Even though the number of insured emergency room visits has stayed about the same in recent years, the cost to step inside the door has nearly doubled, according to new data released by a health care policy group.
In 2016, the average amount spent nationally by insurers and patients for emergency room visits was $247 per insured person. In 2009 it was $125, the Health Care Cost Institute research shows.
The reason for the spike appears to be a dramatic shift in how emergency visits are coded by facilities, with many more designated at the highest levels of severity and therefore billed at steeper prices, said John Hargraves, a researcher and co-author of the report.
The Washington, D.C.-based nonprofit group analyzed 40 million health-care claims for those with employer-sponsored plans between 2009 and 2016. The insurers included United HealthCare, Aetna and Humana.
“Since the population of insured people in emergency rooms is not changing, the only logical explanation is a change in how things are being coded,” Hargraves said.
When a patient arrives at an emergency room — either a traditional one attached to a hospital or a free-standing emergency center located in a retail center — the visit is assigned a procedure code ranging from 1 to 5 for purposes of billing. Level 1 is the least serious, Level 5 is the highest. The way such designations are determined can be tricky and in the eye of the beholder depending on patient history, age and complexity of treatment.
Hargraves said his research focused only on the so-called facility fees, meaning the price charged by a hospital or emergency room center for providing the treatment setting. It did not look at the cost of actual treatment.
He found that over the eight-year period, the facility prices rose for all procedure codes but climbed fastest for those designated as the highest severity. The price of the highest coded visit rose to $1,108, from $627 in 2009. This is particularly significant, Hargraves said, because during the same time his group found there were many more claims being designated as 4s and 5s while the use of lower severity codes actually decreased.
According to the group’s data, the number of emergency room visits was statistically the same in both 2009 and 2016.
Texas was among states that had the highest bump in the use of high severity codes, with the use of 4s and 5s rising to 61 percent, up from about 50 percent in 2009.
The cost of emergency room care has become a hot button issue recently. In Texas the state’s largest insurer, Blue Cross and Blue Shield of Texas, wanted to roll out a controversial new program this month to create a vigorous after-the-fact review system to determine if health maintenance organization (HMO), policy holders were using emergency rooms appropriately. If it was determined they could have reasonably received treatment in a less expensive setting the insurer would pay zero.
But late last week Blue Cross and Blue Shield officials announced its launch would be delayed until early August as the Texas Department of Insurance sought more information and assurances that patients would not be harmed by the new policy. Physician groups and some consumer advocates are also worried that the Blue Cross program would have a chilling effect as people become afraid to get the care they need.
Insurance executives have said the measure was designed to not only discourage inappropriate use of emergency rooms for non-emergency care but to also fight back against what it calls overtreatment and overbilling, including the practice of “up-coding” where the highest level of severity code is used for less serious patients.
Elsewhere in the country, Anthem, the insurance giant, has initiated a similar crack-down on emergency room claims in Kentucky, Missouri, Indiana, Ohio, New Hampshire and Connecticut.
The largest health insurer in Texas was set to change a review process on Monday. But it has been delayed until August 6th, after getting backlash from physicians in Texas.
If the new process is launched, Blue Cross Blue Shield of Texas said its 500,000 HMO members may have to pay the entire cost of an out-of-network emergency room bill, if they go for something not serious or life-threatening.
The insurance carrier said the stricter review policy is designed to help make health care costs more affordable. In an April 18 memo, Blue Cross first explained the change by pointing to examples of people who use out-of-network ERs for things like head lice or sprained ankles.
The push-back from Texas physicians
The Texas Medical Association and 18 other Texas medical societies sent a letter to the Texas Department of Insurance (TDI), in protest of the change.
The letter states, in part:
“BCBSTX is asking [patients] to diagnose their symptoms at a critical and emotional moment, when time can be of the essence. As a result, it is very likely that extremely ill patients will not seek emergency medical care while, bluntly, their conditions worsen or they die…. Scaring them into avoiding emergency care seems a heavy-handed approach that could be detrimental to good patient care.”
The entire letter can be found below:
The Texas College of Emergency Physicians also signed the letter.
“Really core to me is that patients cannot self-diagnose,” said Dr. Alison Haddock, board member of the Texas College of Emergency Physicians. “I think it’s wrong to be putting that extra burden on patients in their times of greatest need. No one wants to go to ER. That’s no one’s idea of a great time. But when people look at their situation think, ‘I think I’m having a medical emergency,’ they have the right to come access our care…. But we also need you to have the right for the insurance company pay appropriately for care that you need. And that’s something that people get really nervous about and afraid of, and will potentially delay care and put themselves in great danger.”
