Policy Roundup 7/22/09

The Mayo Clinic – touted by the Obama administration as a system that provides quality care at a reduced cost – turned around and smacked House Democrats in the face over the recent health care reform proposals. A Washington Times article quotes Mayo Clinic officials as stating that the plan will lower quality and increase costs because the outcomes are not patient-focused or results-oriented. “The real losers [with this plan] will be the citizens of the United States.” Ouch. In other news, President Obama mentioned in a White House press conference that he changed his mind and now thinks that the Mayo Clinic sucks. Comparing healthcare systems in different countries may help the US come up with a viable alternative to our current system. John Aravosis from America Blog describes a situation in France where his emergency department visit at a specialty hospital cost him a rocking $32. Something doesn’t sound right about that story. If it is really true, insurance companies would spend less money by purchasing an air fleet and sending patients with potentially expensive medical problems to France for emergency care. Anyone else have experience with the French system that could comment more about it? More violence in the emergency department. An ED admitting clerk was shot three times by her former boyfriend outside the hospital and then stumbles inside full of blood. I usually don’t believe that the number of malpractice suits against a physician should be used as a measure of a physician’s competence. I know several excellent physicians who have been sued 5-10 times. I have been sued several times myself. Unfortunately, when there’s no reliable way of measuring a desired metric such as physician quality, pencil pushers will take things that can be measured and try to make the argument that the data apply to the metrics. That being said, should an ophthalmologist who has been sued 50 times be subject to discipline just because of the number of lawsuits against him? The largest medical malpractice verdict in Tennessee history was just handed down against an OB/Gyn physician that allegedly ignored a patient’s complaints about an unusual breast lump, stating that the lump was probably a cyst or a fatty deposit. Instead, the lump was a cancer that later spread to the patient’s liver. The jury awarded almost $24 million to the patient and her husband. Here’s a WTF moment for you. Two nurses wrote a complaint with the Texas Medical Board after they became concerned with patient safety when a physician kept trying to sell patients herbal medications. Kind of like an IRS agents offering to sell you tickets to the IRS ball just before an audit? The nurses included patient identification numbers, but no names, with the complaint. The story isn’t clear, but apparently medical records were also sent to the Medical Board. When contacted by the county sheriff, none of the patients complained about their care. The District Attorney then filed criminal charges against the nurses after the doctor complained about being “harassed”. In other news, the Winkler County District Attorney could not be immediately reached for comment, but later was found at home taking a chamomile extract bath with vanilla bean infusion prescribed by the involved physician. Defensive medicine may not exist, but this doctor does a pretty good job of describing this figment of our imagination. Interesting that Congressional Budget Office statistics show that $30 billion was spent to defend against and pay malpractice claims in 2008, but that money was only 1.5% of the total 2008 healthcare expenditures. Also interesting that hospitals provided more than $35 billion ...

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Socialized Medicine Debate

This morning I read two competing views about whether our system should become “socialized.” One view was from Op-Ed columnist Richard Cohen in a piece titled “Socialized Medicine? Bring It On” in the Washington Post. He takes his experiences accompanying a “friend” to the emergency department and tries to generalize them to the medical system as a whole. There were “interminable” waits, there were not enough beds, and his friend had to wait “in agony” sitting in a wheelchair in a hallway for six hours. He then demonizes insurance companies who denied his friend’s claim for a return to the emergency department, saying that private enterprise makes “lots of money” on health insurance. He concludes that our privatized system has failed to the point that “everyone gets miserable treatment” and advocates for government-run health care because he doesn’t think that the government “could possibly do a worse job.” Unfortunately, Mr. Cohen’s view relies on many false assumptions. While Mr. Cohen is correct that our current medical system is “privatized” to some degree, our system is far from completely “privatized.” The government still has a significant impact on the care patients receive. Federal EMTALA laws require that every patient be evaluated – regardless of ability to pay. The threat of government fines and sanctions is hardly a “privatized” system. Through Medicare and Medicaid, state and federal governments control payments to physicians for a significant amount of the care that they provide. Hospitals have to meet their budgets or they will go bankrupt. When reimbursement from the governments declines, hospitals either need to cut staffing and services — which means longer waits and delays in care — or go out of business  — which means longer waits and delays in care. The number of hospitals emergency departments decreases each year.  As our administration struggles with a trillion dollar deficit, does Mr. Cohen or anyone else expect payments to hospitals to increase with socialized medicine? Money is a great incentive. People spend days searching online for the best deal on a new LCD TV. People drive across town to get a gallon of milk twenty cents cheaper from a grocery store. Most people would not think twice about switching jobs if they were able to earn a few dollars more per hour for doing the same work. When insurance stops paying for one doctor’s care, most patients abandon ship and find a doctor that the insurance company will pay for rather than paying out of pocket. Doctors and hospitals are no different. When people are provided with an incentive, they will work harder. When deincentivized, they will work less. At some point, they will leave the system. Look at the state of primary care in this country now. Doctors are leaving because the good aspects of helping patients are outweighed by administrative hassles, paperwork, and decreased reimbursement. Does Mr. Cohen think that there will be less administrative hassles and increased payments in a socialized system? One quote just keeps resonating in my mind: “The government that has the power to give everything to you has the power to take everything away from you.” The competing view I read was from a forwarded e-mail about an economics professor: An economics professor at a local college made a statement that he had never failed a single student before but had once failed an entire class. That class had insisted that Obama’s socialism worked and that no one would be poor and no one would be rich, a great equalizer. The professor then said, “OK, we will have an experiment in this class on Obama’s plan”. ...

