Posted by CEP America on Wed, Jun 30, 2010 @ 09:37 AM
By Marty Ogle, MD
"Those who cannot remember the past are condemned to repeat it", George Santayana said. He wasn't talking about healthcare reform. But he could have been
As an emergency physician, I deal with our still-broken healthcare system every day. Which got me to thinking about the long and winding road that started 17 years ago surrounding "healthcare reform". The road has not only been long, it's been bumpy.
Let's venture back to 1993, when the "architect" to fix the broken American Health Care System was none other than the US Health Care Insurance industry!
Right out of the gate, President Clinton assigned Hillary to drive the overhaul of healthcare in the U.S. Ms. Clinton plowed ahead, soliciting no input from those involved in delivering healthcare as they may biased. Instead, the ideas was to use policymakers (surely they are unbiased) and academic "experts" in health policy (certainly they know how to deliver better care to Americans). Then create a diagram that resembled UFO landing coordinates to explain it to the American People.
I remember thinking that I needn't worry because the plan would collapse under its own weight.
What I didn't see coming was the insurance companies coming up with "managed care" as the final wooden stake, just in case the Plan regained a pulse. "No need for sweeping reform", the Insurance Industry would claim. "We can control costs".
Over the years, managed care established it's "footprint" across much of America - similar to how a tornado establishes a footprint when it takes out a trailer park.
Then came 2009. The players changed, and now "ObamaCare" was here. Sort of. The bipartisan version of ObamaCare didn't work so well and the Dems and their colleagues across the aisle couldn't agree on anything. So the President took things into his own hands, developed ObamaCare and put on a bipartisan summit. Great news, except that the Dems and Republicans still couldn't agree to agree. In fact, the Democrats had trouble agreeing with each other.
But wait - let's try politics! Get the AMA's support by promising an SGR fix. Mollify the Hispanic Caucus by providing Immigration Reform (yeah, that worked). And so it went.
Sadly, it was not to be. And ObamaCare limped to a halt. Except a gaffe by the Insurance Industry gave the plan an 11th hour "elixir of life".
Public indignation caused by Anthem Blue Cross's announcement that they were raising premiums 39% for thousands of policyholders pushed ObamaCare across the finish line, with the assist of some questionable procedural footwork in Congress.
So there you have it; a rather truncated history of U.S. healthcare reform over the last 17 years. Don't you feel better off? Or maybe we should start over. I hear Bill Clinton is looking for work!
I look forward to your comments.
Posted by CEP America on Tue, Jun 22, 2010 @ 08:10 AM
By John Ruffner
If you're a physician, physician assistant, or nurse practitioner, you probably have a definite opinion on peer review. Personally, after 25 years of participating in peer reviews I'm convinced that there is definite practical /clinical value for these programs in medicine. That said, the question is: how can we maximize the benefits of the effort?
It's my viewthat organizations that can learn from within exhibit significantly higher levels of effectiveness. They are better at discovering error or opportunities for improvement - and translating that knowledge into action or changed behavior.
It seems obvious that organizational culture is key to successful efforts at improvement from within - where frank, specific and sometimes pointed discussions are encouraged
The literature is replete with examples of very sophisticated organizations where, notwithstanding a lot of very skilled individuals, the culture actually discourages accurate and open discussion of problems ("Skilled Incompetence", Harvard Business Review). NASA culture has been criticized on this point and the Shuttle accident was blamed on the organization's unwillingness to hear ‘bad news'.
While most medical peer review operations start by looking for ways to improve best practices, a number of factors often erode the effectiveness over time. These include:
- Medicine requires professional training and practice where complete information may not be available (Medicine is still an art)
- Professional behavior is often protective of its own
- Legal consequences are always a risk factor
- By definition, peer review is considered ‘Monday morning quarterbacking'
- Sociology of the Group or Group Think - what's ok to talk about and what's not
- Talking ourselves into the picture we want to see (related to the above item)
- The discussion focuses on how to shift blame self reinforcing thinking (sometimes appropriate)
- The discussion focuses on how to classify the case
- Focus on getting through the agenda
So, with these forces at work, what can be done to maximize the benefits (improve clinical care) of peer review? In my opinion, establishing a culture of openness and inquiry - one that encourages questions and scrutiny - is key. If a peer truly does not feel that the culture allows for honest comment, they will never speak up.