Haddock believes the change is a violation of Texas’ prudent layperson law, which was passed in 1997. It protects patients’ rights to seek emergency care without preauthorization for coverage and doesn’t allow insurance companies to base that coverage on a final diagnosis; but rather the initial symptoms.
“Patients come to the ER because they feel that’ they’re having a medical emergency,” said Haddock. “The patient charts don’t tell us the mindset of patient. And that really what the prudent layperson standard is about: in the mind of that patient, were they worried about an emergency, about a danger to their life, or limb, or organ system? That’s what the law is about. Blue Cross Blue Shield said they’ll look at patient charts to figure out if they met the prudent layperson standard or not, but there’s no way to really do that, because this isn’t the patient’s diary. This is their medical chart. So, I think we can pretty safely presume that when patients come to the emergency room, they are coming because of their concern for a medical emergency.”
Blue Cross Blue Shield of Texas responds
“If you have or think you have an emergency condition, go to emergency room. And if that’s the case, it’s going to be covered,” said Dr. Robert Morrow, Southeast Texas Market President for Blue Cross Blue Shield of Texas. He said the new process, in fact, embraces the prudent layperson standard.
“It doesn’t look at diagnosis that somebody leaves the emergency center with. The review looks at the reason the person sought emergency care,” said Morrow. “We follow the law now. That is not going to change.”
Morrow said there is no change to benefits to HMO members: it’s a stricter claims review process. He said the emergency claims would not be denied without being reviewed by licensed physicians, which would then still open to the appeal process. Morrow added Blue Cross’ SmartER website helps inform members where to go for non-emergency care, and tries to direct non-emergencies away from the ERs.
In a statement, Blue Cross Blue Shield of Texas said:
Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to work closely with TDI over the next 60 days. During this time, BCBSTX will provide any further information TDI or Commissioner Sullivan requests while continuing to educate our members on the importance of appropriately using emergency services.
We anticipate this thoughtful, multi-step review process will be implemented on August 6, 2018 to provide protection for our members from inappropriate billing, egregious charges and fraud, waste and abuse by out-of-network emergency departments.
In an e-mailed statement, Brad Shields, Executive Director of the Texas Association of Freestanding Emergency Centers (TAFEC), said the “real” abuse is “confusing patients and jeopardizing lives by making it more likely that someone in need of emergency treatment won’t seek it…. BCBSTX stands to gain by discouraging Texans from seeking emergency care and they are misleading lawmakers, regulators, and patients with claims they are attempting to prevent the use and abuse of ‘out-of-network’ emergency departments,” said Shields. “The reality is that, according to law, all emergency care must be provided to patients at in-network benefit levels.”
The growing popularity of freestanding emergency rooms in Texas
Texas became the first state to allow freestanding ER’s almost a decade ago, in 2009. Now, there are more than 200 such facilities across the state.
According to a study of more than 16 million Blue Cross Blue Shield of Texas insurance claims between 2012 to 2015, the use of the state’s freestanding emergency rooms shot up 236 percent, as opposed to a 24 percent increase for urgent care clinics and a 10 percent growth rate for hospital-based ERs. Data analysts with Blue Cross Blue Shield of Texas co-authored the study with experts at Rice University, Baylor College of Medicine, the University of Texas Health Science Center at Houston, and the Michael E. DeBakey VA Medical Center.
Vivian Ho, a health economist at Rice University’s Baker Institute for Public Policy and the institute’s Director of the Center for Health and Biosciences, was one of the co-authors.
“The notion that people are walking into hospital emergency departments for things that shouldn’t be treated in an emergency room has been widespread throughout country,” Ho explained. “Ten to 20 percent of emergency department visits could have been taken care of in lower cost, less aggressive care sites. So, we’ve known for a long time that there is a proportion of the population that is wasting the time and the complex resources that we offer in emergency care centers.”
Ho said that probability increases when you introduce freestanding emergency rooms into the mix. And, those can get expensive for patients.
In 2015, a freestanding ER bill averaged $2,199, as opposed to $168 at an urgent care clinic, according to the aforementioned study. Researchers said there was still an expectation for patients to pay approximately one-third of the price in each case. An average hospital-based ER bill was $60 more expensive than the freestanding ER average, but patients were only responsible for 33 percent of the cost of treatment, the study concluded.
Insurers vs. Freestanding ERs
Dr. Robert Morrow said Blue Cross Blue Shield of Texas data shows over 80% of their out-of-network ER claims are from freestanding emergency rooms.
