Alternative Therapies That May Help in Sleep Disorders
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managing sleep disorders without meds

The following is a guest post by Steven Sanders:

We can probably all attest to suffering a sleepless night at one point in our lives…

You find yourself laying in the dark silence for hours on end, even with your eyes closed, counting sheep just hoping that rest will find you soon. But, it seems to never come.

While most of us experience this due to something common, acute, and short-lived, like stress or anxiety, other people experience this feeling regularly due to various sleep disorders. A few common sleep disorders include restless legs syndrome, insomnia, and sleep apnea.

While a common method of treatment for sleep disorders is sleeping medication, there are other alternative therapies that might offer some relief as well:

Specialized Blankets

You might find that tucking yourself in under all your blankets is soothing as it provides you warmth and a feeling of security and comfort…  However, with a sleeping disorder, you might find that you rarely experience this which makes it hard for you to relax. Or, you might experience this but just not strongly enough to promote sleep.  But, there are specialized blankets which are actually designed to further promote these positive feelings and help fight sleep disorders.

A weighted anxiety blanket helps promote sleep by adding some pressure to your body, which encourages your body to relax and allows you to fall asleep. You simply cover up and sleep with this blanket just like you would your normal comforter.  By stimulating the deep pressure touch receptors throughout your body, a weighted blanket will give you even more of a feeling of security, which also helps encourage your body to allow you to drift off to dreamland.

Herbs

As a child, my mom would always give me chamomile tea at night if I was a little wound up and it helped me relax. I always assumed it was just the warmth of the tea that calmed me, however, I have recently learned that chamomile is actually a herb commonly used for treating insomnia.  Another herb that can be used to help with fighting off sleeping disorders is the root of valerian. Some studies suggest that this particular root aids with the onset of sleep and with sleep maintenance.

Meditation

Aside from stress and anxiety, increased muscle tension and intrusive thoughts also greatly interfere with sleep. If your muscles are tense, you might find yourself never truly reaching that point of relaxation. You might struggle with getting comfortable, as well.  But, this is where meditation comes in…

Meditation teaches you how to control the mind and really become aware of your body. Through breathing techniques and moments of silence and reflection, you will find that you are better able to teach your mind how to calm down.  Using these techniques, even those suffering from insomnia might be able to learn how to wind their body and minds down.

Exercise

Even in those without sleeping disorders, exercise has been shown to help deepen sleep in individuals – young and old. But, it also works well in those who do have a sleeping disorder.  Regular exercise not only helps promote a good night’s sleep but it also helps promote a deeper sleep, leaving you waking up much more rested than normal. It can even be low-to-moderate exercise such as yoga.  Through exercise, you can find some relief from stress and anxiety – both of which can hinder your ability to fall asleep at night. It can also help tire you and get rid of extra energy which also encourages your body to rest.

If you find yourself suffering from a sleeping disorder, try one or a few of these remedies to help encourage your body to drift off to sleep. By getting a good night’s sleep, you will find yourself feeling more rested, more alert, and just healthier overall.

Editor’s note:  I would also include techniques to deal with obstructive snoring.  This is not the same disorder as sleep apnea, which would engender an entire blog in itself.  Obstructive snoring is usually related to jaw size (small), soft palate (long), and overbite, all of which may lead to obstructive snoring.  This is characterized by relaxing of the oral and facial muscles during sleep, resulting in loud snoring and partial and sometimes intermittent complete obstruction of the airway, which disturbs sleep and may cause awakening every few minutes.  The most effective treatment for this disorder is a dental device that looks similar to a mouth guard for grinding, but thrusts the mandible forward (in an adjustable way) relative to the maxilla in order to pull the back of the tongue away from the pharyngeal portion of the airway.  The fitted device tends to work better than those you can purchase over the internet, but is more expensive.  A restful night’s sleep for both you and your partner is often worth it.   The Fickle Finger

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Surprise Balance Billing Study Raises Serious Questions
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Health plans’ latest message to consumers

