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Tag Archives: Medicare

Too Many CT Scans … or Not Enough?

Scary findings. Patients using Coumadin who have any head injury need repeat CT scans. The study looked at 116 patients who were taking Coumadin and who had any head injury with a GCS of 14 or 15 – regardless of loss of consciousness (patients with lower GCS were presumably at higher risk of intracranial bleeding). CT scans were performed on all patients. Of those initial 116, nineteen patients (16%) had bleeding on their initial exam. Of the remaining 97 patients with normal initial CT scans, ten refused to be in the study. Repeat CT scans were performed on the remaining 87 patients 24 hours after the first normal CT scan and showed 5 cases of new hemorrhage. Three of those patients required hospitalization and one delayed bleeding patient required brain surgery. Even after a normal CT scan 24 hours later … two additional patients still developed symptomatic subdural hematomas — one patient 2 days later, one patient 8 days later. Both of those patients had INRs greater than 3.0. The study recommends admitting patients overnight and repeating CT scans in 24 hours. Original study here (.pdf). While admission and repeat CT scan for minor head trauma hasn’t become the standard of care in the United States, this study raises questions about the optimal care of minor head injuries in patients taking blood thinners. Also at issue is the Medicare policy not to pay for “normal” CT scans of the head in atraumatic headaches. Will this policy spill over to deny elderly nursing home patients from receiving CT scans when they can’t remember whether they have hit their heads?

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Certificates of Medical Necessity

  Not too long ago I got a letter labeled “URGENT” in my mailbox at work. The letter was from Walgreens regarding a patient I had seen several weeks earlier. I cut and pasted parts of the letter to make it fit on one page above. As the prescribing physician, in order for our government to pay for the prescription I wrote for the patient … several weeks ago … I had to sign a statement stating the following: “I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for this patient’s well being. In my opinion, the supplies are both reasonable and necessary to the accepted standards of medical practice in the treatment of this patient’s condition and are not prescribed as convenience supplies. By signing this form, I am confirming that the above information is accurate.” Seriously? To get reimbursement for a medication on the $4 list, the government is forcing health care providers to take the following steps: A pharmacist has to receive the denial from Medicare, look at the medication, enter all the information into the CMN and generate a letter to me. The pharmacy must then spend 44 cents to mail the letter to me Once I receive the letter, I don’t remember the patient, so I am then forced to waste time looking up the patient’s chart, reading through it so I could find the diagnosis and make sure that the flipping $4 albuterol prescription wasn’t for the patient’s “convenience.” The pharmacy then spends another 44 cents for the self addressed postage paid envelope. Once the pharmacist receives the certificate saying that the patient really does need his albuterol solution, he then has to spend more time going back on the computer, matching the signed statement with the visit and then forwarding the claim onto the government for medication that has already been dispensed. Then the pharmacy waits months and hopes that it gets back $3 in reimbursement for a $4 medication. In essence, health care providers waste 50 times as much value in time getting paid for something after the fact than the item is worth. And the government knows it. It is just hoping that one of the providers won’t do all the paperwork so that someone else gets stuck paying for the medication – other than the government. No paperwork, no payment. Is this what medicine has come to? Harassing providers so much with pre-authorizations and post-authorizations because they don’t have enough to do? What other ways can we concoct to steal services and supplies from medical providers? Then I thought that since the government uses these authorizations so much, that they must be a good idea. Before I send in my next tax payment, I’m thinking about sending in a similar authorization to the IRS. “I, the undersigned, certify that the above tax payments are necessary for this country’s well being. In my opinion, the government purchases made with this money are reasonable and necessary to the accepted standards of accounting practices and are not spent on wasteful or potentially wasteful projects or items. By signing this form, I am confirming that the above information is accurate.” Any accountants out there? Would this work?

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Why Bundling Payments Won't Reduce Costs – Part 2

