Overtesting: Where Do We Go From Here?
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Overtesting, how did we get here?

Overtesting, how did we get here?

I heard recently about a case of over-testing that seems so typical nowadays that it makes me wonder not just how we got here, but how we go back.   A 9-year-old child comes to the ED with abdominal pain and vomiting, RLQ tenderness and guarding, and a CT that is read as ‘equivocal, appendix not well visualized’. White count was up a bit. No surgical consult in the ED. Child sent home. Goes to a different ED a day later, same story, exam more pronounced with rebound tenderness and a 19,000 WBC with temp of 38.9. Surgeon called, insists on repeat CT before seeing patient. Repeat CT shows acute appy. Appendix found to be ruptured in the OR with early multiple abscess formation. How did we get here?

In 1976, when I first started practicing emergency medicine, the diagnosis of acute appendicitis was made clinically, and confirmed (or not) in the OR, or with the tincture of time and reexamination. The only value of an elevated WBC was that it helped us get the surgeon out of bed. A classic set of signs and symptoms would do the same, if you were confident enough and the surgeon trusted your judgment, though admission and surgical consult in the AM was a reasonable approach if the patient did not look toxic. No CT, no ultrasound, just plain old clinical judgment. Sure, there were a few negative explorations, but the operative risks, even in ‘them old days’, was low, and I suspect perforations were no more frequently encountered (though socio-medical reasons for these ruptures are complicated, then and now).   Certainly that initial and subsequent additional dose of radiation might have been avoided in this case by use of ultrasound. The increasing skills of EPs behind the U/S probe have reduced the stress on the ultrasound techs, who are often in limited supply, especially after hours. Still, our reliance on diagnostic testing when the clinically obvious is clinically obvious seems like economic, legal, and medical overkill.

There are so many reasons why this is happening to medicine and to patients in the U.S. that returning to the era of decision-making based on sound clinical judgment as the standard, rather than the exception, seems all but impossible. Patient expectation, fear of malpractice suits, lack of access to close follow-up post ED discharge, de-linking of care and primary care provider relationships, reluctance to pay for revisits to the ED, high copays for ED visits, physician life-style issues, poor reimbursement for the care of most children, job insecurity, pressure by hospitals to over-test, contractions in time spent with patients: the list goes on.   Not even capitation can overcome these incentives to over-test and over-treat. Choosing Wisely? Yea, that’s certainly caught on like wildfire.   I fear that even if we could reverse or eliminate some of these factors that predispose physicians to over-test, physicians may have lost too many of their clinical skills, and/or lost the ability to pass them on to clinicians in training.   Even as testing gets more ‘accurate’, it seems to get more overly sensitive, causing physicians to chase down every borderline abnormality, and ‘over-diagnose’ these findings to justify the over-testing. A slightly elevated creatinine due to dehydration becomes renal insufficiency and then acute renal injury resulting in renal ultrasounds and who knows what else.

If I had a way to return to the days before CTs and Ultrasounds, MRIs, sensitive troponins, and the rest, would I do it? Of course not: the problem isn’t with these miraculous instruments and tests, it is with those who use them, the incentives to rely so excessively on them, and the system that incorporates their overuse into standards of care.   We can’t afford to go forward in the same vein: it could bankrupt the country. We can’t afford to go back: we will lose the real advantage of advances in care. All physicians can do at this point is, like the addict, acknowledge their dependence, strive to do better, and hope for forgiveness.

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Mandating Coverage for Emergency Care
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Gutting Mandated Health Plan Benefits

Gutting Mandated Health Plan Benefits

The federal mandate that hospital emergency departments (EDs) and the physicians who staff these departments provide medical screening and emergency care to all people who present to the ED for care (the Emergency Medical Treatment and Active Labor Act) ensures that everyone in our country has guaranteed access to emergency care when they need it, regardless of insurance coverage or ability to pay. Everyone. Regardless. With the last twist on the failed ‘repeal and replace Obamacare’ effort in the Congressional House (the American Healthcare Act), the conservative wing of the Republican Party coerced House leadership to include language that would have eliminated requirements that heath insurers include coverage for emergency care and any hospitalization or surgery that was required to resolve the medical or traumatic emergency. EMTALA has always been an ‘unfunded mandate’, meaning that Congress mandated this service but declined to allocate funding to pay the physicians and hospitals that provide these services. It should be fairly obvious that if no one paid for these services, and there was no funding to support them; mandated or not, there would be hardly any one providing them. You cannot expect hospitals, or physicians, to offer emergency care unless most of the costs incurred are covered, somehow.

