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Tag Archives: Medicare

University of Chicago's EMTALA violation

There’s suddenly a lot of conjecture flying about a patient who died in the University of Chicago’s emergency department a couple of months ago. Everyone that reads this blog had a heads up on the event way back on February 8. According to news reports, a 78-year-old man was brought to the emergency room by ambulance about 12:30 PM. He was put into a wheelchair in the waiting room, but was neither triaged nor logged in. At 4:15 PM, the patient’s daughter wheeled the patient to the triage nurse to ask about the delay. The triage nurse noted that the man wasn’t breathing and called a code, even though rigor mortis had already set in. Unfortunately, rigor mortis is one of those things that usually precludes a successful cardiac resuscitation. We don’t know anything about the man’s health or his complaints. All we know is that he was brought in by ambulance, sat in the waiting room for 4 hours (at least some of the time accompanied by his daughter), and was dead for a while (rigor mortis takes several hours to set in) before anyone noticed it. Be careful drawing conclusions without knowing all the information. The University of Chicago admitted that procedure wasn’t followed. In other words, given the recent adverse publicity at the University of Chicago, a couple of nurses had to take the fall for what happened. The University of Chicago posted a statement about the incident emphasizing the U of C’s commitment to quality and safety. Illinois State, the Medical Marijuana Advocates, and federal investigators are all looking into the incident. Some news reports stated that the feds have now cited the University of Chicago Hospital for an EMTALA violation. Then comes the big stick. CMS allegedly sent the University of Chicago a letter threatening to take away the University of Chicago’s Medicare funding. What an idle threat. If I were the CEO at the University of Chicago, and the feds told me they were considering whether to revoke the hospital’s Medicare funding, I’d give them a double dog dare to go right ahead. The Emergency Medical Treatment and Active Labor Act (“EMTALA” for short) only applies to “participating hospitals” – those hospitals that receive federal funding under Title 42 of the US Code. If the feds kick the University of Chicago out of the Medicare program and it no longer receives federal funding, then, just like free-standing emergency departments, the University of Chicago has no further duties under EMTALA. It wouldn’t have to provide a screening exam to patients. It wouldn’t have to provide stabilizing care to patients. If the patient doesn’t have insurance, the University of Chicago could essentially tell patients to “go to the county hospital.” It could even call an ambulance and have the ambulance transport the patient to another hospital. It could transfer patients to other hospitals without the transfer being “appropriate” under the EMTALA rules. EMTALA requires that hospitals accept transfer of patients if the hospital provides specialty services, so the receiving hospitals would be stuck taking any patients that University of Chicago decided to send them. Added bonus: the Joint Commission would no longer have any business in University of Chicago’s affairs. A termination from the Medicare program could be a blessing in disguise. Without being subject to EMTALA, the University of Chicago could technically engage in “patient dumping” and only accept patients with insurance. True, a hospital would lose the income from Medicare (which is the dominant player in the market), but maybe that shift to providing only funded care would make up some of the difference ...

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Tightening The Thumbscrews

Another thought-provoking article was just published in EP Monthly about how Medicare is cutting more payments to physicians. It will be interesting to see the unintended effects of Medicare’s decision. Medicine is unique in that you can’t just leave one job on Friday and start another job at another hospital on Monday. Before you can get privileges to work in a hospital, you have to fill out a staff application, have all your references checked, go through committees, have the committees sign off on your application. Then you get your privileges. You also have to apply for all the new billing numbers, get insurance companies to change to your new location, yada yada yada. All of this takes time. Sometimes a lot of time. In emergency medicine, you used to be able to begin working at a new hospital a soon as you got your staff privileges – even if your billing paperwork had not been approved. You’d see patients, then hold your charges until you get your insurance approvals, then bill the insurance companies for all of the work you performed. Medicare is now changing the rules. According to the new Medicare Retroactive Billing Policy, Medicare will no longer pay for retroactive charges. This policy doesn’t even make sense. Provider payments are held up until Medicare gets around to approving the providers’ applications. Think this policy is going to make Medicare work faster at processing applications?

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Emergency Care – Where's The Line?