There have been various reports of ongoing battles between insurers and freestanding emergency rooms; both of which claim to be in the patient’s best interest. And Blue Cross Blue Shield of Texas’ potential change in review process adds another layer to that.
“Make no mistake—lives will be lost if this policy is allowed to go into effect,” said TAFEC Executive Director Brad Shields. “Patients’ lives and wellbeing are being threatened by health insurance companies who are treating Texans like second-class citizens. Blue Cross Blue Shield of Texas’ ER patient penalty policy that was set to go into effect on June 4th is a direct violation of both federal and state laws, and indefensible by any logical, ethical, and moral standard.”
In addition to TAFEC believing the review change is in violation of prudent layperson standards, the group also thinks, “by not providing usual and customary reimbursement rates, insurance providers violate the intent of the medical community, and legislators who turned the prudent layperson standard into law,” according to its website. The organization referenced Section 1301.155 of the Texas Insurance Code; which references the prudent layperson standard, defines emergency care, and outlines how insurers must provide reimbursement.
But Ho believes there is a direct correlation between Blue Cross Blue Shield of Texas wanting a stricter claims review process and the existence of freestanding emergency rooms.
“I think a small group of bad actors who are operating certain freestanding emergency departments have brought this intervention upon themselves,” said Ho. “I think that this campaign, and it seems to me like a publicity campaign, is being led by a small number of doctors who are making substantial amounts of money off of operating freestanding emergency departments. And I think they’re managing to cloak their behavior well.”
Ho believes Blue Cross Blue Shield of Texas’ review change could end up saving money for policy holders, because it lowers the amount of wasteful expenditures.
Ensuring patients’ rights
The Texas Department of Insurance (TDI) is the state’s regulatory body that makes sure companies are in line Texas’ insurance laws and patients’ rights are maintained. Houston Public Media obtained TDI’s letter to Blue Cross Blue Shield of Texas, which outlines specific questions about how the new review process would be implemented.
“Our central concern is that the consumer protections are maintained with any changes that goes into effect,” said Ben Gonzalez, spokesman of the Texas Department of Insurance. “One of the things we’re interested in finding out is: HMO’s typically provide coverage for emergency room screenings. And, so, we want to make sure that is maintained. So, when a patient goes into the emergency room with something that they feel is an emergency, something that is life-threatening, they should be covered for that until it’s determined that it’s not emergency. So, any screens that take place to determine whether or not that [emergency] medical condition exists should be covered, as far as we’re concerned.”
Gonzalez said, most importantly, people have the right to seek reasonable and legitimate emergency care. Blue Cross Blue Shield of Texas has said it agrees with that sentiment, and will work closely with TDI to answer its questions before the August 6 rollout. But will those forthcoming answers satisfy both TDI and protesting physicians in Texas?
As it currently stands, emergency physician Dr. Alison Haddock still believes a review change like this would be crossing a line. “I’m hoping this is not the place where we’re going as a country,” said Haddock. “Seeing the system break down in this way for our patients is just really scary for us, as emergency physicians.”
And she said you never know who won’t seek care, out of fear of receiving a surprise bill.
A rule that could effect how Blue Cross Blue Shield of Texas customers are treated during a health emergency has been postponed for at least 60 days.
Local urgent care centers will not be effected if the new rule were to be put in to place.
However, emergency room services will be impacted and have you double-thinking whether or not you need medical assistance.
“We’re concerned about a new rule that Blue Cross Blue Shield is implementing, where they are going to stop paying for out of network ER visits, even when a patient believes they are having an emergency,” said ER Now Dr. Gerad Troutman, MD, FACEP.
Medical professionals across the state are concerned the new rule will change the mindset of an emergency.
Once in effect, Texans could be left questioning the state of their own health.
“Those patients now, may stay at home when they are really having an emergency,” said Dr. Gerad Troutman. “They [will get] that little twinge of chest pain, and then they think in their head: you know, I might get stuck with that bill, maybe I shouldn’t go to the ER. I’ll wait around, maybe it’s just gas. Then they wind up dead, or have a worsening heart attack and have worsening heart failure because of that.”
If the rule is put in to action, local urgent care centers say they could see an increase in patients.
“Hopefully we’ll see an increase in the volume of patients, but we’re always ready to handle that,” said family nurse practitioner for Amarillo Urgent Care Nicole Slatten. “[Amarillo Urgent Care] is open seven days a week, eight [in the morning] to 8 [at night], holidays, weekends and everything. We are able to handle an influx of patients at any given time.”
Slatten believes for those who know the difference between an urgent care center and emergency room the new rule won’t matter. For those who do not, it could be a teaching moment.
