Tag: ER

Roulette

Nov 1, 2018

By Rob Lamberts, MD

“I want you to get me a new doctor,” she told me, a bit of disgust coming out in the sharp tone in her voice.

“What happened?” I asked.

“He asked me if I was nauseated, and I told him no, I was just vomiting. Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting. He then told his nurse to write down nausea and abdominal pain. When I objected, he just gave me a bad expression and walked out of the room.”

I tried to come up with a plausible explanation for his action, but there was none. ”I’m sorry,” I said. ”There are a lot of people who come back from him feeling really happy and listened-to. It’s obvious that you saw none of that from him.”

“I asked his nurses if he aways acted this way,” she continued, “and they just shrugged and told me that he sometimes did.”

“I’m happy to send you to a different doctor,” I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

I am not qualified to offer the treatment or procedures the specialist can give.
The specialist has far more experience with the problem, and so can offer better care.

HCA: The Bashful Giant

Sep 24, 2014• 14

JEFF GOLDSMITH

Judging by its nearly invisible public presence, you’d never know that this is prime time for HCA, the nation’s largest hospital chain. A former HCA regional VP, Marilyn Tavenner, runs the nation’s Medicare and Medicaid programs. Former CMS Head and Obama White House health policy chief Nancy Ann DeParle, sits on the HCA Board. Its longtime investor relations chief, Vic Campbell, is immediate past Chair of the highly effective trade group, the Federation of American Hospitals. And its Chief Medical Officer, Jonathan Perlin, MD, is Chair Elect of the American Hospital Association.

This astonishing industry leadership presence is something most health systems would be trumpeting, perhaps even placing ads in Modern Healthcare. But not HCA, the bashful giant of American healthcare. Most hospital systems make a show of “branding” their hospitals with the company logo. Yet in its corporate home, Nashville, and the surrounding multi-state region, HCA’s 15 hospital network is called TriStar. Everyone in Nashville’s tight knit healthcare community knows who owns their hospitals, but you have to read TriStar’s home page closely to find the elliptical acknowledgement of HCA’s ownership.

Despite a nationwide merger and acquisition boom, HCA hasn’t done a major deal in twelve years (Health Midwest in Kansas City joined HCA in 2002). The company has not participated in the post-reform feeding frenzy, continuing a long-standing and admirable tradition of refusing to overpay for assets. For the moment, owning 160 hospitals is plenty.

Stop the War on the Emergency Room!!! (Fix the System Failure)

Apr 21, 2014• 13

By Nick Dawson

There’s a war being waged on one of America’s most revered institutions, the Emergency Room. The ER, or Emergency Department (ED for the sake of this post) has been the subject of at least a dozen primetime TV shows.

What’s not to love about a place where both Doogie Houser and George Clooney worked?

Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.

Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is ok, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.

But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have.

It’s just a stomach bug, you shouldn’t be here for this… Or, it’s not my job to fill your prescriptions…

Some history

The Emergency Department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat —wait for it —minor accidents.

Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M Levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.

When is a Health Care Facility not a Health Care Facility?

Feb 14, 2013• 5

By David Dosa, MD

There are 900,000 people in the United States who reside in assisted living settings, at an average age of nearly 87. On average, these individuals pay privately between $3,000-$6,000 per month for services that often include room and board, medication delivery and pill box set-up, supervision, and assistance with activities of daily living. Assisted living facilities are an integral part of the health care delivery system for many of our nation’s frailest older adults. Despite the high quality care that is often provided, the assisted living environment can often leave healthcare providers scratching their heads about what they can and cannot order for their patients. My recent experience with such a facility involving a patient with possible influenza illustrates the complex middle ground these facilities occupy.

A phone call from an assisted living facility in town interrupted me from my afternoon schedule. The facility’s nurse introduced herself and began to give me a report about my 85-year-old patient with dementia.

“Mr. Smith has a fever to 102 and is coughing up some ugly looking sputum. I’d like to order some labs and perhaps a chest X-ray. We might also want to consider an antibiotic.”

I asked the nurse a series of questions. Was my patient’s blood pressure unstable? Was he short of breath? Was he confused or disoriented?”

In each case, she told me, “no.”

“He is sitting quite comfortably watching a talk show on television. His only complaint is the occasional cough.”

I asked a few more questions and was reassured that he was otherwise fine. I told her that her initial request for blood work and a chest X-ray sounded like a good idea. We would wait on the antibiotic until the results came back.

“I’ll call you later today with the results,” she said.

Is It Time To Charge Medicaid Members for ER Usage?

Nov 24, 2012• 62

By Al Lewis

No one would deny that we’ve reached a point in public healthcare finance where tough choices have to be made about what gets covered and what doesn’t. There is, however, one fairly easy choice, and that is to reconfigure the $3 copay for Medicaid members using the emergency room.

I would propose a replacement benefit of $0 for the first visit and $20 for each subsequent one, in a given calendar year. Not every state, but any state that reaches certain thresholds for physician access or urgent care availability may switch to this policy.

Here are the arguments in favor. First, each $3 visit costs the state and federal government about $500. There are few discretionary or semi-discretionary patient decisions that cost so little to trigger so much taxpayer spending. (Hospitalizations have that kind of ratio, but a patient can’t check himself into a hospital the way he can visit an ER.)

