‘Dear Doctor’ Letters Reduce Opioid Prescribing : NPR

For a doctor, learning that a patient has died is often an emotional moment. Emergency room physician Roneet Lev wondered if telling doctors when their patients die of an overdose might motivate them to rethink their prescribing behavior.

“I asked other physicians if they would want to know if a patient had died,” says Lev. “They said yes. I needed to help make that happen.”

Lev, the director of operations of the Scripps Mercy Emergency Department in San Diego, coauthored a study published Thursday in Science that tests this idea.

The study evaluated the effect of sending letters to San Diego area clinicians informing them of the deaths of patients to whom they had prescribed opioids. Half of a group of 861 doctors received such a letter from San Diego’s medical examiner, detailing the name, birth date and death date of the patient. The other half got no letter.

Among the letter recipients, opioid prescribing decreased between 6.2 to 13.2 percent compared to those who didn’t get a letter.

“What’s important about what we’ve found is that you can do very simple things to change prescribing and make prescribing safer,” says coauthor Jason Doctor, an associate professor of health policy and management at the University of Southern California.

Opioid overdoses went up 30 percent between 2016 and 2017. Despite policy efforts to limit prescribing, opioid prescribing rates are still far higher than they were in the late 1990s.

The letter-writing intervention targets the riskiest prescribers, Doctor says.

Physicians are aware of the opioid crisis, but they might see it as happening somewhere outside of their own practice, he says. Putting a face on overdose victims can give them a perspective about what’s going on in their own clinics, he says.

“Right now, doctors are getting biased information. They are only seeing patients that are coming back alive to their clinic, not those who die and never return,” Doctor says. “A lot of times, they never learn about a patient’s death.”

The letter provides some safer prescribing guidelines, such as avoiding co-prescribing opioids with benzodiazepines, a sedative which can raise the risk of overdose. Nearly 30 percent of overdoses involving opioids also involve benzodiazepines.

Jason Doctor hopes that other county or state medical examiners will consider the idea of sending overdose letters to physicians, nurses, dentists and other providers who prescribe opioids.

The study noted that the 170 patients in the study who had fatal overdoses had on average gotten opioid prescriptions from five and half prescribers.

This could reflect the problem of doctor shopping, says Amy Bohnert, an associate professor of psychiatry and mental health research at the University of Michigan. That is when a patient seeks several prescriptions for the same ailment to acquire more drugs.

Bohnert, who was not involved in the study, says that doctors don’t always know about all the other prescriptions a patient is receiving, so they may unintentionally prescribe an opiod that overlaps with another prescription.

Study coauthor Lev remembers learning of the death of a patient she had prescribed pain medications to. The young woman had come in to the emergency room with a traumatic injury. Lev wrote her a prescription for painkillers, not realizing that this woman was a chronic pain patient who had only one day before been prescribed a large dose of another opioid.

While the small prescription she wrote likely wouldn’t have been the turning point for this woman who died 15 months later, it still upset Lev since she hadn’t taken the chance to intervene then and there. “The fifteen pills I prescribed her didn’t kill her, but it was a missed opportunity,” Lev says.

Bohnert says that the approach of sending doctors letter was “clever.” It took advantage of existing systems, and could be done for a very low cost.

“It’s something that the health departments in each state could feasibly undertake with relatively little cost,” she says.

But Bohnert says that while implementation is doable, the effect might diminish over time if doctors keep getting these letters, shrinking the impact they may have on their choices.

Kelly Dineen, an assistant professor specializing in health law and bioethics at Creighton University School of Law, who was not involved in the study, says she is concerned that this intervention misses part of the picture of opioid addiction. She says that when opioid prescriptions are reduced, some patients could end up resorting to using risky illicit drugs instead, because they lack support in finding addiction treatment.

The outcome measure of this study is prescription amounts, but Dineen says she’s curious to see if mortality rates fall after doctors get these letters.

Jason Doctor of USC agrees there’s a risk that if you cut patients off of addictive painkillers suddenly they may turn to street drugs like heroin.

But he says, in this research, the doctors who got letters weren’t much more likely to abruptly drop their patients than the control group. And, in an optimistic result, he says, those who got letters showed a decrease in the number of new patients they introduced to opioids, therefore potentially preventing addiction from starting at all.

San Diego County will be sending out these letters regularly to doctors whose patients fatally overdose, according to Lev.

“The letters are just a small way to make a difference,” says Lev.

Source: ‘Dear Doctor’ Letters Reduce Opioid Prescribing : Shots – Health News : NPR

BCBS Controversial ER Claims Process Begins – Houston

The largest health insurer in Texas changed an ER claims review process Monday.

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.

In our recent News 88.7 In Depth, we reported backlash from physicians in Texas prompted the insurance company to delay rolling out the new change.

In a statement provided to Houston Public Media, the Texas Medical Association said it’s disappointed Blue Cross Blue Shield of Texas is moving ahead with the change.

“Unfortunately, even the announcement of this plan has already planted a seed in patients’ minds that they’ll be left with a big bill if they go to the emergency room for the ‘wrong reason,’” said TMA President Dr. Douglas Curran. “We encourage TDI to join us in monitoring this closely to make sure no patients are denied necessary care.”

Dr. Alison Haddock reviews a patient chart before her shift in the Ben Taub Hospital emergency room on May 28, 2018.