If you haven’t read Part 1 of this post, please do so. In that part, I try to explain the main drivers of cost in our health care system. Now that everyone has a basic grasp of the drivers of cost in our health care system, I want to try to show how the proposed changes to the system will have little effect on lowering cost in the system. Through the Affordable Care Act, government is now moving towards “bundled payments” as a means to reduce health care costs. In the current system, providers receive separate reimbursements for each of the multiple services a person may receive during a specific illness or injury. For example, a patient with chest pain may have an EKG. The hospital gets paid for doing the EKG. The cardiologist gets paid for interpreting the EKG. The emergency physician gets paid for acting on the results of the EKG. If the patient is later admitted, the hospital gets paid for the use of the hospital bed and gets paid separately for the medications the patient receives or for the machines that the patient uses. Doctors get paid separately for visiting the patient in the hospital. Bundling would add up all the payments for a given medical event and lump them into one. Instead of the government making separate payments to the hospitals, physicians, and other providers, the government pays the hospital one fee for everything and lets the hospital divide payments. Bundled payments are touted as a means to improve quality and reduce mistakes. CMS considers Bundled Payments for Care Improvement. Ezekiel Emanuel in the New York Times “Opinionator” blog says that, as a means to “save real money and improve care,” we should embrace bundling and eliminate fee-for-service. A New York Times editorial also noted how “most [unnamed] experts agree” that the solution to spiraling fee-for-service costs is to pay providers “fixed sums” to manage a patient’s care and then decide which services are truly necessary. Mayo Clinic President Denis Cortese was quoted as saying that bundled payment plans prompt hospitals to deliver the best possible care: “Once you have a bundled payment, the delivery system can really do anything they want because the money’s on the table,” Cortese said. “But the incentive is to get it right the first time. If there’s a failure, you have to redo it on your nickel.” A 2009 USA Today article noted that not only is the government advocating bundling of services, but it is also paying patients to go to hospitals that accept bundled payments. One 79 year old patient on a fixed income said that the government bribe, er, um “incentive payment” helped to “seal the deal” for her because the $271 check she received from the government for going to the hospital would come in handy for “helping get my car fixed.” I think that it is good that the federal government acknowledges it is appropriate to provide “incentive payments” to encourage patients to go to certain hospitals. Wait. Isn’t that illegal? Oh well. You call it a bribe, they call it a tax refund. Have to look at that in another post some day. Before getting into medical payment models, I want people to think about how bundling would affect us in the real world if we implemented it outside of health care. Imagine that you were going to receive a bundled payment of $100 for ten pieces of winter clothing. What would you do? I know that I would go to my closet and find the 10 cheapest pieces of clothing there. Some of ...

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Why Bundling Payments Won't Reduce Costs – Part 1

Probably one of the largest pending changes in health care is payment reform. Right now, payment for medical services is essentially a fee for service model. Patients (or their insurers) are generally charged for the services utilized. If a patient goes to hospital for chest pain, and a physician evaluates the patient, either the patient or the patient’s insurer pays the physician for those services. If the physician orders an EKG and lab tests, either the patient or the patient’s insurer pays the hospital for the EKG and lab tests. If the patient is admitted to the hospital, the hospital gets paid a given fee for the admission. It goes on and on. The feds want to reduce costs by changing the payment model for medical care to a “bundled” approach. I don’t think it’s going to work. Bundling won’t change the behaviors necessary to save money. This will be a two part post on why. This part will discuss incentives and how they drive utilization of health care. Next part will apply those concepts to bundled health care. Why is our current system going bankrupt? It is all about incentives. There are three main concepts driving health care costs: profit, demand for services, and fear. Before we can see the effects of a policy change on health care costs, we need to understand how these concepts drive the actions of the major players in the health care market. For Providers, the incentive is currently to provide more services. Demand for services is created by illness. When ill, patients often demand as many medical services as the providers are willing to provide. Patients may seek alternative providers if their demands are not met. There is little incentive to provide less care with increased demand. Profit is created by providing services. In a fee for service environment, the more services that are provided, the more that the providers are paid. If patients want the testing or services, more often than not, they get the testing or services. Unhappy patients tend not to come back. No patients = no income. The most pervasive fear for providers is fear of liability – either legal or professional. This fear is often mitigated by providing more services. Increased testing decreases the fear of liability because if there is a bad patient outcome, the provider can point to all the testing and argue that they should not be liable because “we did everything we could.” It is uncommon for a provider to suffer adverse consequences for performing too much testing. Fear of liability may lead to extremely expensive and questionably beneficial medical care. Hospitals also fear regulatory sanctions. It is comical to watch hospital administrators scurry about when there is a JCAHO survey. Poor performance on a JCAHO survey threatens a hospital’s Medicare reimbursement. For Insurers, there is an incentive to increase customers who pay into the system, but who do not take money out of the system. Demand for services is still created by illness, but as demand for services goes up, insurer profits go down (or, in the case of government insurance, debts increase). Insurers profit by having healthy and wealthy subscribers. Healthy subscribers pay into the system, but don’t take as much out of the system. Insurers can increase profits by raising insurance premiums, but must be careful when setting prices. If premiums are raised too high, healthy insurers may drop their coverage because they perceive too much of a disconnect between the premiums that they are  paying and the services that they are utilizing. In that case, the profits from increased premiums ...