It is true that Medicare does pay for these services, though at rates that fail to cover the cost of providing them. If States were allowed to modify or eliminate coverage for emergency care under State-operated Medicaid programs, as might have been the case under block-grants or waivers proposed by Republicans; Medicaid programs would no longer cover emergency care. As it is, the rates paid by Medicaid are in many cases way below the cost of providing these services. The Veterans Administration is supposed to cover emergency care, though in many cases claims go unpaid or inappropriately denied, and the rates, when the claims are paid, are likewise borderline. The fact is that government sponsored health care coverage programs do not begin to cover the costs of providing emergency care for all. In fact, the 40% of emergency care patients who are insured under commercially operated health plans cover close to 70% of the total revenues collected to cover these costs.  In many hospitals, the number of commercially insured patients is so low that operating emergency departments represents millions of dollars in unreimbursed services, huge losses for a business that typically operates with extremely thin margins.

If the House Freedom Caucus had their way in Congress, not only would Medicaid enrollment have fallen and many more emergency care patients have been uncovered and unable to pay for their care; but in addition may commercially insured patients would have ended up with insurance plans that failed to cover emergency care as a part of their benefit package. As ACEP and every one else familiar with the economics of emergency care warned, passage of this flawed plan would have most certainly trashed the emergency care safety net. This in turn would have guaranteed that, despite protestations to the contrary, patients would be ‘dying in the streets’ for lack of access to emergency care, because loss of coverage would translate directly into loss of access for many Americans, despite the EMTALA mandate. What these very conservative Republicans may not have considered was that this would not just impact the poor, it could just as well result in the richest campaign finance donor dying in the street as well. That’s the thing about medical emergencies: they happen at the most inconvenient of times. Your rich person might just find himself in desperate need of an ED only to discover that the nearest hospital has closed (as many already have), and the next closest ED that is still open is miles away, understaffed, underfunded, and overcrowded. Poor people have that experience now all the time, even though Obamacare had stemmed the tide of uninsured and helped to shore up many failing hospitals. Medical emergencies have a way of leveling the playing field, often putting rich and poor in ED gurneys side by side. In fact, if that very conservative Republican congressman suffered major trauma, a hospital ED serving mostly the poor might be the best place for him to get trauma care. Gutting funding for emergency care, from a purely self-preservation point of view, might well have been the dumbest thing the House Freedom Caucus ever espoused.

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Emergency Care: Guaranteed Coverage or Guaranteed Access
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EMTALA is not Health Insurance Coverage

EMTALA is not Health Insurance Coverage

In a recent interview on CNN’s New Day, Rep. Mark Meadows (R-NC) responded to a comment from host Alisyn Camerota that ‘access and coverage were not the same thing’ during a discussion about replacing the ACA. He said: “Well, we’ve got 318 million people. The goal is to allow access to all. There’s a federal law right now that if you show up at a hospital, you get coverage, Alisyn. And so, it’s a false narrative to suggest we have people who can’t go in and get coverage. It’s a federal law.” The congressman was talking about EMTALA, the federal law that requires hospitals that operate emergency departments, and the physicians who staff these EDs, to prove a medical screen exam to anyone who comes to the ED, and stabilizing care to anyone who has a medical emergency, regardless of insurance status or ability to pay.   EMTALA, however, is an unfunded mandate: the federal government never allocated funds to pay for these services. As a consequence, EMTALA provides a guarantee of access to emergency care for all, but if you have no health insurance coverage, you will receive bills for these services, and be expected to pay them. Without insurance coverage, a single medical emergency could easily bankrupt many families, and this has already happened hundreds of thousands of times.