Dr. Alison Haddock, board member of the Texas College of Emergency Physicians, previously told Houston Public Media she feels this change requires patients to “self-diagnose.”

“I think it’s wrong to be putting that extra burden on patients in their times of greatest need,” said Haddock, in a May interview. “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.

Blue Cross Blue Shield of Texas 

BCBSTX previously said it firmly does not believe the change is in violation of the prudent layperson standard.

Over the past two months when this change was pending, Blue Cross Blue Shield of Texas said it provided all requested information about the new review process to the Texas Department of Insurance.

“Combined with continued education and information, we believe this thoughtful, multi-step review process will provide protection for our members from inappropriate billing, egregious charges and fraud, waste and abuse by out-of-network emergency departments,” Blue Cross Blue Shield of Texas spokesman James Campbell said, in an e-mail to Houston Public Media.

In a May interview, Dr. Robert Morrow, Southeast Texas Market President for Blue Cross Blue Shield of Texas, told Houston Public Media there is no change to benefits to HMO members: it’s a stricter claims review process.

“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 Morrow. “It doesn’t look at diagnosis that somebody leaves the emergency center with. The review looks at the reason the person sought emergency care…. We follow the law now. That is not going to change.”

Morrow 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.

Texas Department of Insurance 

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.  In an e-mail to Houston Public Media, a spokesman for TDI said the agency has worked with BCBSTX over the past couple of months, to make sure consumer protections were in place.

TDI stated those protections are:

  • Emergency room claim reviews will be done by a doctor.
  • Any claim denials would come only after a review of medical records by a BCBSTX medical director. When the medical director is contemplating a denial, the provider will be offered a peer-to-peer conversation.
  • Consumers will be able to appeal if the claim is denied as not medically necessary. This would include an appeal to an independent review organization.

Freestanding emergency rooms speak out

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. Proponents of the BCBSTX review change say overuse of these centers with non-emergencies propels rising healthcare costs.

But in a statement, the Texas Association of Freestanding Emergency Centers (TAFEC) said, in part:

“While the reasons for issuing this intimidating, anti-patient, anti-ER policy were presented as positive (saying that non-essential ER use by members “drives up cost for our members” and taxes “limited ER resources”), in reality, what they were doing then and now served to accomplish just two things—and neither are to the benefit of Texans: drive down the use of ER care (regardless of need) and increase the profits of Texas’ largest insurance provider at the expense of everyday Texans and their medical providers.

An attack on state and federal law, this policy—which was originally scheduled to go into effect on June 4, 2018, created so many questions and concerns for the Texas Department of Insurance (TDI), that the Department decided this patient penalty policy could not go into effect at the time.”

Source: Blue Cross Blue Shield of Texas’ Controversial ER Claims Process Begins – Houston Public Media

Texas allows Blue Cross Blue Shield to deny payments for some out-of-network ER visits

Blue Cross and Blue Shield of Texas will begin a controversial new program Monday in which it will not pay any expenses for an out-of-network emergency room visit if it is later determined the patient should have gone elsewhere for treatment.

The measure was originally set to roll out June 4, but vigorous complaints from the public and physicians, as well as concerns from the Texas Department of Insurance, delayed it for 60 days of further review.

Blue Cross and Blue Shield of Texas officials and TDI confirmed late last week that the deeply contentious program will now launch and that any sticking points have been resolved.

The new measure is expected to affect about 500,000 Texans with Blue Cross and Blue Shield health maintenance organization (HMO) plans.

Claims will be scrutinized after the fact by a medical director hired by the insurer to determine the reason a patient chose going to the emergency room and whether treatment could have instead been handled at a less expensive clinic or by a family physician. The company also will look for over-treatment.

“We have, quite frankly, identified quite a bit of fraud, waste and abuse that happens within the context of some of these treatments at some of these facilities,” Dr. Robert Morrow, president of the Houston and Southeast Texas office of Blue Cross and Blue Shield of Texas, said in a May interview.

Doctors outside coverage networks can bill at much higher rates, sometimes two to three times higher than if they were in-network, according to health care policy experts. Then, any portion of a bill not paid by the insurer can be shifted onto the patient, who must make up the difference in a practice known as “balance billing.”

But critics continue to slam the program as harsh and punitive as it seeks to not only underpay providers but also forces patients to make untrained diagnoses and potentially skip treatment if they fear their medical bills will not be paid, doctors and their advocates have said.

Rhonda Sandel, CEO of Texas Emergency Care Center, a chain of four free-standing emergency rooms in Houston, Dallas and Lubbock, called the measure intentionally “intimidating” and “anti-patient.”

In an email Sunday, Sandel, a board member of the Texas Association of Freestanding Emergency Centers, said the true motive of the insurer was to “drive down the use of ER care (regardless of need) and to increase the profits of Texas’ largest insurance provider at the expense of everyday Texans and their medical providers.”

The rapidly growing industry, which got its start in Texas and operates walk-in emergency rooms, has frequently locked horns with insurers over reimbursement rates. The centers are staffed around-the-clock and provide much of the same testing and treatment options as traditional emergency rooms but are often out-of-network.

Insurance regulators initially questioned the program, announced in April, with worry of a chilling effect for sick or injured patients who might avoid care if they feared the bills. Twice state officials asked the insurer to clarify the guidelines ahead of the June launch and also to provide proof for the allegations that some emergency physicians and facilities were over-charging.