“The group of people who realize the difference between emergency versus urgent care visits,” said Slatten. “I think it’ll just be education given out by providers to their patients as where to seek care or not to seek care. I think it’s just going to be an educational opportunity for the public in general.”
Dr. Troutman believes the new rule could lead to dire consequences.
“When Americans have insurance, they expect to have access to emergency care, and we think that this rule decreases that access,” Dr. Troutman. “That’s a problem. I think Texans and Americans will die because of this type of rule.”
All medical professionals would like the public to know if you do have an emergency seek medical attention immediately. Do not worry about what type of emergency it is and whether or not it requires a certain level of care. Go seek a medical professional immediately and call 911 if necessary.
Bay Area Regional Medical Center, LLC (Bay Area Regional) a diversified, integrated multi-specialty health care delivery system, today announced the closing of Bay Area Regional and will be filing for bankruptcy next week.
Bay Area Regional invested $200 million during the past five years during construction and operation. The company continues to work with lenders on an orderly closing process, including the payment of Bay Area Regional’s payroll obligations.
“It is with a heavy heart that I announce that Bay Area Regional will close its doors on May 10, 2018,” Stephen K. Jones, Jr., CEO at Bay Area Regional said in a statement. “We want to thank our staff who worked tirelessly, physicians who chose to practice medicine and patients who received care at our hospital.”
Bay Area Regional, which opened its doors on July 21, 2014, has been committed to providing exceptional care while making a difference in people’s lives. Bay Area Regional offered some of the latest technology for physicians to provide advanced diagnostic and treatment techniques. With a pursuit of excellence, Bay Area Regional was recognized for having some of the highest patient satisfaction scores and many different service lines and achieved the highest level Chest Pain Center Accreditation, Comprehensive Center Accreditation for Bariatric Surgery by MBSAQIP, it was the first hospital in Texas achieve Center of Excellence for Hidden Scar Breast Surgery, Primary Stroke Center Accreditation, and a Level III Trauma Designated hospital.
Pharmaceutical executives appeared before Congress on Tuesday to answer questions about a congressional investigation into drug companies’ role in the nation’s opioid epidemic, The Washington Post reports.
A Cardinal Health executive, George Barrett, apologized for his drug company’s slow response to the unprecedented influx of prescription opioids to small towns in West Virginia, while Joseph Mastandrea of Miami-Luken admitted that his company had worsened the opioid crisis.
Current and former leaders of McKesson, AmerisourceBergen, and H.D. Smith are also testifying in front of the House Energy and Commerce Committee. The panel has been probing the pharmaceutical companies in light of discoveries that they shipped 12.3 million doses of hydrocodone and oxycodone to small pharmacies in West Virginia, one of the states that has been hit hardest by the drug epidemic.
Most executives denied that their companies were at fault for the opioid crisis, even as lawmakers expressed anger that the companies hadn’t taken responsibility as their products spiraled out of control, reports The Washington Post. The pharmaceutical industry supplies distributors with medications, but does not prescribe drugs or sell to individual patients. The executives who appeared before the panel Tuesday represent companies that make up more than 85 percent of the country’s prescription drug shipments.
“With the benefit of hindsight, I wish we had moved faster and asked a different set of questions,” said Barrett of Cardinal Health’s lack of action in West Virginia. “I am deeply sorry we did not.”
The world consists of three types of doctor. Three types of doctors who will grace your presence on any given stay in the hospital, foray into the nursing home, or visit to the office. You might have never given these archetypes a specific name, but they are immediately recognizable.
I’m not talking about medical knowledge or clinical savvy. I’m not pointing to differences in education or training.
Bedside manner. We’re talking about bedside manner people!
Dr. Too Grumpy
She storms into the room with her mobile phone glued to her ear. Or better yet, a blue tooth device. She spits sarcasm at the invisible nurse on the other end of the line, or medical assistant, or god forbid, patient.
She barely regards you as she types away at the electronic medical record. Questions are stated, not asked. Eye contact is minimal, and the exam is brusk. Mechanical. There is no discussion, just bald commandments. Patient centered care and shared decision making is scoffed at.
She will not describe to you the physiologic underpinnings. She will not discuss the pros and cons. And if you dare to delay her from attending to her next patient, she will regard you with scorn and sarcasm.
She is perfectly capable, yet utterly unacceptable.
Dr. Too Nice
He will show his toothy grin as he coos in your ear. He will say that everything will be alright, even when it won’t. His manner is soothing and infinitely gratuitous. You are the only one who exists at the moment. The only one he cares for.