That's why it's imperative for a practice or healthcare organization to establish a mechanism for clearly stating and presenting ‘lessons learned' or the conclusion with differential explanations. This can most often be accomplished by a summary of findings at the end of each review and a clear statement of the conclusions with everyone's attention turned to this activity.
What are your thoughts on peer review? Do you have a system in place where you practice? Please share your thoughts.
Mr Ruffner has served in many roles both in acute care and physician organizations over the past 25 years. He holds a MPH degree from UC Berkeley and has served on the faculties of several universities.
Posted by CEP America on Wed, Jun 16, 2010 @ 07:39 AM
People coming into the emergency department hoping to score illegal pain medications are a widespread concern for emergency physicians.
But as recently reported on Starnews.com, one North Carolina hospital's crackdown on powerful painkillers for emergency department patients has led to something very interesting. A quieter ED.
People Dosher Memorial Hospital has seen "a bit of a decline in the emergency department in the number of patients that we’re seeing,” said hospital spokesperson Kirk Singer. “We believe it’s a pretty direct result of the passage and publicizing of our policy.”
The story goes on to state that the crackdown on painkillers in the ED was adopted in December of last year. Emergency department physicians would no longer use or prescribe Schedule II, III or IV narcotics for patients who come in with ongoing, chronic conditions.
The drugs in question include codeine, oxycondone and morphine among other narcotics. The new rule – while strict – is not Draconian. It's not meant for patients who come into the emergency department after a painful accident or aliment and legitimately require painkillers for their situation.
Instead, Singer said, it was directed to people who visit frequently with complaints of migraines, back and neck pain, dental pain, fibromyalgia or other chronic pain syndromes out of concern they could be faking to get the pain medicines.
In these cases, the emergency department must direct these people to their primary care physicians if they need a new prescription or are given a list of area clinics if they don’t have a primary doctor. They also might get info about resources for substance abuse counseling and treatment.
According to Singer, “There are a number of people out there who have been shopping for pain medication, and it’s a real problem when they start using controlled substances and prescription medications. In talking with the folks in law enforcement, we’re told by them, that it is a real problem not only in our community but statewide and across the country.”
Is Dosher hospital's new rule the secret to "emergency department overcrowding"? Not likely. But it is an interesting approach to a longstanding problem.
Posted by CEP America on Tue, Jun 08, 2010 @ 08:30 AM
By David Birdsall MD
As an emergency physician and hospital Chief of Staff, I can honestly say that not since Medicare has there been such a boisterous and spirited debate regarding health care.
Until recently, when I was asked what we should do to fix health care, I took a thoughtful pause (at least that was the look I was going for) before opining ontort reform. “Just reign in the lawyers. That should take care of everything,” one colleague claimed.
While malpractice suits are a big problem, they’re just one of the symptoms of the
very complex disease that is our national health care system. And just like a complex disease, we need multiple “specialists” to work together to cure it.
We in the U.S. claim to have the best health care in the world, yet only 40% of those polled were satisfied with their health care. Compare that to Denmark’s 91%, Austria’s 73%, and France’s 61% (France is rated the best health care in the world by many.) How do we judge success with that variance?
Yet, if we continue along our same path, Medicare will be bankrupt in six to eight years and we’ll continue to fall farther behind other industrialized nations.
So what should we do and what model should we follow? Should we look at France and Japan who provide health care using private insurance financed by employers and employees, and accomplished through tight regulation of cost and utilization?
Or perhaps the U.K., which finances health care through large income and sales tax revenues.
We could look at Canada which uses a system where the payer and the insurer is the government and the providers are private.
Or what about Third World countries who make health care selfpay.