The company responded with 56 pages of documentation, including copies of submitted claims and itemized bills, obtained by the Chronicle through a state records request. Included was a billed charge totaling $8,719.10 for bronchitis. The patient underwent a CT scan for $4,155.95 as well as what appears to be 15 separate lab tests. The charges also included an emergency room facility fee of $2,226.40 which was coded at the highest severity level. Such fees are coded on a scale of 1 to 5 depending on the amount of time, number of tests and complexity of the treatment. This one was given a 5. The name of the patient and provider were redacted.

Another submitted claim totaled $45,000 for a 22-year-old patient with tonsillitis whose treatment included 18 hours of observation. Yet another showed a $7,000 claim for a first-degree sunburn.

Last week a TDI spokeswoman said in an email that the agency’s concerns had been satisfied.

Sandel on Sunday was critical of TDI’s capitulation to Blue Cross and Blue Shield.

“By permitting this harmful policy to go through, TDI is allowing for insurance consumers’ rights to be violated and potentially putting everyday Texans in clinical and financial distress,” she said in an email.

Morrow and other Blue Cross and Blue Shield officials bristle at the accusation they are putting anyone at risk. They say that they will not punish patients if they guess wrong, such as thinking they are having a heart attack that turns out to be indigestion.

And if it appears a patient made a reasonable decision in seeking care, even if it is out of network, their claim will likely be paid, Morrow has said, adding that denials only will happen if a patient’s treatment is found to be excessive or if they intentionally sought treatment in the wrong place.

“Over the last two months, Blue Cross and Blue Shield has diligently worked with the Texas Department of Insurance, providing all requested information regarding a process — being implemented (Monday) — to review emergency room charges of our retail and group HMO members” the insurer said in an emailed statement on Friday.

TDI said last week that its decision to let the measure stand came after assurances that any claims reviews would be done by a doctor, and that before a denial is issued a patient will have the right to have their doctor debate the treatment plan with the insurer’s doctor. Also, consumers will be able to appeal to an independent review organization.

In general, HMO plans already have tight restrictions on out-of-network care. The legal exception comes when a patient is having an emergency. In that case the insurer must cover out-of-network screenings, tests and treatments as if they were in-network, according to TDI.

Baked into the controversy is a piece of state insurance law called the “prudent layperson” standard which assesses whether a reasonable consumer without medical training would see a need for emergency care. Both sides in this fight say the standard is on their side.

Consumer groups in Texas are warily watching the drama unfold. They worry that patients rarely have any control over the tests or treatments that doctors order, especially in an emergency situation, yet they could be on the hook for hundreds if not thousands of dollars in bills if their insurer balks.

Similar restrictions on emergency room visits by insurance giant Anthem has faced harsh criticism across the country as patients found their claims denied more and more often. The company faces a lawsuit over the policy, and a recent report shows that many of the initial denials were ultimately overturned after the patients appealed.

Source: Texas allows Blue Cross Blue Shield to deny payments for some out-of-network ER visits – Houston Chronicle

9 unforgettable emergency room stories

The next time you have an embarrassing situation or accident, I want you to keep in mind that compared to what doctors see on a daily basis, it is likely no one will blink twice. Here are some of my favorite emergency room stories – all true – from my career in medicine to date.

1. Peanut butter balls

A 5-year-old girl came in with her sister, who was pregnant but unconscious, in an ambulance. We kept asking the little girl what had happened to her sister, and she kept saying, “She needs her peanut butter balls.” We were absolutely confounded and running every test we could think of and had neurology, psychology, OBGYN (me) critical care and even gastrointestinal looking at things.

Then, one of the little third-year medical students who was watching from the corner came up and said, “I think I know the problem.” Everyone gave an eye-roll or a skeptical look, but she went on bravely. “It isn’t peanut butter balls. It’s phenobarbital. Her seizure medicine. She had a seizure and needs her meds.” The young doctor-to-be got an ovation from the entire ER.

2. Hungry schizophrenic

A woman was brought down from the psychiatric unit with a distended belly and in a lot of pain. As gynecology chief, I was called in to see if I had anything to add. The CT scan showed a large mass in her abdomen, but it was unlike anything any of us had ever seen. As radiology and surgery were reviewing it, I went over to her and said hello and asked her how she was doing. She said that we had it all wrong, that it wasn’t a tumor.

What was it? No answer. Did you eat something? Maybe. What was it, maybe? It might have been my sheet. Your sheet? Yes. Why did you eat your sheet? I was bored. Why didn’t you tell anyone? No one asked. True story.

3. The homeless guy on MTV

In Seattle, a scraggly looking guy, presumably homeless, came in the ER with a laceration on his forehead. The attending told me, the fourth-year medical student, to go take care of it. As I was sewing him up, I was talking to him, and he turned out to be really intelligent and funny. He said he got jumped walking back to his car after a show. Who was the band? Were they any good? He laughed and said, “Pretty good, I hope. I’m in it.”

There are thousands of bands in Seattle, so I humored him some more. What’s your band called? “Soundgarden.” It turns out that I had just watched one of their videos on MTV in the break room. I recognized him now. He’s the drummer. So every time I have seen them on TV since then, I always look to see how his scar is looking.