He will give you narcotics if you ask for them. He will treat your common cold with antibiotics. The plan is to do what ever it takes for you to like him. For you to tell all your friends and keep coming back to his office.
He hates confrontation and would rather pander than have an honest, open conversation. Difficulty is his greatest adversary. Not illness. Not well being.
He will tell you exactly what you want to hear. Hold your hand. Lie through his teeth.
He is a perfectly nice guy, yet the most dangerous provider you will encounter.
Dr. Just Right
There are, believe it or not, doctors who are both kind and calm, but firm and knowledgeable. They exist in every hospital, nursing home, and physician office. They might not be the favorite. They may upset you from time to time.
They know how to just stand there and do nothing. When nothing is called for.
They may lecture you on diet and exercise, smoking and alcohol, stress and anxiety.
But you will know them when you see them.
If you see them.
They’re a dying breed.
Please check out my other blog about personal finance here.
Louisiana is in the middle of an opioid crisis, but a pervasive state budget shortfall may lead the state to eliminate some drug and alcohol treatment options for people with Medicaid after July 1.
The latest state budget proposal, passed by the Louisiana House, scraps $47 million worth of state and federal funding that pays for outpatient drug and alcohol treatment programs for adults enrolled in Medicaid. In January, 4,600 people were using services paid for with this money that would no longer be available, according to the Louisiana Department of Health.
It could be worse. The original budget proposal considered by lawmakers completely eliminated drug and alcohol treatment for adults with Medicaid after July 1. It scrapped all inpatient and outpatient substance abuse treatment funding — a total of $74 million from state and federal sources.
House members voted to restore some of those cuts however, including all money that goes toward inpatient treatment programs for adults in the Medicaid program. Some outpatient treatment funding, though not all of it, was also restored.
That larger cut proposed earlier in the process may still be on the table though. The Louisiana Senate hasn’t voted on its version of the state budget yet and there are a lot of competing interests for scarce dollars, particularly when it comes to health care.
Louisiana has a $648 million budget shortfall starting July 1. Substance abuse services are vying for money with group homes for people with intellectual disabilities and hospitals that train medical students. The Senate could decide to take some of the funding the House put toward drug treatment and use it for other purposes.
Gov. John Bel Edwards and the Senate leadership would like the Legislature to meet in another special session — after this session ends — to raise or renew taxes to avoid drastic health care cuts. It’s not clear whether the House will agree to do so, however.
The health care cuts would affect drug treatment centers in the New Orleans area, possibly shuttering them for good. Eighty-five percent of the clients at Odyssey House Louisiana, located in New Orleans, have health insurance through Medicaid. Over 90 percent of people treated at Responsibility House in Jefferson Parish are enrolled in Medicaid. Many of those patients would lose their ability to access drug treatment completely through the proposed cuts.
If Louisiana eliminated funding for inpatient drug treatment in the Medicaid program, Edward Carlson, chief executive officer of Odyssey House, anticipates 60 percent of drug treatment facilities around the state would close. Mike Martyn, executive director of Responsibility House, said his center — which serves about 45 inpatient and outpatient clients — wouldn’t be able to operate anymore. His funding would go from about $2.4 million per year to $200,000 per year.
Odyssey House would survive — but it wouldn’t be able to offer most of the substance abuse services it does now.
Its detox center and residential treatment program would shutter. Carlson said it would only survive to offer other types of services — including HIV/AIDS treatment — that it has federal grants to dispense. The number of people it could treat would drop from from around 900 per month to 340 per month and the facility would have to cut 60 percent of its staff, Carlson said.
Odyssey House has the only drug and alcohol detox center in South Louisiana that doesn’t require private insurance and serves people who are poor, according to Carlson. Hospitals in the area do detox sporadically, but most just try to stabilize drug and alcohol users before releasing them.
If a hospital does have to guide someone through detox — which lasts a few days — it can cost seven or eight times what it would at Odyssey House, Carlson said.
Carlson sees the impact of the opioid crisis on a daily basis at Odyssey House. Seven or eight years ago, only about 20 percent of the treatment facility’s client struggled with a heroin addiction. Typically, those people were longtime users. Now, over 60 percent of Odyssey House’s clients are heroin or opioid users — and most of those people were introduced to street drugs after becoming addicted to prescription medication, he said. They are more likely to be a “soccer mom” or other person not typically associated with street drug use.
Odyssey House’s detox center is necessary and in high demand, Carlson said. People line up early in the morning outside the treatment center hoping that a bed opens up for the service.