Intro: Cooper paper sets organized EM back a pace

This summer Zack Cooper et al gave a kick in the teeth to efforts by ACEP, EDPMA, and Physicians for Fair Coverage to try to reframe the message about balance billing with their paper “Surprise! Out-of-network Billing for Emergency Care in the United States,” published in the National Bureau of Economic Research. The study, which explores when, and why, out-of-network billing occurs when patients present to an in-network emergency care facility; purports to answer the question of who is really responsible for surprise balance billing: the physicians, the hospital, or the insurance company? By now, most impartial observers have already concluded that this is a health systems issue, and all three stakeholders (not to mention legislators and regulators) bear responsibility. What is most disturbing about this study is that uncovering the incentives that appear to drive and enable surprise balance billing may reveal behaviors that are far more troubling.

What Cooper’s paper alleges – and it’s not pretty

Cooper’s study points the fickle finger of blame (pardon the expression) squarely at EmCare (now named Envision) and the hospitals that contract with this group to staff their EDs, though undoubtedly there are other groups and hospitals that also have been utilizing similar strategies to maximize their revenues. This group had an average out-of-network (OON) billing rate of 62% and the authors allege that EPs working at for-profit hospitals are also much more likely to generate surprise balance bills. The authors go on to state that: “To motivate hospitals to allow out-of-network billing to occur inside their facilities, we show that physicians and physician outsourcing companies may need to compensate hospitals with a sufficiently large transfer to outweigh the costs they incur from the practice.” In other words, some form of excess financial return exchanged for utilizing these groups to staff the hospital’s ED. The findings of the study purport to show that when this outsourcing group took over an ED, facility payments increased by 11%, “driven in part by increases in imaging rates of 5% and a 23% increase in the rate that physicians admitted patients to the hospital”; average ED physician charges increased by $556 (96%), and that the group’s physicians were 43% more likely to bill for ED visits using the highest acuity billing code.   When a competing outsourcing EM group, TeamHealth, took over an ED, however, increases in hospital revenues were driven by increases in ED volumes, and not by changes in imaging or admission rates; though surprise balance bills did increase significantly. In short, the authors accuse EmCare’s physicians not only of applying a strategy of aggressively balancing billing patients, but also of up-coding, over-charging, over-ordering expensive diagnostic tests, and inappropriately admitting patients to the hospital.

Is the Cooper study trustworthy?

There are a lot of faults, potential confounders, and suspect bias to be found in this study, all of which can be used to challenge both the findings and conclusions derived. All of the charge and payment data from the 13 million ED visits examined in this study were sourced from a single health plan with a known agenda (akin to: “take that, unnecessary ER visits”), which in itself is cause to suspect the validity of the data. The methods used to identify transitions in ED staffing contracts were circumspect; the timeline (2011 – 2015) for the study covers a period in which many changes in charging, balance billing; and clinical practices have taken place; average admission rates were surprisingly low at only 9%; EPs generally are not solely responsible for the decision to admit a patient to an inpatient service; and regions of the country were not proportionally represented. In addition, the statistical and mathematical modeling of incentives for physicians to engage in OON billing, for insurers to contract, and for hospitals to contract with EM groups that engage in surprise balance billing, are obtuse and based on a lot of questionable assumptions (for example, that: if the ED physician is OON she obtains a quantity of patients that is equal to what she would receive if she were in-network). The authors do acknowledge that some balance billing of ED physician services is inevitable, but fail to appreciate that 70% of EP services are provided on nights, weekends, and holidays when comparing EP claim payment rates to other specialists. Moreover, the authors gloss over the impact of coercive contracting, narrow networks, and market monopsony by health plans as a significant contributor to the surprise balance billing problem.

Analysis: The realities of balance billing and emergency medicine

The authors recommended solution to address surprise balance billing is to require hospitals and physicians at those hospitals to bundle their ED services under a single claim or under a single contract with plans, and for the hospital to ‘buy ED physician services’ in a local labor market, producing a market price for ED physicians. Would the bundled payment option be successful? Many older EPs may remember when hospitals billed insurance plans for EP services, and how bad a job these hospitals often did billing and collecting for these physician services. As bad debts rose and reimbursement rates fell, hospitals were quick to pass this risk back on to EM groups; and the hospital industry is unlikely to reverse course now.