4. Assaulted friend

I was called to the ER to evaluate a sexual assault. She was so beat up I didn’t recognize her as a nurse from Labor and Delivery that was a very good friend. I was so angry. She was so calm and just said, “Do you job and be thorough, so when they catch him they can convict. Don’t be mad. Don’t make any mistakes.” Cool as a cucumber with her face all covered with bruises and cuts.

I cooled down and I got the evidence, they caught the guy, I testified and they convicted and sentenced him for a long time. I’ll never stop admiring her for her calmness and bravery. Amazing woman.

5. Can’t go home

A young woman came in by ambulance, 16 weeks pregnant, and thought she might be leaking fluid. She had been home alone. I went down and evaluated her and diagnosed an infection that was easily treatable. I explained it all and said she was free to go.

“I can’t go.”

“You can go. You and your baby are fine. We have a ride waiting.”

“No, I can’t.”

“Are you unsafe at home? Are you scared?”

“No! I just can’t go!”

She then looks around and whispers, “I ain’t got no pants.” She lifted up the sheet and sure enough, no pants, no undies. Nothing.

“Um…Why, um…why?”

“I forgot.”

I am not sure what more you can even say about that one. I think the take-home lesson is that there is almost always time to grab some pants on your way out the door.

6. Exploding uterus

A patient of mine came into the obstetrics triage area with some pain at 32 weeks. In the process of evaluating her, I was looking at the baby with ultrasound and I literally saw the baby pop out the top of the uterus. This is a bad thing. Really bad. I grabbed the gurney, ran it to the elevator and down the ER, yelling for pediatrics and nurses.

In less than three minutes, we got the baby out, and somehow it did just fine and is a beautiful, feisty 17-year-old young woman today. There are still gouges in the floor of the unit where I took the corners as fast as I could. That took a few years off my life, I think.

7. Being at the right place at the right time

I was called by the ER that one of my patients was in the parking lot bleeding. It was a woman with twins, near term. I saw her in the parking lot, leaning on her car, with blood running down her legs. The ER staff got there about the same time and had an IV into her before we even got through the ER doors. I could see the people waiting in the ER with looks of horror as we ran by with blood running down onto the floor.

The OR staff was waiting when we got there. I didn’t even have time to change. I quickly scrubbed, and by the time I was gowned, she was asleep and draped and still actively bleeding. The babies were out within a minute, and amazingly, though premature by six weeks and stressed by the placental abruption, they did great and are two of the rowdiest set of twins you will ever see. That probably took a few more years off my life, too.

8. Cellphone hide-and-seek

I was called one night to evaluate a woman, still fairly inebriated, who had been asleep/passed out, and her also-inebriated partner had hidden her cellphone in a body cavity, but didn’t tell her which one.

After I figured out which one it was (in the lower colon), we gave her some sedation and I set out to retrieve it. The phone kept buzzing and ringing every minute or so. When I finally got it out she wanted to see who was calling and laughed. It turns out that her boyfriend, who was sitting in the waiting area, was the one calling. Actually, that was kind of funny.

9. Follow post-op instructions!

I got called one night to see one of my post-op hysterectomy patients in the ER. The ER attending sounded very worried so I got there ASAP. When I got arrived, her husband was pale and looked terrible as he sat in the corner. The patient, however, was laughing and talking on her cell phone. She hung up and said, “I did a no-no. I know you said no sex for at least six weeks but I felt so good I thought I’d give it a try (three weeks early).”

“Did you have bleeding?”

“Not exactly.”

The ER nurse then moved her sheet down, where some moist dressings were covering about 12 inches of small intestine that had herniated out (she had recently had a hysterectomy).

“Crazy, huh? Just popped out of nowhere. You can fix that, right?”

After taking one more selfie of it, we took her back to the OR and fixed her up. And I will say that the second time around, her husband would not touch her until they both came in and I absolutely guaranteed him that it wouldn’t happen again.

So, whatever happens to you and you need to be seen, don’t worry about it. It would take a lot to surprise the ER staff.

Source: From an exploding uterus to cellphone hide-and-seek: 9 unforgettable emergency room stories – St George News

Victoria freestanding ER closes amid battle with insurers 

Mercer ER, a slick, stand-alone 24-hour emergency center near Home Depot, closed its doors for good last week.

Patty Lutes, a 29-year-old executive assistant in Victoria, said she wasn’t surprised it closed, especially after her experience of receiving a surprise bill in the mail.

She remembers the facility had just opened in Victoria – its signs weren’t even up – when she woke up feeling terrible. There was no time to schedule an appointment with her family doctor before an important work event that night.

“I felt like death,” she remembered thinking. She thought she could have strep, a highly contagious infection, and could not risk getting anyone else sick.

She thought she would just run up to Mercer real quick and make sure it wasn’t strep. “I was the only person there. In-and-out in 20 minutes,” she said. She paid her $250 copay, got a prescription and went on her way.

Later she learned her insurance company paid more than $1,000 for the test and she was being charged the rest of the balance to the tune of more than $500.

She learned later “balance billing” is a national problem that Texas lawmakers have been working on.

Texas legislators passed two bills last year aimed to help protect consumers from surprise bills. The laws, passed in September, state that freestanding emergency rooms must post notice of whether they are part of any insurance networks or risk losing their license and updated a process so that patients can dispute the bill. Not all consumers know that since 2009, they can contact the Texas Insurance Department with complaints or help with mediation.

A former staff member of Mercer said Wednesday that the business closed because Blue Cross Blue Shield and a couple others are not paying their bills.