Some people even overdose in line, while waiting to get into the detox facility, Carlson said. Odyssey House has had to use naloxone — the overdose reversal drug — to revive people while they wait in line on a detox bed more than once. Staff then calls an ambulance to haul them off to the hospital — where they will be stabilized, released again and typically go back to using drugs.
Carlson said Louisiana already does a poor job of managing the opioid problem because it has no coordinated plan to handle the epidemic. Louisiana needs about three times the number of drug treatment beds that it currently has, but the budget cuts would make what is already a bad situation worse, he said.
Doctors shouldn’t lie to their patients, even now when the parsing of words and the telling of white lies is common at the highest level of our government. But they do it all the time — sometimes for personal reasons but most of the time for what they believe is the good of their patients.
As a neonatologist and a pediatric cardiologist, we know that truth and honesty are key parts of the foundation of the doctor-patient relationship. “Commitment to honesty with patients” is a primary responsibility for physicians set out in the Charter on Medical Professionalism.
Yet physicians — including us — do lie.
We have said to parents of newborns, “She will sleep through the night,” or, “Your breast milk will come in any day now,” knowing there is a distinct possibility that neither might happen.
We have said to parents with children in the cardiac intensive care unit, intubated and sedated after major heart surgery, “He isn’t in pain; he knows that you’re here,” when we have little idea whether such awareness is possible in states of induced coma and paralysis.
We have said to parents whose infant has features of a lethal genetic abnormality, “She is beautiful and perfect,” when there is nothing else to say.
And we have said to parents who desperately rushed to their dying baby’s bedside, “He is still here,” while placing him in their arms and shutting off the monitor so they can’t see that his heart is no longer beating.
We tell these untruths not to deceive parents, but to offer words that lighten their hearts in moments of despair. We do it, we tell ourselves, to spare their feelings.
But perhaps we sometimes lie for our own sake, and it is our feelings that need to be spared so we can get through the night without breaking down in the call room when all signs indicate the outcome will not be good.
The dilemma is not new.
In 2012, a nationwide survey showed that one-third of the 1,981 physicians sampled said they should not necessarily share serious medical errors with their patients. Two-fifths of the doctors did not disclose their financial relationships with drug and device companies to patients. These sorts of lies are clearly harmful and transparency is necessary.
Some physicians lie to third-party payers to obtain approval for treatments or procedures their patients need. Their willingness to deceive payers varies by disease severity: 58 percent said they would do this for coronary bypass surgery and 35 percent for screening mammography, but just 2.5 percent for cosmetic rhinoplasty — a nose job.
In an imperfect health care system limited by resources, the morality of whether physicians should advance what they believe is in the best interest of their patients above and beyond existing rules and regulations can be debated.
Yet white lies are also problematic. Medical ethicists have argued for decades on the moral distinction between lying and deception, and physicians have long struggled with absolute honesty versus withholding dismal facts.
One study found that more than 55 percent of physicians sometimes or often described a patient’s prognosis in a more positive manner than the facts support. A deception flowchart has been developed to help doctors “who are not absolutist” decide when it is morally acceptable for them to deceive patients.
In reality, the flowchart, or saying “I don’t know,” doesn’t always help. And being brutally honest doesn’t always help families make decisions or guarantee the preferred outcome. We could — and should — dutifully cite statistics of morbidities and mortality to families, such as, “Your child has a 60 percent chance of survival.” As physicians, we may feel that at least they heard the numbers. But for families, survival is a dichotomous yes or no. Giving hope and sometimes describing a prognosis in a more positive manner than the facts might support is the reality of what physicians do.
To be sure, deception that limits an individual’s or a parent’s ability to make informed decisions is reprehensible. Sugar-coating devastating results, or making light of grave situations as if there will be meaningful recovery is also wrong. Patients and their family members must be told results and expectations based on experience and evidence, as honestly and as clearly as a clinician can. But the art of medicine calls upon us to be nuanced and possibly shield them from unnecessary pain.
The foundations of a doctor-patient relationship can remain strong even with “white lies,” as long as our actions are grounded in kindness and we are doing our best for our patients in difficult times.
Even small practices can adapt to new payment models — but they need the right incentives to get going, Bill Golden, MD, medical director of Arkansas Medicaid, said here at the annual meeting of the American College of Physicians.
“We’ve been doing payment transformation in a very often rural state that has ‘onesie-twosie’ practices, often with limited resources,” Golden explained.
Those very small practices have been struggling financially, “dependent on 5-minute visits” for simple conditions such as ankle strains and urinary tract infections, he said. “The profit on that is better than seeing a hypertensive diabetic, which takes 10-15 minutes.”