To patients, receiving a balance bill from an out-of-network emergency physician for amounts that insurers will not cover, when the patient goes to an in-network ED, smacks of a bait and switch. I get it that EM groups, as EMTALA-obligated providers, are at a big disadvantage when it comes to negotiating with health plans, especially when these plans apply coercive contracting pressure through the hospital C-suite. Still, one way or another, inadequate payment for EP services by plans inevitably has negative impacts on ED services at the hospital, and EM groups need to know how to make that clear to hospital administrators. I think at this point, most EM group managers understand that surprise balance billing is no longer an effective business strategy. If this had been widely recognized (or accepted) five years ago, ACEP might have had a better shot at establishing a charge-based OON benefit standard for EM services in exchange for abandoning surprise balance billing. Unfortunately, articles like the one published by NBER make this goal, at the state and federal level, much harder to reach.

ACEP may have won its lawsuit against CCIIO over the unenforceable ‘greatest of three’ standard for OON benefits, though with the future enforcement of PPACA regulations in doubt under Trump, this may be a pyrrhic victory.   In any case, demanding that plans reimburse OON EPs at the 80th percentile of usual and customary charges is going to generate a lot of resistance in legislative houses when legislators understand that plans would be required to pay 8 out of 10 OON EPs more than what those EPs charge. The findings in this study will only magnify the pushback. A follow-up study of surprise balance billing might well show that the practice has been disappearing since 2015; but what else might it reveal?

The more important question

Despite the faults of the study, it is disturbing to hear the allegation that certain EM groups are, or at least were, consistently encouraging up-coding, over-ordering, over-admitting, and over-charging by their physicians; and aggressively using surprise balance billing as a business strategy, all with the encouragement of their hospitals. One suggestion is that public or private equity ownership of these outsourcing companies plays a role here. There are always going to be outliers in medical practice and medical group business practices; but this study, however biased, of 13 million claims implies that the outliers may be way out there. Parts of the FAIR Health database certainly show wide variation in charges for EM services, and stories abound of hospital CEO’s demanding higher admission rates from their EDs. The issue that may be more important than balance billing is: are the other revenue enhancing practices alleged in this study real, and do they persist? Since its inception, the specialty of EM has been touting the role of EPs in reducing unnecessary inpatient admissions; of being good stewards of health care resources; of having excellent claims coding compliance programs; of wearing the white hat with a ‘no shirt, no shoes, no problem’ motto; and of being, first and foremost, advocates for patients. How are EM groups and their physicians who rely on up-coding, over-ordering, over-charging, and over-admitting to maintain revenues going to be able to adapt as more and more hospitals go at risk for the cost of care in their facilities? What does the House of Emergency Medicine do if mounting evidence suggests that even some of these allegations are true, and these practices continue?

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Emergency Medicine Up Against the Ropes
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Emergency Medicine Up Against the Ropes

The specialty of emergency medicine has often found itself under attack, particularly by insurance plans and consumer advocates.  The former is understandable, the later never made much sense to me, given that emergency physicians provide more un-reimbursed care to the under- and uninsured than any other specialty.  Recently, two different studies, both using health plan claims data, cast aspersions on the house of emergency medicine, leading to inflammatory stories in the press, and raising the ire of EM advocates and leaders within the specialty.  The recently published study on ‘Surprise! Out-of-network Billing for Emergency Care in the United States’ by Zack Cooper et al for the National Bureau of Economic Research was a blow to efforts by ACEP, EDPMA, and Physicians for Fair Coverage to try to reframe the message promoted by health insurers and consumer advocates that blamed EM groups for putting patients in the middle of disputes between plans and providers over coverage and fair payment of out of network emergency care services. The authors of this study beat up on in particular on EmCare, a large EM outsourcing group, for allegedly using aggressive surprise balance billing, claims up-coding, unnecessary inpatient admissions and use of excessive diagnostic testing and scanning, and excessive charging practices.  Another study by Vivian Ho, et al, recently published, then retracted, and then republished in the Annals of Emergency Medicine along with a number of secondary articles expressing critiques of the original article and defense responses from the authors, purported to show that Freestanding Emergency Centers, particularly those in Texas, were relatively expensive compared to Urgent Care Centers providing care to the same types of patients with less urgent problems.  According to Dr. Ho: “Insurers are being forced to pay higher prices for many health care services at freestanding emergency departments that could have been dealt with at much lower cost. These unnecessary medical costs then get passed onto all insurance consumers in terms of higher premiums.”   Emergency physicians throughout the country were, needless to say, disturbed by these studies and by the breadth of press coverage and the extent of public reaction that was generated.