The next day, Chris Callahan, a spokesman with Blue Cross Blue Shield of Texas, confirmed that Mercer ER was out-of-network but didn’t have any other information about working with this specific center.

Accepting all insurances and being in-network are not the same thing, Callahan said. “It’s a difference that can cost our members, or a patient, thousands of dollars out of pocket.”

“We take very seriously the obligation to pay claims for our members’ covered services,” he said. “If a member or provider, whether in- or out-of-network, has questions about claims payments, we are here to help.”

Some say the problem is that people are confused about what kind of center they are walking into despite the clear “emergency” signs.

recent study from Rice University’s Baker Institute analyzed insurance claims from 2012-2015, finding a huge overlap – 75 percent of the 20 most common diagnoses at freestanding emergency departments – were the same as at less-expensive urgent care centers.

In 2015, the average price per visit of a hospital-based ER and freestanding ER were similar at $2,200. The price for urgent care centers was only $168.

In recent years, freestanding ER operators say insurance companies are denying coverage for emergency room visits that the companies say didn’t constitute a “true emergency.”

Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers, said this isn’t good for patients and such policies could cause freestanding ERs to go out of business.

“We continue to grow into different parts of the state, but the challenge that does exist is the ability to be paid for our services,” he said.

Shields says insurance companies shouldn’t be able to penalize patients who believe they are having an emergency by outright denying or underpaying a claim after the fact.

“We believe this new policy by Blue Cross Blue Shield is against the law and puts people’s lives in danger,” he said. “Unless the Legislature addresses it, there’s a fear that patients are going to be put in a difficult spot.”

Last summer, Neighbors Emergency Center on Houston Highway closed before opening for business, citing a saturation of the market. A call to Victoria ER wasn’t returned, but the business is still in operation since it opened in 2015.

As for Lutes, next time she’d rather wait for her doctor’s office or go to an urgent care center. She said the convenience of a freestanding ER wasn’t worth the extra out-of-pocket cost.

“I told them I’m not paying that. That’s insane,” she said. “They’ve sent me like two bills since then.”

Source: Victoria freestanding ER closes amid battle with insurers | Local News | victoriaadvocate.com

If it’s not an emergency, Blue Cross Blue Shield won’t pay 

It’s the middle of the night and that nagging chest pressure seems to be getting worse. Could be a heart attack. Could be indigestion from the bad burrito at dinner.

Do you a) Go to the nearest emergency room; b) Find an open urgent care clinic; or c) Take a Tums and wait until morning to see your doctor during office hours?

Choose wisely, Texans, because the stakes are about to get a whole lot higher.

Starting June 4, Blue Cross and Blue Shield of Texas, the state’s largest insurer, will step up its scrutiny of all out-of-network emergency room claims for patients who have health maintenance organization, or HMO, plans. If, after treatment, a company review finds patients could have reasonably gone elsewhere for care, it will pay zero.

That means even insured patients could potentially be on the hook for thousands — if not tens of thousands — of dollars in medical bills if they make the wrong choice.

As word of the new initiative seeped out, doctors across the state were swift in their outrage and accused Blue Cross Blue Shield of forcing frightened patients to self-diagnose when they are at their most vulnerable. Guessing wrong, the doctors contend, could be deadly.

Blue Cross and Blue Shield flatly denies putting customers at risk.

“One thing I want to make very clear right off the start is if any of our members, or quite frankly, anybody in general, if you have or think you have a medical emergency you need to seek treatment at the closest place you can that can provide needed treatment or call 911,” said Dr. Robert Morrow, president of the Houston and Southeast Texas office of Blue Cross and Blue Shield of Texas.

Instead, the after-the-fact review and potential for denials can help weed out people inappropriately using expensive emergency rooms for non-emergencies. The insurer also seeks to push back against inaccurate billing, overtreatment and “excessive and unconscionable charges” from the physicians who treat emergency patients, Morrow said in an interview with the Houston Chronicle.

“We have, quite frankly, identified quite a bit of fraud, waste and abuse that happens within the context of some of these treatments at some of these facilities,” he said.

The Texas Association of Health Plans has previously said its internal claims data shows that nearly half of emergency physician claims in 2015 were outside the networks of the state’s three major insurers: Blue Cross and Blue Shield of Texas, Aetna and UnitedHealthcare. Doctors outside a network are free to bill two to three times more than those within network coverage, the health insurance lobby’s data showed.

In the example of chest pains, Morrow said his company would review the circumstances but most likely pay the claim even if it is out of network.

The ‘prudent layperson’

HMO plans already sharply restrict members seeking out-of-network services, typically not paying for care. The legal exception has always been if a patient truly believes they are having an emergency. In such cases the insurer must cover out-of-network screenings, tests and treatment, according to the Texas Department of Insurance.

A piece of legalese buried in most state insurance codes and in the federal Affordable Care Act is called the “prudent layperson” standard, and that is what’s at the heart of this fight, both in Texas and across the country where other insurers are trying similar measures. Does a patient think they are in crisis?

In Texas about a half-million people have Blue Cross Blue Shield HMO plans. It is not immediately known how many in Houston, the company said.

Morrow, who previously practiced family medicine, said his company will not penalize a patient if the ultimate diagnosis rules out an emergency — a stomach bug rather than appendicitis, for instance.

