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Tag Archives: News Commentary

Growth of Emergency Medicine Contractor Groups

Interesting statistics from a September 2012 Modern Healthcare magazine survey regarding the number of contracts held by major emergency medicine contract management groups and the rate of growth in their contracts from 2010 to 2011. Firm / Percent Change in contracts 2010 to 2011 / Contracts in 2011 EmCare / +8.9% / 428 TeamHealth / +11.4% / 322 Schumacher Group / +11.0% / 181 ECI Healthcare Partners / +10.5% / 105 CEP America / +11.1% / 80 Emergency Medicine Physicians / +1.6% / 62 ApolloMD / +23.4% / 58 Premier Medical Associates / -5.1% / 37 Emergency Medical Associates / +33.3% / 28 Emergency Service Partners / +4.5% / 23 Hat tip to Applied Knowledge, LLC

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Fair Payment?

This story is making the rounds on the internet recently. A plastic surgeon is being sued by California State because she charges patients fees in excess of what insurance pays for her services. California’s lawsuit alleges that the doctor poses a “substantial, irreparable, and unjustified threat to the financial livelihood” of her patients. In addition, the California Medical Board is attempting to revoke her medical license because she is allegedly engaging in “unprofessional conduct” by requiring patients visiting emergency rooms to sign agreements to pay her costs if their insurance companies didn’t. I’m not going to try to justify the fees that the doctor charges. More than $12,000 to repair a fingertip is a lot of money. However, with one caveat, I think that the actions taken by the state and the medical board are way out of line. Suing a doctor and trying to revoke her license because she wants to get paid the asking price for her services? If people don’t want to pay her price, then don’t use her. Go see another “professional.” You go to work at a new job where you agreed that you would be paid $50/hour. You work 40 hours, and expect to get a check for $2,000 at the end of the week. As you leave work Friday, your boss gives you a check for $200. “Sorry,” he says, “if you don’t like it, you’ll have to go take it up with the company CEO. That’s all I’m paying you for your work.” The company CEO tells you “we pay other workers $5/hour, therefore we can pay you that much, also.” You try to sue to get your money, but a court says it is against the law for you to demand to be fully reimbursed for your work because the corporation that reimburses your boss pays $5/hour, therefore it is legally entitled to pay you that same amount. Since you’ve already completed the work, you try to sue the company for your back wages. Then the state files a lawsuit against you because you filed a lawsuit against your employer. Or imagine going into a lawyer’s office, agreeing to pay the lawyer his fee, receiving the services, then sending the lawyer a check for 10% of the total fee as payment in full. You’d be back in court so fast it would make your head swim. That is the position this doctor is being put in. She performed the work at the patients’ request, the patients signed a form stating that they would pay her full price for her services, then, when she tried to collect the money from the patient after performing her services, the state stepped in and said that the doctor must agree to the amount a third party wanted to pay her. The caveat in this whole mess is that the patients should know what they could end up paying the plastic surgeon before she renders her services. If that occurs, the patients get to decide whether or not the costs are worth the perceived benefits. If the patients agree to such costs, then they should be held responsible for paying the agreed-upon price. The patients refused to have the emergency physician repair their wounds and demanded that they be treated by a “professional”. Now they’re accepting the “professional’s” services without planning on paying her the price that she asked? Wonder why there are so many specialists who aren’t providing care to emergency department patients? I also wonder whether specialists would be considered “unprofessional” if they required retainer fees before providing services. Would the state take action ...

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GNYHA STOP Sepsis Collaborative Guidelines Revealed

The Greater New York Hospital Association guidelines Jim Dwyer cited in his Rory Staunton articles about physicians who “missed obvious signs” of sepsis were hidden in his article. Fortunately, Alissa D’Amelio who is the Senior Project Manager for Regulatory and Professional Affairs at the GNYHA was kind enough to forward me a copy of the guidelines. The disclaimer at the bottom of the guidelines that was partially hidden in Mr. Dwyer’s article stated in full: GNYHA and UHF hereby disclaim all warranties, express or implied, as to the accuracy of any of the information contained herein, or its fitness for any particular use or purpose. These materials are intended to provide you with information and resources that may assist your organization and should not be used as a substitute for clinical or medical judgment. In addition, Ms. D’Amelio also specifically stated in her e-mail Also, please note that the STOP Sepsis Collaborative is a quality improvement initiative that focuses on the adult population, which is the target population for this template tool. Jim Dwyer did not return e-mails for comment on these issues. And he still hasn’t given me the names of the editors who approved his story for publication, either.

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Jim Dwyer New York Times Pediatric Fever Article Debate

This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times. I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post. If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading. UPDATE See additional commentary about Mr. Dwyer’s articles here and here. ———————————————————- Dear Mr. Dwyer, When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well. So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms. JIM DWYER COMMENT: 1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage. Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children. 1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90. 2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20. So now in children who have entirely normal vital signs for their age, right away you have ...

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Jim Dwyer New York Times Article – Irresponsible Journalism?

By an Anonymous Emergency Physician The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed. In addition to the points the author raises below, I would add these additional points of information: 1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made. I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article. -WC UPDATE JULY 22, 2012 Also see an important update to this debate at this link. —————————————— The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock.  Those are just about the only facts that are not in dispute.  The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up.  However, as is frequently the case, the truth is much more complicated than the media would have you believe.  There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism. This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better.  This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better.  I say “possibly” because I did not examine the patient and all of my information is through the New York Times article.  If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading.  If you want a fair and evidence-based discussion of the article then read on. The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis.  The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines.  There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis.  Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis.  The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context.  Most physicians see pediatric patients every day who meet the “Stop ...

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Mail Order Prescriptions Just Went From Bad to Worse

As if drug shortages aren’t enough. Remember the post about Medco patients “accidentally” running out of their prescriptions because Medco “didn’t receive” faxes, because Medco was trying to pitch your doctor to prescribe other medications, and because of “delays” from the mail? Well you don’t have to worry about Medco anymore. The Federal Trade Commission just approved a buyout of Medco by Express Scripts. Now there are just two mail order houses – Express Script/Medco and CVS/Caremark. Think your mail order prescription problems were bad before? You ain’t seen nah-thing yet.    

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