The underlying problem with these studies was that data, generated over millions of claims, which the authors relied on for their analysis and conclusions was provided to the authors by health plans that clearly have an agenda.  Attempts to access and validate this data have been unsuccessful (no big surprise there), and I really do not think we can feel confident that this data was clean.  Nonetheless, it does not take a great stretch of the imagination to accept the possibility that emergency departments, and emergency physicians, often charge a lot more than urgent care centers for the treatment of similar problems.  It may be appropriate from a cost standpoint, but it is indeed difficult for legislators and regulators to reconcile the idea that out-of-network charges for EP (and ED and FEC) services can run as high as 4-6 times what these same physicians and facilities charge for these same services when provided on a discounted, in-network basis.  The surprise of getting billed for OON EP services at an in-network facility feels like bait and switch to the consumer; and trying to redirect the ire this engenders back on the health plan for aggressive or coercive contract negotiating or excessively restrictive narrow networks and surprisingly inadequate coverage is difficult, at best.

What is a specialty under fire to do?  Emergency Medicine organizations can make some effort to police their members and member-groups in order to address outliers and overly aggressive behavior; but that is going to be very difficult, and is likely to hurt the entire specialty more than it curbs the appetites of those who are at the far end of the bell curve.  Although I and others have argued that the motive underlying these attacks by plans and regulators has less to do with outliers and the higher cost of ED care and ‘unnecessary ED visits’, and more to do with trying to undermine the real commercial value of all physician services in the entire house of medicine, focusing on EMTALA-obligated providers who may represent the Achilles heel of fee-for-service medicine.   If you look, however, at the focus of these complaints about EM, the majority have to do with the high cost of care for lower acuity patients.  You don’t hear many complaints about the cost of care in the ED for major trauma patients, or patients with sepsis or cardiogenic shock.  In fact, often times EDs and EPs don’t even begin to charge enough to cover their costs when it comes to providing critical care services, or prolonged acute care, in the ED.  What you hear is the complaints about the cost of treating sore throats in the ED.  My suggestion would be to stretch the charge-master for both professional and facility fees:  lower for lesser acuity care, higher for greater acuity care.  For those EM groups and hospitals that already charge in the 70th or 80th percentile of fees or higher, ignore that bit about ‘higher for greater acuity care’ and just reduce the fees at the lower end.  You have already caused enough trouble.

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No, I Have Not Stopped Publishing The Fickle Finger
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The pause that refreshes…

A few folks have asked, so I guess it is time to explain my recent pause in posting to The Fickle Finger.  My wife and I have moved permanently to Lake Tahoe, purchased a home there, and moved our lives, lock, stock, and semi-retirement, up to a wonderful community called Incline Village, Nevada.  I am still doing some consulting work, and we are both trying to become thoroughly integrated into our new environment with a whole new set of great friends.  Unfortunately, moving is a real chore, almost a full-time job for the last few months, and thus the dearth of commentary on emergency medicine and the health care universe in this blog.  I hope to reverse the trend, as there is no lack of opportunities to pontificate on what is clearly a medical system, and an emergency care services sector, that is in great turmoil.  Please stay tuned, and look for my next post, which you may find stimulating, if not outright challenging.
The Fickle Finger

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Anthem: Rash? Don’t Go To The ER
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Anthem:  Rash?  Don't Go To The ER