Instead the measure seeks to look at patient intent, of “what brought them in,” he said. Morrow calls it a “well thought-out” remedy to a stubborn problem.

Emergency room doctors call it something else entirely.

“This is a war going on,” said Dr. Cedric Dark, an emergency physician at Ben Taub Hospital and CHI St. Luke’s Health and a health scholar at Baylor College of Medicine Center for Medical Ethics and Health Policy.

Dark accuses Blue Cross and Blue Shield of circumventing the prudent layperson rule in an effort to underpay doctors and enrich the company. Doctors and the insurance industry have been locked in an escalating fight over reimbursement insurance for years. Dark says this is just the latest volley.

Morrow counters that his company’s policy adheres to the prudent layperson standard and in fact “embraces it.” He also points to Blue Cross and Blue Shield’s efforts to educate members on what constitutes an emergency.

Still, the Texas Department of Insurance was concerned enough to send a letter May 9 to the insurance company asking for clarification.

“The review is performed to determine if the claim accurately reflects the services rendered according to the medical records, and if the medical record supports the determination that an emergency existed in accordance with the prudent layperson standard in the Insurance Code,” Dr. Dan McCoy, Blue Cross and Blue Shield president, replied in a May 17 letter.

McCoy’s letter, obtained by the Chronicle through a records request, added that “HMO members will have their appeal rights if they disagree with the decision that their visit was not an emergency.”

Emergency room doctors argue it is wrong to try to divine patient intent in retrospect.

“Why do people come to an emergency room? Because they are afraid. They don’t know what to do. It’s the mom who brings in her child at 2 a.m. because a fever is spiking,” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program.

“They are Monday morning quarterbacking,” said de Moor. “The physicians who are reviewing records are not laypersons.”

A trained doctor might look at the circumstances of a case after the fact and see it differently than a patient or doctor in the heat of the moment, she said. In addition, a doctor might need to perform a battery of costly tests to arrive at the correct diagnosis or rule out more serious ones.

De Moor said what’s really at play is the insurer taking aim at the proliferation of free-standing emergency rooms. The retail centers, equipped and staffed like a hospital emergency room, are a Texas phenomenon that is starting to spread in a handful of states across the nation. De Moor is chair of the American College of Emergency Physicians’ section on Freestanding Emergency Centers.

Patients are often confused by free-standing emergency rooms and their less expensive cousin, urgent care clinics. Often the two care centers are close to each other and sometimes even in the same facility. One big difference between the two, however, is that free-standing emergency rooms typically are not included in patient insurance coverage.

‘Land mines’ for patients

Morrow of Blue Cross and Blue Shield of Texas acknowledges the bitter feud between his company and the free-standing emergency room industry but lays the blame at the provider’s doorstep. He pointed to a $45,000 bill to treat a patient who came into the emergency room with a sore throat, later diagnosed as tonsillitis.

Currently, about 80 percent of Blue Cross and Blue Shield out-of-network claims for emergency care come from free-standing emergency rooms, according to insurance claims data.

Stacey Pogue, a senior policy analyst for the Center for Public Policy Priorities in Austin, is wary of the new initiative.

“I can see why they are doing this,” she said of the unsustainable trajectory of health care costs. But the test will come in how it is implemented — and how well the appeal process works, she said.

Pogue and other health policy watchers worry most about how patients could get stuck in the crossfire. If their insurer decides to deny payment to the doctor or facility, the entire bill could then get passed on to the patient with a demand for payment. And unlike in other types of insurance plans, HMO coverage is not eligible for the state-sponsored mediation process.

“There are land mines all over this,” she said.

The Blue Cross and Blue Shield rollout is not happening in a vacuum. Elsewhere in the country, Anthem, the insurance giant, has initiated a similar program in six states — Kentucky, Missouri, Indiana, Ohio, New Hampshire and Connecticut. In the Anthem program, the final diagnosis can be part of the denial decision.

Anthem has faced harsh criticism from emergency room physicians and some health policy experts who worry about a chilling effect among patients trying to decide when and where to get emergency care.

The insurer denied thousands more emergency room claims last year over the previous year, according to an analysis of claims by the American College of Emergency Physicians. The spike corresponds with the implementation of Anthem’s program, said Laura Wooster, associate executive director of public affairs for the physicians organization.

While not identical to Anthem’s program, she said her organization is still concerned about what could happen in Texas.

“You can’t look at intention in a medical record. At best, you can look at presenting symptoms,” she said. Mostly she worries people may skip care and then something goes wrong. “Will you ever be able to forgive yourself?”

Source: If it’s not an emergency, Blue Cross Blue Shield won’t pay – HoustonChronicle.com

HCA helps fill gap in care left by Houston hospital closure

Nashville, Tenn.-based HCA Healthcare’s Gulf Coast Division will open a new freestanding emergency room in Houston July 17, according to the Houston Business Journal.

The new ER will help fill the medical gap left by the closure of HCA’s East Houston Regional Medical Center. The hospital closed Nov. 9 after suffering extensive water damage during Hurricane Harvey.

“The Gulf Coast Division is committed to providing emergency services in the east Houston area and has been for more than 40 years,” HCA Gulf Coast Division President Troy Villarreal said in a press release. “Unfortunately, Hurricane Harvey destroyed East Houston Regional Medical Center, leaving many people in the area without a nearby, easily accessible place to seek medical attention in case of an emergency.”

