Are emergency departments drowning with insured patients?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

By Ellis Weeker, MD

I just read an interesting story on Kevin.MD.com that discusses the idea that emergency department waits are growing as more people become insured. 

The premise being presented is that due to expanded health care coverage, more people are now going to the doctor. However, because expanded coverage doesn’t mean an expanded number of physicians, patients are finding that they have to wait weeks to see their provider. When this happens, they inevitably find their way into the emergency department.

As an emergency physician, I don’t doubt this scenario. But I don’t agree that emergency department waits necessarily have to grow as more people become insured.

A good example of this is the emergency physician partnership in which I belong. We’ve developed our Rapid Medical Evaluation® (RME) program that enables emergency departments to evaluate and treat patients faster, i.e. see more patients. Over time, RME has been shown to improve an ED’s Time to Provider performance regardless of volume – which decreases overcrowding.

In my experience, it’s also very important for an emergency department to have excellent physician-nurse-PA collaboration that enables all members of the team to respond effectively, quickly, and provide the best patient care possible. Think of it as a NASCAR team servicing a car as it comes into the pit. It’s amazing what communication and a team effort can do to facilitate the highest levels of productivity without burning everyone out.

The fact is no matter how many primary care physicians there are, patients will always desire rapid, unscheduled medical care when they have minor medical problems. That means a certain amount of primary care will continue to be provided in the ED.  This is not necessarily a bad thing – with the right efficiencies and systems in place, an emergency department should be able to handle higher levels of patient loads without breaking.

What are your thoughts on the topic? Are you seeing increased numbers of patients in your ED? Please share your thoughts.

Is your emergency department a radiation hotbed?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

By Joel A. Stettner, MD

As an emergency physician, I’ve certainly had to deal with patients who seem to equate more tests with better medicine. “What’s that you say, you bumped your head last week and you’ve heard that a CT scan is needed to make sure there's no serious injury?”

For patients like these – and you know the one’s I’m talking about – I have no problem drawing the line with a gentle but firm “no” accompanied by an explanation.  Granted, denying unnecessary tests that most patients in the United States are accustomed to requesting is not always the easiest road to take. But it’s the right road. And it’s one more emergency docs need to take.

According to a recent story reported by the Associated Press, the U.S. accounts for half of the world’s most advanced procedures that use radiation, and the average American’s radiation dose has grown six-fold over the last couple of decades. That also means that American patients receive the most radiation in the world.

To which I say let’s help get a grip on this problem.

I understand the reticence to say no, with fears of malpractice lawsuits driving a good portion of unnecessary tests. However, there’s a real danger since it is almost impossible to keep track of the number of CT scans and other exposures to radiation patients accumulate. A patient with, for example, renal colic symptoms could easily accumulate multiple scans over a short period of time, especially if multiple ED visits are required for evaluation and pain control. We now know that up to 2% of cancers are due to radiation from diagnostic tests, so these patients could well be at high risk for malignancy later in life. 

In my view, managing a patient’s testing expectations and warning them about the dangers of potential high levels of radiation due to non-mandatory tests should be emphasized. 

Efforts to do so must go beyond the ED and extend to private physician offices, health-related publications, and the popular press. Of course it would be helpful to reduce litigation fears, and the associated defensive testing, but healthcare tort reform remains an elusive goal, at least for now.

Please let me know how you deal with this problem in your practices.

The U.S. Census report on Diversity: is health care keeping up?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

By Wesley A. Curry, MD

Almost a decade before health care reform is scheduled to be completed, the United States is on the verge of a powerful demographic tectonic shift. One that’s impossible to stop.

We’re becoming a nation of minorities.

While the focus of discussion today in health care reform has been on the complexity, cost, and manpower issues of health care reform, it’s clear the diversity of the population in the near future will also be a major factor.

Conor Dougherty has reported on this population trend in a very insightful article. The graph below is based on data from the Census Bureau which shows the top ten states where the population has reached or soon will reach the status of a “majority of minorities”.

What does this mean to future emergency health care manpower issues? Will the health care providers in the next 20 years reflect the diversity in a population of majority minorities which is likely to be a reality as early as 2011? Will health care reform mandate that new job creation be distributed to all “minorities” in this new majority, i.e. a requirement for a more diverse health care workforce?  Does any of it matter?

Increasing racial and ethnic diversity among health care professionals is important because evidence indicates that diversity is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better educational experiences for health professions students, among many other benefits. 

Many groups have worked to increase the preparation and motivation of underrepresented minority students to enter health care careers. But there’s more work to be done.

As part of a recent panel discussion sponsored by San Francisco’s Commonwealth Club, it was agreed that the state of California’s health care workforce has failed to keep up with its increasingly diversified population. According to the speakers, diversity in California health care professionals has remained flat for years. In fact, about half of the students entering California medical schools are from upper-income backgrounds, with less than 6% coming from families in the nation’s lowest income group.

Diversity is an issue that virtually all businesses must grapple with, and health care is no exception. In fact, I would propose that diversity in health care needs to be embraced as a major focus.  A more diverse health care workforce will enable better communication and care for underserved groups. It will help our “minority majorities” (including women) climb the ladder to attain management positions. And it could very well lead to new ideas and business/clinical practices that come with fresh thinking.

So as we see health care reform evolve over the next several years, I look forward to the issue of diversity in medicine becoming a larger and more important discussion. It’s an issue whose time has certainly come.

What are your thoughts on diversity in health care? Please share your views.

What does Specialty Certification mean to PA’s?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

By Natalie Schmitz, PA-C

In emergency medicine, any decision that has the potential to impact a large group of people, can elucidate many pros and cons.  Such is the case with specialty certification – which is a very contentious issue right now. 