No matter the direction, I believe we should heed the standards employed by all the top health care systems around the world in the following areas:
1. Insurance companies should be “not for profit” with regard to basic medical care (U.S. insurance companies only pay 80 cents of each premium dollar on health care compared to 90-95 cents elsewhere. Why? Because these companies have to make a profit for shareholders.)
2. Costs and charges need to be contained and standardized. A CT exam at one hospital should cost the same at another. Clearly, this will require changes in our payment structure, which needs to be changed anyway.
3. Utilization needs to be curtailed. For many reasons we order more tests and perform more procedures than most other countries. Japan is the exception, but they have tight cost controls.
4. Quality of care should be high.
5. Preventative and primary care should be stressed (in the U.K., 60% of
all physicians are in primary care vs.35% in the U.S.).
6. Health care should be provided for all (regardless of employment status or pre-existing conditions) with all citizens contributing to that end. This means that everyone, except the
extremely poor, pays into the system in some form or fashion.
Health care reform in its current state is not the complete answer but it has gotten the ball rolling. The one thing that is clear is that physicians need to be intimately involved in whatever reforms or changes are made. We need to stick up for our patients, ourselves and our hospitals. Do you agree?
Posted by CEP America on Wed, May 12, 2010 @ 12:29 PM
Seemingly, there is always something in the news that affects emergency physicians and emergency medicine in general. Here's a summary of some of the stories circulating this week's news venues...
American's health coverage has changed during the Recession. Surprised?
A new study published in the May 2010 issue of the Employee Benefits Research Institute examines some surprising and not-so-surprising changes in health coverage among workers during the recession which began in December 2007. The study's findings include:
- After the 2001 recession, the percentage of the non-elderly population with employment-based coverage continued a downward trend until mid-2005, when it flattened out at or slightly above 60 percent through 2007. The percentage of uninsured also flattened out, remaining at about 12.5 percent through 2007.
- The unemployment rate was as low as 4.4 percent in May 2007. By July 2009 it had reached 9.4 percent.
- The percentage of the non-elderly population where employment-based coverage was 61.3 percent in May 2007 and by July 2009 it was down to 58.2 percent.
- The uninsured rate was 12.3 percent in May 2007, and by July 2009 it was up to 16.4 percent.
New government office created to oversee insurance overhaul. Good news or....
A story posted this week on KevinMD.com sheds light on how a little known government department could have a big role in reforming health insurance. As reported by the government, the Department of Health and Human Services recently announced that it has created an Office of Consumer Information and Insurance Oversight to assist with implementation of the newly passed health insurance reform law.
Among the responsibilities overseen by this Office and its Divisions will include administering new high-risk pools and their funding. Putting in place new rules governing the insurance market and the rules regarding the percentage of revenues that health insurers will be required to spend on medical care. The collection and maintenance of comparative pricing data for the HHS health insurance website. The development of rules governing state-based health insurance exchanges, and overseeing their operations. All sounds good, but as with anything our government does, it remains to be seen what the final verdict will be.
Insurance companies are refusing to pay for early discharges. Or are they?
The April 2010 issue of Annals of Emergency Medicine includes an article that attempts to debunk the theory that insurance companies are refusing payment for patients who leave the emergency department against medical advice. The authors reviewed 104 AMA discharges in a suburban hospital emergency department and queried 19 insurance companies including HMOs, PPOs, Medicare, Medicaid, and worker's compensation. Out of 104 AMA discharges, every visit was fully reimbursed by the insurance companies. Surprised? You're likely not alone.
Are on call ED physicians being compensated?
Being on call at a hospital's emergency department has been the price physicians paid for admitting privileges. But an article appearing in Medscape Today states that in 2009, hospitals compensated 61% of physicians who covered EDs. This is according to a survey by the Medical Group Management Association (MGMA).
Neurosurgeons commanded the top daily on-call rate of $1671. Family physicians who didn't deliver babies were at the bottom, earning $100 per day. Most physicians were paid daily stipends for ED call coverage; others received annual, monthly, or weekend stipends.
These findings appear in the MGMA publication Medical Directorship and On-Call Compensation: 2010 Report Based on 2009 Data. This report reflects the survey responses of 2924 on-call providers in 319 medical groups.