Demolition of East Houston Regional Medical Center is scheduled for late July. HCA is still considering several options for the property’s future, according to the Houston Business Journal.

Source: HCA helps fill gap in care left by Houston hospital closure

Why you may start seeing fewer free-standing ERs around Houston

 Gavin Grajales is a typical little boy.

“He’s very, very active. I mean, into everything,” said Gavin’s mother, Holly. He never stops moving, until something, such as an accident at the park, gets in his way. “He fractured his wrist and his elbow at the same time,” Holly said. She thought she was taking Gavin to a neighborhood urgent care center, but it was really a free-standing emergency room. “They X-rayed his arm, gave him some pain medication and they splinted it, and that was it,” Holly said.  Then she got the bill.

“It was sticker shock. I don’t even know how to describe it. You gave him Tylenol, a splint on his arm and I receive a bill for almost $2,000,” Holly said. Free-standing emergency rooms are not the same as urgent care centers. KPRC first showed youdramatic price differences between the two in 2014. One example: The cost to treat a urinary tract infection was six times more expensive at an ER than at an urgent care.

It’s the same with sinusitis and bronchitis.  Free-standing ERs were a hot business in Texas. Their use is up dramatically since the state licensed these facilities in 2010. But that trend may be coming to an end. The largest free-standing ER company — Texas-based Adeptus health — has seen stock prices plummet. The company is facing a class action lawsuit claiming Adeptus “actively conceals its billing practices and operates a business model meant to “trick patients into believing that its centers are appropriate for non-emergent care for the purpose of extracting extravagant fees.”  Adeptus Health has also filed for bankruptcy. “If we had gone in and said, ‘Is this an emergency room? Or is this an urgent care facility?’ is the only way we could’ve known the difference,” said free-standing ER customer Ginger Pine. Pine got stuck with a $1,700 bill after seeing a doctor for a fever and cough, at what she thought was an urgent care center. “Yes, it’s labeled an emergency center. But to me and my husband, we’re educated people. We don’t know that that means,” Pine said. If the word “emergency” appears anywhere on the building, it’s an ER. By law, an urgent care center can’t use the word “emergency” anywhere. It’s also important to know which facility can best treat your condition.

Dr. Marc Melincoff is a family medicine physician with Memorial Hermann Medical Group who practices at Memorial Hermann Urgent Care Washington Avenue.

You can schedule appointments online. It’s open 9 a.m. – 9 p.m., seven days a week with board-certified family physicians on-site. Patients ages six months and older have convenient, walk-in access.

He told Channel 2, especially in Houston, dehydration is a perfect reason to visit an urgent care.

“They could come here and in a matter of 15 minutes be taken to the back, be given an IV and an hour and a half later, they’re feeling much better,” Melincoff said. “Because it’s not really an emergency situation. It’s more of an urgent type of situation.”

Urgent care is also a good choice for stitches, X-rays, lab tests, broken bones and allergic reactions.

“Where you would (go for an allergic) experience with peanut butter, we can treat that here as well,” Melincoff said.

Life-threatening conditions should be treated in an emergency room.

“A heart attack is not here. A stroke is not here. We call 911 and they come here urgently,” Melincoff said.

Adeptus declined to comment on the lawsuit, but defended its marketing and signage practices in a statement to KPRC Channel 2 News:

“We actively work to educate patients on when to properly seek emergency medical care with highly visible emergency department signs, informational materials, outreach to the community and patient guidance on arrival. Patient satisfaction is rated above the top 5 percent of emergency departments across the country, according to patients surveyed by Press Ganey. We work to maintain this high level of satisfaction from our patients by delivering exceptional emergency medical care when needed and referring lower acuity patients to urgent care facilities as appropriate.”

Source: Why you may start seeing fewer free-standing ERs around Houston

Financial problems threaten Houston-area freestanding…

There are 300 freestanding emergency rooms across Texas, down just slightly from a year ago, according to the Texas Association of Freestanding Emergency Centers (TAFEC).

While business has been booming for almost a decade, one company located in Houston is now struggling.

Clara Chapa of Pearland said she’s never used the facility near her, Neighbors ER, but knowing an emergency room is nearby brings her comfort.

“They’re really close, so if you need easy access rather than having to rush to the hospital,” Chapa explained.

She prefers freestanding emergency rooms to a hospital because she said there’s less paperwork and less waiting time.

“Maybe by 30 minutes, maybe if not faster, sooner than that,” she said.

Neighbors ER near her home is now facing financial trouble. The company just filed for bankruptcy.

In a statement they wrote:

“Neighbors Health LLC and Affiliates files voluntary petition under Chapter 11 of United States Bankruptcy Code.

“To expedite the sale of its Houston and non-Houston operations, Neighbors Health has filed a voluntary petition under Chapter 11 of the Federal Bankruptcy Code in the United States Bankruptcy Court for the Southern District of Texas, Houston Division.

“The company has sufficient liquidity to continue its normal business operations, including on-going employee, supplier and service provider obligations.

“Neighbors will continue to deliver extraordinary, 24/7, healthcare to patients from our board-certified physicians and medical staff al all of the 22 Free Standing Neighbors Emergency Centers.”

Channel 2 Investigates first warned you about troubles among freestanding ERs last year when the largest company in Texas had stock prices plummet and also had to file for bankruptcy.