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Reducing Liability on EMTALA care

Here I go with EMTALA again. I wanted to flesh out an issue that Matt and Chris raised based on my previous post. A proposed Ohio law states that a physician who provides emergency medical services is “not liable in damages to any person in a tort action for injury, death, or loss to person or property” based on the services unless there is “willful or wanton misconduct” involved (thanks to Max for the link). Chris’ MedCity News published an article yesterday about the same law. The response from both sides of the issue is predictable. Malpractice plaintiff attorneys state that such a law would remove any incentives for quality control (as if JCAHO regulations suddenly wouldn’t apply once the law took effect). The Ohio Bar Association will come out with its official opinion in a couple of weeks, but for those of you who can’t stand the suspense, I can summarize it right now: We believe that a law restricting the rights of citizens to sue is in direct conflict with the Constitution and would essentially give emergency physicians free reign to kill and maim the very subset of our population we should be protecting the most – those who are suffering from medical emergencies. Proponents of such a law state that emergency physicians are “easy pickins” for lawsuits. They can’t refuse to evaluate any patient seeking care (unlike any other specialty – in fact, unlike any other profession that I can think of), the patients often come to the emergency department in extremis or with vague symptoms, there is usually little time to develop a physician patient relationship, there is very little follow up, oh, yeah, and if you don’t do everything the patient and family want and there is a bad outcome, they have the number to Dewey, Cheatem and Howe on their cell phone speed dial. So allegedly, those physicians who provide emergency medical care (both emergency physicians and on-call specialists) are getting fed up with the threat of lawsuits and are leaving states where there is a high incidence of medical malpractice claims. I have not researched the issue, so I can’t cite any specific numbers. The MedCity News article does cite a link about the projected shortfall of surgeons available to provide emergency care in Ohio. The MedCity News article also notes that many states have either passed or are considering such legislation including Arizona, Michigan, Minnesota, Utah, North Carolina, Florida, Georgia, Texas and South Carolina. I commented on this topic in one of my posts on how to improve the house of medicine. So in answer to Matt’s question about “why we would want a policy insulating ER docs from their negligence, even gross negligence,” I offer the following response from my previous post. Granting medical providers immunity would throw everyone’s legal rights out the window, right? No profession should have immunity for their actions, should they? Funny. Judges have complete immunity for their actions. No one even questions the concept of “judicial immunity” any more. One quote I found here showed why the US Supreme Court feels that judicial immunity is important: To render a judge liable to answer in damages to every litigant who feels aggrieved during the course of judicial proceedings, “would destroy that independence without which no judiciary can be either respectable or useful.” Bradley, 80 U.S. (13 Wall.) at 347. It is OK for a judge to be grossly negligent and wholly biased in their duties. Litigants have no recourse whatsoever. The judges are immune from liability. At some point our nation is going to have to decide ...