Anthem: Rash? Don’t Go To The ER

According to the St. Louis Post Dispatch, in a recent letter to policy holders in Missouri, Anthem advised that: “Should members choose to receive non-emergency care in the ED [emergency department], they will be responsible for the charges incurred,” and that “minor conditions include sore throat, rash, mild fever, eye or ear pain and that can be “safely treated in less acute facilities.” This non-payment policy is similar to one Anthem already implemented in Kentucky and Virginia, in an effort to ‘change members’ behavior when it comes to accessing the emergency room’ in order address increasing costs to the plan for inappropriate ER use. This policy is consistent with the overall trend of health plans shifting costs, and risks, on to their policy-holders, through increasing deductibles, co-insurance payments, narrow networks, and now restricted coverage. One wonders if eventually health insurers will be out of the business of insuring risk altogether.

The consequence of such restricted coverage payment practices go beyond just shifting more of the cost of care to the patient. They now involve strategies that discourage enrollees from using the ER lest they get stuck with the entire bill for ER services. This strategy will, inevitably, backfire, when patients who should go to the ER are deterred from seeking these services, and suffer the consequences (which, of course, also increases long-term costs for the insurance company). Pictured in this blog is what appears to be a benign rash. If your sixteen year old comes to you at 10 pm complaining about this uncomfortable rash on his arm, and has a slight temp, and you go to Anthem’s website and read that Anthem might stick you for the entire ER fee for ‘inappropriate use of the ER to seek treatment for a rash, or a mild fever’; you might be persuaded to tell your son to go to bed and if the rash is no better, you will take him to an urgent care center in the morning. If so, there is a good chance your could find your child had died in his bed during the night. This rash is caused by the meningococcus bacteria, and this highly contagious and not uncommon infection can be fatal in just a few short hours.

You have seen this issue before in common stories about how manufacturers and insurance companies play the numbers and endanger consumers and policy holders in the calculated expectation that the financial risks are mitigated by the higher profits generated. Profits-made versus lives-lost is just a numbers game to them, but with this particular issue, there must be more to it. The cost of care for patients who ‘misuse the ED (the ER)’, compared to all the other costs that health insurers cover, is budget dust. In a study I did using data provided by a major health insurer, the total cost of care for the those 20% of patient visits that represented the least costly ER visits (facility plus professional ‘allowable payments’) accounted for less than 4% of the total cost for all non-admitted ER patient visits., and patients who get admitted to the hospital from the ER generate five times the ER costs of patients who are discharged.   The actual savings that might be generated by eliminating ER visits for non-emergency care probably amount to less than 0.05% of the total cost of ALL health care services covered by a health insurance plan. That is 50 cents for every $1000 spent on premiums. Why would insurance plans put patients at so much risk to save so little? Honestly, I don’t understand it, but I suspect this not just about ER services, it is about testing ways to use financial disincentives to change patient behavior. This new policy, I suspect, is just the first of many future efforts to dissuade patients from using their health insurance coverage to obtain health care services. For example, in Indiana, Anthem is rolling out a new plan that provides no out-of-nework benefits, and higher ER and Urgent Care copayments.

You might think that non-coverage payment policies like the one in Missouri would cost the plans greatly if patients start suing the plans over the consequences of this kind of manipulation, but plans have legions of lawyers who are responsible for mitigating these risks. That is why, when you go to Anthem’s website and read their recommendations about where to get care for different types of problems, you will see this disclaimer: “Call 911 or go to the emergency room if you think you could put your health at serious risk by delaying care.” In other words, the onus is on you to ignore the threat that Anthem will stick you with the entire cost of the ER visit if you think you need to go, and Anthem decides (retroactively) that you chose wrongly.  Likewise, if you are dissuaded by this threat, and chose not to go to the ER, and that was a bad decision, that’s also on you, not Anthem. Unfortunately, ‘life threatening or disabling conditions’ like the one pictured in this blog are not always recognizable as such to the ‘prudent layperson’, so when it comes to Anthem and plans like it, you pays your premium and you takes your chances.

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