Bankruptcy wasn’t the only challenge facing Adeptus. The company faced a lawsuit for deceptive business practices, accused of not being entirely open about the difference between urgent care and emergent.

It’s a problem we’ve been tracking for years.

“They’re not connected to a hospital. A consumer is looking at that as potentially an urgent care facility when really it’s an ER,” said Memorial Hermann Urgent Care Vice President Jennifer Zimmerman.

She said urgent care centers are intended to fill the gap between when primary care physicians are unavailable (evenings, weekends) and it’s not an emergency issue.

The Texas Association of Freestanding Emergency Centers said their facilities may be more expensive than urgent care centers, but they are usually less expensive than going to a hospital.

The trick is knowing what kind of care you need.

Trauma, heat stroke, trouble breathing should be treated at an emergency room.

Urgent care is a good choice for dehydration, stitches, and primary care complaints.

If the word “emergency” appears anywhere on the building, it is an ER. By law, an urgent care center cannot use the word “emergency” anywhere.

Source: Financial problems threaten Houston-area freestanding…

The Cognitive Dissonance of Narcotic Prescribing by Dr. Edwin Leap – EdwinLeap.com

I know a bit about the opioid epidemic ravaging America.  My wife and I grew up in West Virginia and follow the news from home. I practice emergency medicine in rural South Carolina, and have worked in Georgia, North Carolina, Kentucky and Indiana.  I have seen the enemy and it is terrible to behold. 

The genesis of the epidemic has been covered over and over. It is complex problem with an equally complex history.  No sound-bite by politicians or government regulators can simplify it.

Many people and groups are working to stem the black tide of overdose deaths flowing across America.  Health departments are offering counseling, as well as distributing Naloxone (also known as Narcan) to reverse overdoses.  Pharmacies are limiting the size of prescriptions filled. 

States have data-bases to track opioid prescriptions and are monitoring prescribers more closely than ever.  Physicians are being advised to give fewer opioids per prescription.  State medical boards are also mandating that physicians receive more education on the topic. 

Only a few years ago physicians were called heartless if they had reservations about prescribing opioids for pain not associated with cancer or serious trauma.  Times and policies have changed and the same physicians are considered dangerous for doing what they were explicitly directed to do before. 

However, as we charge forward with assorted plans, programs and schemes to address the opioid crisis, I want to explain why physicians sometimes find it hard not to give narcotics.  

You see, we went into medicine with grand plans to save the dying, heal the sick and wounded, and ease the pain of the suffering.  Those are noble goals, which helped us endure the process and become physicians.

But along the way, we were ill-prepared for the very real struggles of addiction.  In addition, medical school didn’t teach us how to face the cognitive dissonance of being told to believe what patients say while simultaneously having good reason to believe they are lying. (Lying, that is, to either to feed their addiction or to obtain drugs to divert for illicit sales.)

This is tough stuff.  Research is pretty clear in suggesting that many painful conditions are ultimately not best treated by narcotics. (A tough thing to sell to someone who has been inappropriately given narcotics for years.)  Furthermore, some people with legitimate reasons to use opioids still become addicted.  Young people with sickle cell disease often need the relief of narcotics, and through no fault of their own.  The same is true for those with severe injuries that take months or years to heal.  (If they heal at all.)

The situation is made more difficult because we still don’t have a ‘pain-o-meter.’  Oh, we have that ludicrous and completely subjective pain scale.  But it isn’t like a blood pressure or heart rate.  And while some conditions are obviously painful, others aren’t so evident. Dental pain can be truly terrible without ‘looking’ painful.  (This is a thing often dismissed by those who have been able to afford good dental care their entire lives.) Back pain can be unverifiable, and so can the pain of ovarian cysts, the nerve pain of neuropathy, the torture of migraine headaches and many others.

Furthermore, real patients with real (often chronic)  pain often have financial woes and can’t see a pain specialist or back surgeon.  All too often these days, they can’t even see a family physician.  Sometimes they have a pain emergency, after a surgery for instance, when their own physician is out of town. 

So when we see that patient who has many suspicious prescriptions for pain medication in the state data-base, but who is crying real tears and being attended by worried family members, it’s not so easy to turn them down.  Sometimes we say no; but it requires that the physician really have his or her ‘ducks in a row,’ and ensure that the evidence is sufficiently strong to withhold opioid pain medications.

We’ve all been fooled and we’ll be fooled again.  Because for a physician pain is a frustrating mixture of the objective and the subjective.  In the treatment of pain we confront the very real misery of humans and balance it against the very real danger of overdose and death.  

It’s easy to say ‘just stop giving them those prescriptions,’ or ‘oh he’s lying, he always does this.’  But deep in our physician hearts we want to believe people. We want to do the right thing and ease the misery.

We hate this epidemic. We hate seeing lives lost and giving tragic news to the families of the dead.  We grow weary of arguing, endlessly, about pain medications.  And we resent being falsely accused of causing the whole mess.

Mind you, we have to own our fair share of it all. And some of us are worse than others.  Physician run pill-mills, physicians too free with opioids, physicians themselves addicted; we’re sometimes part of the problem to be sure.

But don’t judge physicians too quickly or too harshly until you have looked into the crying eyes of a patient and said, firmly and with some sadness, ‘I’m not giving you a narcotic today.’  And watched them walk away, wondering if you were right.

Source: The Cognitive Dissonance of Narcotic Prescribing | EdwinLeap.com

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