On the one hand, it seems like a good idea.  After working in emergency medicine for some time, obtaining a certification to attest to one’s level of experience seems like a natural progression.  Furthermore, with the estimated emergency physician shortage, PAs will be called upon more than ever to fill the gap in the ER.  It seems logical that there should be some standardization of what it means to be an Emergency Medicine PA!

On the other hand, although not the intention, specialty certification may hinder the very flexibility that has made the PA profession so versatile and allowed PAs to fill a much needed niche in extending healthcare to a growing population.  After attending several SEMPA conferences it’s truly apparent that PAs are utilized very differently in various practice settings.  Some PAs practice only in fast-track settings, while in remote access emergency rooms, a PA may be the only on-site practioner.  This wide range of utilization makes standardization very challenging.

Also to be considered, are there unforeseen consequences of such specialty certification from outside organizations? For example, will certification or lack thereof affect reimbursements from insurance companies?  How will hospital credentialing committees deal with PAs who do or do not have certification in their particular specialty?  If specialty certification is offered, will your hospital or employer require certification and will it affect pay rates?

Regardless of opinion, it’s important to be involved in the decision making process.  For example, when NCCPA approached SEMPA and our ACEP liaisons for input, a focus group put together a proposal of requirements for such a certification.  During the recent AAPA House of Delegates (HOD) meeting, policy was almost unanimously approved to recommend that PAs not take specialty certification exams, but instead have a committee appointed to look at alternatives to specialty recognition. 

As the discussion continues to evolve, it’s necessary to voice your opinions. I urge you to contact your representatives from NCCPA, SEMPA, and/or AAPA and let your voice be heard! 

I look forward to your comments.

Note: The opinions of Ms.Schmitz are designed to encourage discussion and do not necessarily reflect the viewpoint of SEMPA.

Accountable Care Organizations: good for emergency medicine?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

Those of us in emergency medicine have been hearing a lot about Accountable Care Organizations (ACOs). The accountable care organization model has taken on far greater significance since being unveiled as one of Medicare's pilot programs in the Senate's health reform bill.

In an ACO, groups of providers share a financial incentive to control costs and improve quality by closely coordinating care. By being reimbursed a fixed fee for the entire care of such select medical issues as a heart attack or a car accident, providers have financial incentives to keep costs down and quality up. 

For example, ACOs would not receive additional payments if a person is readmitted for that same medical episode within 30 days. Theoretically, this encourages providers to eliminate medical errors. 

Some people say ACOs are nothing more than HMOs in disguise. But when you dig a little deeper, there are differences:

• The "accountability" rests with the providers. Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care.
• Physicians can contract directly with provider organizations without the reliance on a health plan intermediary.
• The ACOs allow for flexibility in the type of organization. Some regions may prefer independent practice associations (IPAs) while othersmay prefer a physician-hospital organization (PHO).

So what does this mean to an emergency physician or emergency department? In my view   there is risk and opportunity. Single specialty groups such as emergency physicians could find themselves contracting with ACOs instead of hospitals or insurance companies in the future. If they do, they must make sure they are at the negotiating table whenever possible.

If the local IPA moves in this direction, emergency physicians should seek to become part of the governance structure in order to have a voice. If not, we will have as little control as we currently have by contracting with the insurers. If we do, we might actually increase our influence!

Whether the ACO model is the panacea for runaway heath care costs remains uncertain. What is certain is that our current fragmented system incentivizes providers to offer neither cost-effective nor coordinated care. The status quo has got to go.

What are your thoughts on accountable care organizations? Please send me your comments.

The never ending road to reforming healthcare reform.

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

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 11^th 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.

Talking to ourselves: does Peer Review in Medicine really work?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

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.

Hospital sees drop in emergency department patients after crack down on pain meds.

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

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. 

Are the answers to true health care reform all around us?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

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?

 

 

As emergency physicians age, how to we prepare?

 Twitter |  Facebook |  digg it |   StumbleUpon |   LinkedIn | 

As a now-seasoned emergency physician, I started my emergency medicine practice in 1974, moving directly from a rotating internship and internal medicine residency to a community hospital emergency department.

The transition was easy, since I had done ER moonlighting during my residency (back in the day, I guess), and I really enjoyed the practice. As you might imagine, I have accumulated a few years since then, and I continue to see patients - although with reduced clinical hours. Not surprisingly, I have noticed that many practicing ED and community physicians' colleagues are also aging. In fact, in some specialties, including emergency medicine, there seems to be a developing shortage of younger doctors who will be there to take over what promises to be a growing workload.

When I first started, emergency medicine seemed to be a young person's game. Especially given the stress and shift work requirements that came with the job. Over time, emergency physicians  found ways to continue practicing with the help of mid-levels and creative schedules. But as more and more physicians make the decision to retire, who will be there to step in and do the work?

Several developments are especially worrisome in this regard. Population growth in the United States continues its upward trend and health care reform legislation will add millions of newly insured patients who will be seeking care. A widely recognized lack of primary care physicians, coupled with a shortage of boarded-certified ED physicians - as well as retirement for many in these and other specialties over the next few years -  portend a growing demand for services in the face of a declining ability to deliver. And new organizations, including ACOs, Medical Homes, and Foundations, will need to meet their health care service needs.

We can hope that technology (telemedicine, EHRs, Internet applications, etc.) will help, and that mid-levels can take on greater responsibility. But I think we need to take a careful look at how we train young physicians, and the environment in which they are expected to practice. Then perhaps we can develop a more comprehensive approach to what will happen as our physician population continues to age in emergency medicine and other specialties.

I look forward to hearing your thoughts on the topic!