The University of Chicago case is getting a lot of press and is polarizing the people on either side of the argument about Dontae Adams’ care. Read about it at one of my previous posts, at ShadowFax’s place, over at Kevin’s blog, or at Scalpel’s blog. The Chicago Tribune is getting a lot of play out of the controversy. It has published several articles already and just put up another one last night. Just by the sheer number of people writing about the topic, you should be able to tell that the outcome of this topic is going to help define how medical care will be provided in the future. On one side of this issue is Dontae Adams and his mother. Dontae happened to be in the wrong place at the wrong time. He was bitten in the mouth by a pit bull and had a large cut on his lip. It is obvious that he needed medical care. Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program. Stop here for a minute. If you read through the comment boards at the Chicago Tribune web site, they are rife with people who criticize indigent/uninsured patients who may or may not be citizens of this country for “clogging up the emergency department” by going there for “routine” care. It’s easy to look down on someone is viewed as “abusing the system.” So let me ask you this: Suppose you lost your job tomorrow and had no insurance. Suppose you had to take a minimum wage job at WalMart to keep food on the table for your kids and you weren’t eligible for health insurance. What would you do for medical care? If you called a random doctor’s office and told them you needed an appointment for “routine” care and could only pay a small amount of cash, what are the chances that you’d get seen that same day? What are the chances that you’d be seen at all? Our family has good insurance, my daughter needs to see a specialist, and the earliest appointment is 4 months away. Let’s say you’re living on a fixed income and want to pay for your doctor’s visits in cash. How can you afford to spend well over a hundred dollars for a single doctor’s office visit? Ah, but there are free clinics all over the place, right? In the rural hospital where I moonlight, the closest free clinic is about 40 miles away and has very strict criteria on who it will treat at no cost. Cook County, IL, where the University of Chicago is located, is in the midst of a budget crunch and has closed down many free clinics. See articles HERE, HERE, and HERE. There’s also an issue of whether or not the care some people seek in the emergency department is “necessary.” Clearly, much of the care that emergency physicians provide is not “emergent.” But I can say that because I have had eight years of medical training plus all the continuing medical education each year. Going to the emergency department to get an excuse for missing work, or trying to get a three day government-paid babysitter for grandma so you can leave on a trip is one thing, but in general, we have to give the benefit of the doubt to the patients. Back to Dontae. According to federal EMTALA laws, patients must receive a medical ...

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Why I'm A Bad Doctor – Part 2

It isn’t just the patients who think I’m a bad doctor. Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous. For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ. I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site. In other words, Medicare thinks I’m a bad doctor. Let me tell you about the patients I screwed up on. The first patient was a gentleman in his 70’s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction. According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (“clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine. Now I’m faced with a choice: A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him. -OR- B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window. If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov‘s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!” If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines. I chose “B.” According to HospitalCompare.hhs.gov, my decision made me a bad doctor. The second patient was an elderly lady who came to the hospital with leg pain and weakness. She was in a lot of pain. We did some testing and she ended up having a blown disc in her back that was pressing on a nerve root. She was admitted and had surgery. Five days after she was admitted, she ended up having a heart attack while she was recuperating on the medical floor. According to the quality indicators at “HospitalCompare”, if a patient has a heart attack and does not have contraindications to receiving aspirin or beta blockers, the patient must receive aspirin and beta blockers within 24 hours of their arrival in the hospital. The brainiacs at Medicare who run this HospitalCompare site expect that I put on my Amazing Kreskin glasses, bust out the crystal ball, and predict with 100% certainty which patients I admit will ...