So a group of payers — public programs such as Medicaid and private insurers including Blue Cross, the state’s largest private payer — started the Health Care Payment Improvement Initiative in 2011 to change the payment system for doctors in the state. “We said, ‘The healthcare system pays for things it shouldn’t pay for, doesn’t pay for things it should pay for, and it’s unsustainable,'” said Golden.
The group started things off in 2012 with an “episodes of care” reimbursement program. The payers calculated a risk-adjusted average cost per case for various conditions. Practices spending below that amount got 50% of the savings; those who spent above that amount had to pay 50% of the overage. “You had to outrun your colleagues, or at least not be in the ‘red zone,'” Golden said. The payers created an online portal so providers could see their data.
“I had doctors come in and say, ‘I’m an ob/gyn.; why am I in the red zone?’ ‘Well, your pathology costs are triple everyone else’s.'” It turned out that the doctor was sending every placenta to pathology because he thought everyone did that.
Another practice had high costs for treating upper respiratory infections because they were over-ordering lab tests and antibiotics; at the same time, their emergency department costs were at the state norm. “So it’s very instructive,” Golden said. But episodes of care don’t work so well with ongoing chronic conditions like hypertension and diabetes.
So the payers also started a primary care medical home program in 2014, and now about 85%-90% of patients are in voluntary medical homes, with 200 practices and 1,000 doctors participating, Golden said. That model involves giving primary care physicians a set per-member-per-month fee to care for the patients in their practice, with $5 per member per month available for risk adjustment.
The payers also told the practices that they would give them an extra per-member-per-month fee for performing additional services. “This money is not for taking home and making a boat payment; this is an investment in your practice, and we expect you to do extra stuff,” said Golden. “And we’re going to give you coaches because we want to raise all boats.”
One thing they asked practices to do was get rid of their answering machines that they used on weekends, telling patients to go to the emergency department with any problems. It worked. “Believe it or not, we no longer have answering machines in our state,” he said.
“After 6 months, we called people to see who still had answering machines — about 15 or 20 still had them; we gave them 6 months to fix it” and if they didn’t do that, they were out of the program. The payers started out with 120 practices the first year, and threw out four or five who “either took the money and did nothing, or they were too disorganized.”
They also asked the practices to see their high-risk patients every 6 months, and to develop care plans for those patients’ conditions, even if they were just a few words (“Hypertension out of control; added beta blocker; will monitor”), Golden explained.
The payers also had a second bucket of money; they told the primary care practices that they would calculate an average per-member-per-year cost, and if a practice came in below that cost it would get 50% of the savings. “If you think about the fact that most primary care doctors are 5% of the healthcare spend but they control 80% of the dollar, and you’re offering to give 50% shared savings on that 75%, suddenly that’s a big relative chunk of change … so that got people’s attention.”
This new program wasn’t without its challenges, however. “Some of these folks were wedded to a high-volume world,” he said. For example, “some people were never getting their HbA1c [tests] for diabetes because they were never seen for diabetes; they always came in for head colds and broken ankles … So we had to change that paradigm.”
Before the program, people were seeing 50-60 patients a day, and they weren’t doing chronic care management. “Now [providers] can make triage decisions, and determine who to see and why,” said Golden. “And you’ve empowered a nurse clinician. In my practice now, [I say to the nurse] ‘I just saw X; please make sure she understood what’s going on, and make sure she gets to her orthopedist.’ I think it’s just more talking to a team as opposed to being a guy or gal with sneakers running between rooms. They’re using their time more wisely.”
As of 2015, the latest data available, the payers had given out $14 million in per-member-per-month payments, paid out about $13 million in shared savings, and avoided $27 million in costs on an inflation basis.
And the practices have done interesting things with their money, he added. “When some of the bonus checks went out, one practice gave bonus checks to front desk clerks; they said they were instrumental in keeping the flow going.”
Every action that is taken, especially when it comes to healthcare, has ripple effects, which often end up being more far more significant than we anticipate, turning that ripple into a tidal wave.
Every time somebody besides actual healthcare providers steps into the mix and tell those of us taking care of patients that there is “something else that we have to do,” we often see it open up a proverbial can of worms that in many cases we didn’t want opened.
Whenever government regulators, hospital administrators, the makers of electronic health records, or bureaucrats from insurance companies, come up with creative new things they’d like us to measure or insist that we do, this usually leads to an increase in the burdens on an already stressed-out and burned-out healthcare community. And it often happens in the vacuum of not asking us, the ones right there taking care of patients, whether this is really worth it, really the right thing to do.