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Healthcare Policy Update June 16, 2009

Want fries with that? Stanford Hospital experiments with the first drive-thru emergency department. Examining people sitting in their driver’s seat may “keep them from infecting others” but it will also keep doctors from fully examining a patient. Would be interested to see outcomes measures with this idea. If outcomes are similar, what is the big leap between drive up EDs and telephone medicine? After all, you can just ask a patient to put the telephone receiver to their heart for a moment … Ohio is breaking new ground in its tort reform attempts. According to this article, the legislature is seeking to make it harder to file lawsuits against emergency physicians and against obstetricians (text of bill here). Other states such as Florida and Georgia have already passed such laws. Good idea? What’s with violence in the EDs lately? A Washington man walks up to the emergency department doors and shoots himself in the head while ED staff watches on the security camera. A cop cuffs a stabbing victim to a wheelchair in the ED and then beats him with a sap. Smile, bud, you’re on Candid Camera. That lapse in judgment will get you a few years in the Greybar Motel. One way to reduce wait times in the ED — order sets. Instead of waiting for the physician to see a patient to order tests, nurses order tests at triage and have the test results ready before the doctor goes into the room. This Canadian hospital reduced wait times by 50% after implementing such a system. A hospital in the lower Florida Keys used to receive a subsidy to treat indigent patients who were not eligible for Medicaid. Now the subsidy is gone. So is a lot of the care. UTMB in Galveston is reopening its hurricane-damaged emergency department effective August 1, 2009. Second article here. Previously commented about UTMB’s decision to close its emergency department and open an urgent care clinic, therefore being able to skirt EMTALA requirements.  One commenter to the article jokingly wonders whether a forecast for a hurricane to hit the area on August 2, 2009 had any bearing on the opening date. Another Texas hospital is using a nursing call-in line to direct patients to “the right place to go.” They’re apparently trying to direct non-urgent patients away from the emergency department. But is their idea of doing phone triage on patients already in the emergency department going a little too far? OK, ACEP and Chicago Tribune, dust off your pitchforks. The nation flipped out about the University of Chicago’s plan to discharge non-urgent patients from its emergency department if the patients could not or would not pay for their medical care. Now HCA, the nation’s largest for-profit hospital chain, is planning to do the exact same thing. In a pilot study at several of its hospitals, HCA noted that 40% of ED visits were classified as non-urgent. When given the opportunity to pay in advance to receive medical care, only 1% of the non-urgent patients decided to do so. Lest you had any doubts … in the article, the Chief Operating Officer of HCA assured everyone: “It isn’t about the cash.”

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Promises Promises …

Very poignant article in Yahoo news about how the federal government is failing to meet the needs of many patients in the Indian Health Services – and the disastrous effects the broken promises are having. A five year old with stomach pain who stopped eating who visited the clinic ten times and was diagnosed with “depression.” Later the family discovered she had terminal cancer. She died at age six. Another patient was given cough syrup for his congestive heart failure and sustained damage to his heart. He died while waiting for a transplant. Another patient visited the clinic with stomach pains for 4 years and was diagnosed with possible tapeworms and stress. Later, she discovered she had metastatic cancer. Yet another patient couldn’t get a prescription filled despite repeated trips to a clinic because of lack of appointments. She died before she was able to see the doctor. Few doctors are willing to work in remote reservations, there is a lack of funding (some reservations warn “don’t get sick after June,” when the federal dollars run out), and care is rationed. In fact, one third more funding is provided for the health care of felons in federal prison than is provided for American Indians on reservations. Then read this Yahoo news story about the massive budget cuts that are coming down the pike in the healthcare reform package. Not too hard to connect the dots.

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"The Ambulance Game"

Want another perspective on why some emergency department staff are on a mission to bust drug seekers? Read this excellent interview that reporter Jim Sullivan does with a prescription drug addict in the Ironton Tribune (Ohio). The addict discusses how she and friends call ambulances to their homes using false medical complaints in hopes of getting narcotic medications when they arrive at the hospital. If they don’t get what they want, they sign out AMA, go home, call the ambulance back, and request to go to a different hospital. The reporter also researches some numbers and discovers that ambulance runs are two to three times higher than expected in these areas. Oh, and guess who pays for all of the medical care provided to the “patients.” I’ll give you a hint … it isn’t the “patients.” Makes this Tennessee law look better and better, doesn’t it?

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