Second, one must consider the historical context. The $3 copay (“$3” is a shorthand for $0 to $10 — I don’t think it is over $10 anywhere) is a vestige of the bad old days when it was very difficult to find physicians who accepted Medicaid patients. That is still the case in some locales; they would not be eligible for this waiver. The world has changed, but the copay hasn’t.

Third, ER utilization rates in the TANF population, which because of its average age is generally pretty healthy, far exceed that of the commercially insured population. This is despite the fact that TANF members in general cost much less than commercially insured people, a gap that widens still further once birth events are removed from the calculation. Clearly there is much excess utilization.

Rational Rationing vs. Irrational Rationing

Sep 13, 2012• 27

By David Katz, MD

Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.

What’s the Real Emergency Room?

Aug 24, 2012• 2

By David Allen

My summer job before I left for college in 1965 was the night admitting clerk in the emergency room in the Huntsville, Alabama county hospital – a facility built to support a few thousand in a small rural community but now taxed with serving hundreds of thousands, brought to town by the new Apollo missile program. Saturday nights in the small emergency room were often pure chaos, with auto wreck victims lined up on gurneys in the hallway. Those shifts passed the quickest for me, and I slept the best, afterwards.

Crisis promotes a kind of serenity. Why do people commonly tend get into their “zone” then? It’s because of what the situation demands: appropriate engagement. Think about the last time you were in such a circumstance. What were the fundamental components of your experience and behavior? Immediate integration of potentially meaningful inputs; clear definition of desired outcomes; trust in your intuitive judgment; decisions about specific next actions and physical movement on the most critical; consistent recalibration of all factors as required; acceptance of what can’t and needn’t be done at that moment. Those are all core elements of triage, and, actually, appropriate engagement with anything. Put together they’ll get you into your “zone.”

Why Reform Will Survive Mandate’s Fall

Jun 21, 2012• 1

By Merrill Goozner

The Supreme Court’s imminent decision on the Affordable Care Act will trigger a political firestorm whether they accept the legislation in its entirety, throw out every page of the 906-page bill or do something in between, which is the most likely outcome.

If the high court follows the polls, it probably will rule the requirement that individuals purchase insurance – the mandate – is unconstitutional but leave the rest of “Obamacare” intact. A CBS/New York Times poll released earlier this month showed that 41 percent wanted the entire law overturned, 24 percent supported it fully and 27 percent supported it but wanted the mandate eliminated.

Pooling the latter two groups suggests there is majority support for the coverage expansion, insurance protections and delivery system reforms contained in the bill – as long as there is no mandate. It was only the Obama administration’s decision to include the requirement that individuals purchase health coverage – something done to win insurance industry backing for the law – that gave opponents the cudgel they needed to stoke widespread opposition to reform.

The insurance industry, recognizing many of the reforms are popular, is already preparing for a thumbs-down ruling on the mandate. Three major carriers, UnitedHealth, Aetna and Cigna, said last week they would continue to allow young adults to stay on their parents’ plans until age 26, pay for 100 percent of preventive services and eliminate lifetime caps on coverage, reforms from the ACA that are already in place.

Why Doctors Interrupt

Jun 12, 2012• 10

By Juliet Mavromatis

A few weeks ago I called a neurosurgeon to discuss a patient’s recent headaches. My patient had been seen in the emergency room several days prior with the worst headache of his life. A complete work-up had not revealed a cause for the headache. Although he was found to have a small aneurysm on CT angiogram, there was no evidence of bleeding by lumbar puncture. The story, however, was slightly more complex than this. There had been several other findings that remained unexplained. One of the findings led me to discuss the patient’s case with a cardiologist. My patient had also undergone cervical spine decompression surgery several months prior to treat cervical myelopathy. I wanted to engage the neurosurgeon and get his professional opinion about my patient’s headache, which had now recurred several days after his ER visit.

The surgeon was cordial, but about 5 seconds into my story he seemed inpatient and interrupted me. “I heard about this guy,” he said, “What he needs is to be seen by one of our neurovascular specialists.” I had more I wanted to say, but the doctor did not seem to want to listen. I raised my voice slightly, interrupted him before he had a chance to end the conversation, and bulldozed through, telling the rest of the story in about two minutes. “Now we’re talking,” he said, as I explained further about a family history of clotting and my concern about a dural thrombus as a potential etiology. Together we formulated a plan that I was satisfied with–though the interaction left me with a feeling of unease.

What Is the Cause of Excess Costs in US Health Care? Take Two

Mar 7, 2012• 59

By Mark Hoofnagle, MD

We’ve discussed it before. Why are costs so much higher in US healthcare compared to other countries? The Washington Post has a pointless article which seems to answer with the tautology costs are high because healthcare in America costs more. How much more? Well, we spend nearly twice as much per capita as the next nearest country while failing to provide universal coverage.

In the WaPo article they make a big deal of the costs of individual procedures like MRI being over a thousand in the US compared to $280 in France, but this is a simplistic analysis, and I think it misses the point as most authors do when discussing this issue. The reason things costs more is because in order to subsidize the hidden costs of medical care, providers charge more for imaging and procedures. For instance, Atul Gawande, in his New Yorker piece “The Cost Conundrum” wonders why it is that costs are higher to treat the same conditions in rural areas and in a major academic centers like UCLA than at a highly specialized private hospitals like the Mayo Clinic? I think the reason is it’s not nearly as expensive to administer and provide care for a select group of insured midwesterners at the Mayo than it is to provide care to the underserved in the poor areas of inner-cities and in poor rural locations.