Have a comment? We'd love to hear your viewpoint!
Posted by CEP America on Fri, May 07, 2010 @ 11:45 AM
As a follow up to a story that was posted to this page in April, there is now a short video that further discusses how California's Riverside Community Hospital's "Know Before You Go" text system is generating positive benefits in the emergency department.
To view the video, click here.
As the largest emergency department in Riverside County, averaging over 77,000 emergency patients annually, the hospital recently implemented the system and is reporting increased patient and emergency staff satisfaction levels. The text message program works using a technology that links the computer system in the emergency room with the texting abilities of cell phones.
While the national average wait time exceeds four hours, Riverside Community Hospital's wait times can be as low as just a few minutes. Hospital administrators say the system not only cuts a person's wait time once they arrive at the ER, but also helps the hospital design ways to become more efficient.
Of course, many emergency situations can't be predicted, and in a true medical emergency, patients should call 911 for assistance. But for situations where texting is an option, the system is clearly providing benefits across the board. Take a look at the video and judge for yourself.
Posted by CEP America on Fri, Apr 30, 2010 @ 09:00 AM
By Joel Stettner MD
As emergency physicians, we're often so wrapped up in the daily "doing" of emergency medicine that it can be difficult to step back and recognize the significant clinical and administrative accomplishments of our colleagues.
Luckily ACEP, through its American College of Emergency Physicians Awards Program, does an excellent job of recognizing those ED physicians who have demonstrated the highest levels of leadership and excellence. The Program provides an opportunity to honor members for significant professional contributions as well as outstanding service to the College.
The ACEP Excellence in Health Policy Award is an example of how the program works. Each year, ACEP presents this award to a member who has made a significant contribution to achieving the College's health policy objectives, or who has demonstrated outstanding skills, talent, and commitment as an administrative or political leader.
I am pleased to report that a respected partner and colleague, Miles Riner, MD, was recently named the 2010 recipient of this award. Through his work on state and national regulatory and legislative issues, and as a member of the Board of Directors of the California chapter of ACEP (CAL/ACEP), Dr. Riner has been able to make a significant contribution as a powerful advocate for emergency physicians and the emergency care safety net. Recently retired from clinical work, Dr. Riner is continuing his efforts in support of health care policy advocacy at both state and national levels.
I'm honored to call him my friend and very pleased that his hard work and dedication to emergency medicine have been recognized.
All members of ACEP are eligible for one or more of the College's award programs. Our success as a specialty has always depended on our willingness to get and stay involved beyond clinical work. As busy as we are, it will always be important to take time to recognize the individuals who demonstrate true commitment and excellence in their work.
Have a comment? Please share!
Posted by CEP America on Thu, Apr 29, 2010 @ 08:55 AM
By Marty Ogle MD
What does an emergency physician do on his off hours? In my case, I sometimes like to read – and not just about emergency medicine. Recently an article in the April 2010 Annals of Internal Medicine caught my attention. The article examined the criteria that US News and World Report uses to determine the 50 best American hospitals – which, it seems, is based primarily on “reputation”.
After finishing the piece, I came to the conclusion that there’s apparently little or no objective criteria in the selection process such as mortality rates, size of a specific program, patient satisfaction, CMS Core measures, or the elements of the PQRI program. That, to me, is a real puzzler.
If you've read the U.S. News article, you may very well join me in asking if these are really the “Best” hospitals. Wouldn’t you expect part of the selection criterion to include how well they actually care for their patients?? Isn’t that what hospitals are supposed to do?
The Annals article concludes by stating that “The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals”. To which I say “Amen, brother”.
In an era of increasing scrutiny of outcomes and performance (for both providers and hospitals), I think this would somehow enter into the mix. Not only are objective criteria in the “real world” being looked at by payors, some performance metrics are being linked to reimbursement and I suspect this trend will only accelerate.