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Medicaid Modus Operandi – Limit Access, Save Money

Forget the fact that Medicaid payments to physicians amount to less than the cost of a lunch at McDonalds in some states. According to an article published in the Dec 8 edition of AM News, bureaucratic hassles and delays in payments are also causing significant limitations to the number of physicians that are willing to provide care for Medicaid patients. What good is health insurance if you’re prevented from using the benefits? Pennsylvania and New York take an average of almost 4 months to pay a Medicaid claim. Some claims take even longer to be paid in those states. To put this in perspective, imagine starting work at a new job, then waiting an average of 4 months to get your paycheck (if you’re lucky you’ll get paid in 2-3 months, but if you’re unlucky, you might wait 6 months). Is that somewhere you could afford to work? How would you pay for your mortgage, your car payment, or your groceries? By delaying payments for services, states are forcing some physicians to close up shop. Not only do Pennsylvania and New York withhold payments, those states also happen to be two of the states that pay the least for Medicaid services in the US. New York pays $20 for a one hour consultation on a new patient. Hell, my babysitter makes almost that much – and she doesn’t have to purchase a $1 million malpractice insurance policy. Now New York is going to cut Medicaid payments further? (h/t to Kevin for the link) By encouraging hassles and purposefully delaying payments, states are limiting access to medical care. If you can’t get in to see a doctor, then the states don’t have to pay the doctor. Great way for states to minimize budget shortfalls – receive a portion of the 15.4% taken from every working person’s paycheck, pay a pittance for the services … and delay payment for the services, piss off enough medical providers so that very few people provide the services, and then keep most of the money. If I had a business that accepted money for services and then provided half-assed results, I’d be sued and probably charged with a crime. The state Attorney General may even come after me. Sure don’t see the Attorney General stepping in and going after states to make them pay the money they owe to medical providers. Strange how things work sometimes. Picture credit here Full AM News article below for those who don’t have access to the AM News site

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Mandated Employer-Paid Health Insurance

Among many “changes” advocated by President-Elect Obama is a plan for mandated employer-based health insurance. I can’t find a clear description on exactly how the plan is going to work (the plan is outlined on Obama’s site here, and there is a NEJOM summary here), but there are many opinions out there on what the effects of the plan will be. See posts at Hot Air Blog, The Health Care Insurance Reform Blog, The Cato Institute, and John Goodman’s Health Policy Blog I’m all for changing the current system, and I’m committed to giving Obama a chance to turn things around, but is mandating that employers pay for insurance going to improve healthcare in this country? I admit that I haven’t taken an in-depth review into the pros and cons, but in principle, I think it’s a bad idea. Reminds me too much of the “Hats” post I put up last year. If you’re an employer whose bottom line is hit by a tough economy and you’re now forced to spend additional money to either “pay” a percentage of your payroll into a national plan or to “play” by purchasing “health insurance” for your workers, what are you going to do? You’re going to find the cheapest way out. If I were an employer faced with this directive, I’d probably do one or more of several things: 1. I’d have to fire some of my employees to cut the amount of money I was required to spend on insurance. Now think about the repercussions of employers having to decrease the number of employees. Those former employees will have difficulty finding another job because most companies are downsizing because of the poor economy and to avoid paying extra for insurance for their employees. The former employees then end up sucking money out of the system by applying another mandated insurance plan called “unemployment insurance.” Instead of maintaining productive employees who contribute to the economy, mandated insurance will create out of work employees who take out of the economy. 2. I would purchase the cheapest insurance I can find. As in “Yeah, I’ll take that $100,000 deductible plan right there.” Hey – the mandate says you have to purchase insurance, it doesn’t say what kind of insurance you have to purchase. Exclusions for pre-existing conditions? So? Five thousand dollar policy limit? Big deal. Only pays providers three cents on the dollar so no provider will accept patients who have that type of insurance? Who cares? According to the mandate, insurance is insurance … right? 3. I would consider whether or not to cut my remaining employees’ wages to offset the cost of the insurance I am forced to buy. Depends on how far my company is in the black. If I’m having trouble making payroll and the economy is bad, where do you think the money is going to come from? Now consider the real-world impact. Employees who haven’t been fired will effectively receive less income so that employers can pay for the least expensive insurance they can find. In essence, the mandate is forcing the employees to pay for crappy insurance. Who wins? Not the States. They’re going to lose out with all the extra people using programs for the indigent because they are unemployed. Bigger drain on the system and I don’t know too many States that want to throw more money into social programs – most are trying to figure ways to cut back. Not the employers. They’re losing money by being forced to purchase insurance for the employees. Not the employees. The ones who haven’t been let go ...

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