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More Florida Medical Follies

Yet another reason to stay away from Florida if you are a physician. The inspectors and health care agencies down there leave quite a bit to be desired. The Florida Agency for Healthcare Administration cited an emergency department’s staff for failing to give “adequate care” to 13 week pregnant patient before she had miscarriage of twins. The timeline of events for the patient was outlined in this article. At 9:45 a.m. the patient came to the emergency department with pelvic pain and vaginal bleeding. At 10:30 a.m., the patient was diagnosed with pain and bleeding, a urinalysis and a battery of blood tests ordered, but there was no test ordered that would have revealed her glucose level. There was also no discussion of whether to discontinue or maintain the patient’s insulin pump. Ultrasound tests were ordered, then changed, which “caused a delay.” At 11:45 a.m., the patient was bleeding heavily and was “in obvious labor” according to state inspectors. The ultrasound scan showed both fetuses had normal heart rates. The state inspectors stated that the emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.” At 12:25 p.m., the physician performed a pelvic exam and suctioned some large blood clots from the vaginal canal. The patient then “spontaneously aborted one of the fetuses.” Inspectors noted that the patient was not informed of any risks of performing a pelvic exam, nor did she give informed consent for the pelvic exam. A second ultrasound was ordered. By 2 p.m., the second ultrasound showed a normal heartbeat in the remaining fetus. At that point “the doctor took no steps to stop labor or maintain the second pregnancy.” Additionally, the emergency physician’s report showed that the second fetus had no heartbeat, which conflicted with the radiologist’s report. At 4 p.m., the patient’s blood-sugar level was measured and found to be “critically low.” She then received orange juice and IV dextrose. At 5:30 p.m., an obstetrician arrived and performed a pelvic exam. He ordered no additional procedures or medications. At 6:15 p.m., the woman passed the second fetus. The inspectors stated that the physician failed to monitor blood sugar levels, failed to respond to the patient’s bleeding and pain, and failed to intervene to stop her labor. In eight of ten other cases that inspectors reviewed, the hospital was cited for failing to document the amount of the patient’s blood loss, failing to record vital signs, and failing to record other case information. We need more information about the other cases, but even without extra information, I’m still calling out the inspector and the Florida Agency for Healthcare Administration. Many of these citations are uninformed and inappropriate. #1 No discussion documented about whether to continue or discontinue the patient’s insulin pump. Such discussions are rarely held in the emergency department. Should the patient’s blood glucose have been checked sooner? Probably. However, if a patient is not having symptoms suggestive of low blood glucose, how often should the glucose level be checked — especially with an unrelated complaint? Should hospitals be cited when glucose levels aren’t checked in a diabetic patient with an ankle sprain or laceration? #2 The emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.” How much bleeding was there? What were the patient’s vital signs? Notice how the report is vague about the findings? Also notice how the report doesn’t state what the emergency physician should have done, and only made vague accusations about what the emergency physician didn’t ...

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Is Protecting Yourself a Joint Commission Violation?

There are a lot of bonehead stories about the Joint Commission in the news lately. I just had to post this one. CMS and JCAHO are now investigating Lehigh Valley Hospital in Pennsylvania for using stun guns on unruly patients. In one instance, a patient was using an IV pole as a pugil stick before security guards used a TASER to put him to the ground. In two other instances, patients were beating on security guards when they were “tazed.” Protecting yourself is apparently a “violation of state and federal health rules.” As a result of the stun gun incidents, the hospital was ordered to retrain certain staffers in responding to behavioral emergencies. Security and emergency department staff had to be trained in comprehensive crisis management. The hospitals also had to establish a task force to track “incidents” and ensure that staffers had used the “least restrictive measures” when restraining a patient. When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area. Wouldn’t it be … interesting … to watch an “unruly patient” attack a CMS investigator and then watch hospital staff utilize mandatory CMS protocols to intervene? Sir. SIR! How about you stop disarticulating that man’s elbow. Really now. Would you like some juice instead? We have apple, grape, and cranberry. Maybe some nice Saltines and peanut butter? No? Hey! Now if you don’t stop poking your fingers in that man’s eyes, we’re going to have to bring you to a secluded area. I’m not kidding, Mister. And you, Mr. Investigator – stop trying to fend off his attack with your clipboard. Don’t you know the patient could injure his knuckles if he hits that clipboard instead of your face? OK, Mister. I see the Investigator’s blood dripping all over the place. Someone might slip and get hurt. You are officially creating a patient safety hazard. NOW you’re getting CITED! SECURITY! That should calm those unruly patients.

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