Take for example the well-intentioned addition of pain as the fifth vital sign. This came about in an environment where many people felt that providers were inadequately addressing the patient’s pain, and not using the medications at their disposal (i.e., opiates) freely enough.
I remember our practice getting cited by government regulators making a site visit after reviewing a chart and finding a pain score of 8 listed for a patient, and at a follow-up appointment there was no documentation of why that number had not gone down.
There have been numerous well-written and thoughtful articles recognizing this simple change in the medical record as being a contributor to what we’ve since started to call the opioid crisis in this country.
We created a system where we’re jumping and responding to a click in the chart, a number on a scale, an endless stream of screening questions, performance measures, risk stratification categories, and guidelines.
I’ve written before how the implementation of an accountable care organization at our institution led to a brand-new set of screening questions that someone has decided we are being measured against.
Falls risk, depression screening, blood pressure under control, and being over- or underweight.
Just because someone has decided that these are useful measures to look at, do we really believe that it needs to be done for every patient, and in fact, does knowing the answer really always help us?
By putting this in place, we are essentially agreeing that there is significant evidence that asking this question, getting an answer, and then performing one of the available options is going to make a difference in the future appearance of that event, or avoidance of some future outcome of interest.
Take for instance the falls question built into the electronic health record. This is an automatic default question that pops up once someone is entered in the accountable care organization, and is not based on anything other than their enrollment in Medicare. There is no effort to actually assess whether any particular patient is at increased risk of falls.
In fact, our practice has many patients who are at extremely high risk of falling despite not being over age 65, yet this question is not “available” for them.
And I have many robust 80- and 90-year old patients who I doubt will ever fall down.
“Has the patient experienced a fall in the past 6 months?”
Once the patient screens positive for falls, there are limited options made available for the provider to click to say what they plan to do about this.
These include a promise to change their medications, suggesting that we’ve left them on a medicine that places them at increased risk for falling. Or referring them to physical therapy, assuming that this intervention will prevent future falls.
I’m not saying that these aren’t good things to try, we should all be striving to take medicines that put our patients at risk for falls away from them, and physical therapy could probably help everybody, especially our frail elderly Medicare patients who have fallen in the past year.
Once again, we’re being asked to click a bunch of boxes, the answers to which we don’t always have the right tools to make better, the right team assembled to attack the problems that we’ve uncovered.
When we ask any question or order any test on a patient, we should always be mindful that what comes out the other end is an answer, and we better be prepared to do something with whatever that answer may be.
I’m not saying we shouldn’t be asking, I’m just saying we better make sure we have a healthcare system in place that’s ready to do something about all the answers we get.
Look at the Review of Systems that is built into nearly every encounter between a healthcare provider and a patient.
This is a structured system of inquiry that has been put into place whereby the providers hopes to glean information about symptoms that may not have come up in the patient’s history, or may have come up but need to be further explored.
The shorthand way of asking about these things during, for instance, an annual physical, is the simple question, “So, is anything else bothering you?”
Sometimes this will get a patient to think about their lower back pain, or their problems with urination, or that rash they forgot to mention, but often times, the short question gives you the short answer, “No, everything else is doing okay.”
If you break the Review of Systems out further to the multiple organ systems, you increase your chance of getting more detail, but this comes at a cost of time, as well as more answers to questions that we now may need to pursue further testing and evaluations for.
You can scroll through these systems, working your way up and down the patient’s body with them, again sometimes uncovering new symptoms simply by presenting these large categories to them, but often people will just say “Nope, everything’s okay there.”
But if you really open up Pandora’s Box, and go through what is known as a “detailed review of systems”, the number of questions asked and potentially answered telescopes out very quickly.
For instance, in our electronic medical record, here is the list of review of systems under HEENT:
I’m short of breath just reading the list, and we haven’t even gotten to the respiratory review of systems, let alone dealing with all those positive responses.
I recently wrote about a new project, looking to start remote patient monitoring, where certain high-risk patients will have a medical device placed in their home that allows for nearly continuous monitoring of their vital signs.
For the most part, I don’t want to measure these things unless there’s something that makes me think they’re going to be significantly out of range and that I can do something about it.
Suddenly, outpatient providers are responsible for huge load of data that was previously collected only on sick inpatients who had a team of nurses watching over them 24 hours a day.
To measure something, to ask a question and get an answer, will make providers feel like we need to be the ones owning responsibility for what that answer tells us.
As healthcare providers we need to be the ones deciding what gets asked, and answered.
I am currently a Physician Liaison focused on scheduling Emergency Medicine Providers into our Hospital. We schedule a variety of shifts and with my 8+ years of healthcare experience, I am excited to maximize every provider's personal time.