I know that US News and World Report needs to sell magazines and advertising space, and is skewed toward a “consumer” vs. medical industry audience. So the thinking among their editorial staff most likely is to portray the article as containing empirical content to increase curiosity and sales. Nothing wrong with that -- but let’s get real. Try labeling the selected facilities as the “50 Most Popular Hospitals in the US” for journalistic accuracy. They would likely still sell a lot of magazines. And at least their article would be accurate.
What are your thoughts on mislabeling hospital quality and performance?
Posted by CEP America on Tue, Apr 20, 2010 @ 11:26 AM
By Prentice Tom, MD
What would life be like in the emergency department if patients had greater access to primary care physicians? A recent article in the Journal of Emergency Medicine, authored by K. Tranquada, et al, addresses that same question - and concludes with something that emergency physicians have known for years: the demand for emergency services is not related to the availability of primary care physicians.
Over the past few years, there have been a number of studies that suggest a significant percentage of ED visits are "unnecessary" i.e. treatment could have been provided in a primary care clinic or office. Emergency physicians have long understood lack of a primary care physician is not necessarily the reason that patients seek "non-emergent" care through the ED, and that significant numbers of patients with non-emergent medical conditions, who have access to a primary care physician prefer to obtain their medical care through the emergency department.
There may be a multitude of reasons why patients preferentially seek care through the ED, and if increasing the number of primary care physicians does not change patient behavior, than as emergency physicians, we need to ensure that the emergency department is able to efficiently provide care with a marginal cost similar to the marginal cost of providing care through a primary care setting.
For episodic care, where diagnostic testing and labor resource expenditure are similar, this may already be true. For conditions where the emergency department has much greater experience, it may be possible to provide even less urgent care at a lower cost than that provided in a primary care setting. For example, an experienced mid-level provider may be able to treat minor trauma requiring laceration repair and evaluation for simple fractures faster and with less use of diagnostic tests than may a primary care physician.
Instead of trying to screen patients out of the emergency department, the solution may be to learn to efficiently treat patients so that necessary medical care can be provided through a number of alternative venues that meet patient needs.
Agree or disagree? Please let me know your thoughts.
Posted by CEP America on Fri, Apr 16, 2010 @ 11:55 AM
By Wesley A. Curry MD
For all of the hand wringing and hyperbole, health care reform is ultimately about ensuring that the appropriate health care services are available in a timely manner to the people who need it.
As an emergency physician, my view on health care reform is that it has already happened in one area of the healthcare system, namely the emergency room. With this new legislation, we now have an opportunity to take some of the burden off the "emergency" part of our health care system, which is long overdue.
The "reform" that I refer to was EMTALA (Emergency Medical Treatment and Active Labor Act), which was enacted in 1986 as part of the Social Security Act, and is included in the section of the U.S. Code which governs Medicare. EMTALA was passed as part of the Comprehensive Omnibus Budget Reconciliation Act (COBRA). It remains the largest unfunded healthcare mandate ever enacted by the federal government.
Generally, EMTALA applies to a "participating hospital", with provisions applying to all patients (including those under managed care). The hospital must have an emergency room (or service) to fall under the provision, but based on a broader interpretation by the courts and regulatory agencies, this law applies to all areas of the hospital - even offsite medical practices or clinics. It requires that all hospitals with emergency rooms evaluate everyone who presents to participating hospitals in order to determine that a serious, disabling, or life-threatening emergency does not exist.
Lest we forget, EMTALA happened because of egregious practices decades ago toward patients who had no medical insurance and were turned away - often suffering from serious conditions - from emergency rooms by hospitals and physicians. While laudable, it has often applied a heavy burden on ERs.
One thing is clear however; we're about to experience a true sea-change that will define the future of health care in this country. During the next decade I believe that something will be built to radically change how people consume health care services and the way money flows within the healthcare portion of the economy. This development is long overdue, because now the question is not "whether" Health Care Reform will happen, but what it will look like a generation from now when the wrinkles have been ironed out.
History teaches us that this historic legislation is the beginning of a new phase in the long and tortuous process to achieve a more effective and equitable health care system for this country. Once implemented, it will provide much improved healthcare services to a significantly larger segment of our population.
Where do you stand on the issue? Please send me your comments.