Now it is possible that Representative Meadows does not really understand that EMTALA guarantees access, but does not provide coverage. Many legislators are ignorant of the provisions of this law, or misinterpret what EMTALA really means for patients who do not have health insurance. Even when confronted with the assertion (by Ms. Camerota) that access and coverage are not the same thing, however, the congressman went on to conflate the two terms by stating that access to emergency care for all was the same as coverage for these health care services. This leads me to believe that Representative Meadows was not inadvertently confusing these terms: he was deliberately misleading his constituents. In defending the effort to repeal Obamacare, and replacing it with something that might leave a lot of Americans who currently have insurance coverage with nothing to help them pay their medical bills, Rep. Meadows was throwing up a smoke screen by equating the EMTALA guarantee of access to emergency care to having a form of health care insurance coverage. The false narrative here is not that people may not be able to get coverage under Trump Care, or whatever the replacement plan may be called. The false narrative is that all Americans have health insurance coverage by virtue of guaranteed access to emergency care.

Why is coverage important? Many people who have health insurance coverage currently pay through the nose for that coverage, but the single most important advantage of coverage is that those who do not have it have to pay retail for health care services, while those who have coverage usually have to pay only a portion of a discounted (call it wholesale) fee for the same services (including services falling under the deductible). When it comes to really expensive, complex, or prolonged health care services, like one might experience in a true medical emergency, the net effect of having this coverage and access to this discount is huge, even when the plan carries a large deductible. Coverage, either through Medicaid or through a government subsidized commercial plan, is even more important for those who are not wealthy. A single health care bill not covered by insurance of some sort can cripple a family, and destroy whatever credit they may have. The uncovered may not be allowed to ‘die in the street for lack of health insurance’, but EMTALA will not protect them from the death of a 1000 cuts inflicted by unpayable health care bills that pile up. Health care coverage is also important because, at least under Obamacare, health insurance plans must provide coverage for routine and preventative health care services, and not just coverage for health care catastrophes. There is a price to pay for failing to receive such care, and the price may be paid, not just by the individual, but also by the community and by taxpayers, which suffer from lost productivity and the cost of providing other incurred social support services.

Wading through Rep. Meadows smoke screen, and similar assertions by his colleagues, you can readily see that access to emergency care is NOT health insurance coverage, even for medical emergencies. Why legislators, and even Presidents (Bush and others) continue to promote guaranteed access to emergency care as a backstop for the failure to provide universal health insurance coverage, while at the same time bemoaning the high cost of a visit to the ED, and the ‘unnecessary’ use of ED services, is baffling. You can trace the path from this kind of political dishonesty to the closure of hundreds of emergency departments all across the country. It is a circuitous path, no doubt, crossing through inadequate Medicaid reimbursement and failure to enforce fair payment rules; around circumvented PPACA regulations and inadequate (soon to be expunged) network adequacy standards; and under uncollectable high deductibles and health plan consolidation and profiteering. The end result is reliance on an emergency care safety net that is overburdened, underfunded, inappropriately castigated, and constantly under assault even though it is essential to the maintenance and proper function of the existing health care system and the security and well being of more than 150 million citizens a year. This is what happens when deceitful or uninformed legislators confuse access to emergency care and health insurance coverage.

Ps:  Congressman Mark Meadows’ DC office tel. no. is:   (202) 225-6401

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Kitzhaber Nails Healthcare Cost Reduction
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The Hon. Dr. John Kitzhaber

The Hon. Dr. John Kitzhaber

Dr. John Kitzhaber is an emergency physician who transitioned to politics after 18 years in the ED, and became a two-term Governor in Oregon. Recently, he gave the keynote speech at a Health Policy Conference in Hawaii that outlined perfectly what America needs to do to reduce health care costs, and more importantly, improve the health of US citizens. If you are fiscally conservative, or socially liberal, you will find that Dr. Kitzhaber has finally achieved a fusion of the two political ideologies that is both profound and achievable. John became famous in health reform circles when, as state senator, he developed and implemented the Oregon Health Plan, predicated on health care coordination in the Medicaid program, early childhood intervention, and the use of Coordinated Care Organizations to address a huge budget hole the state experienced as a result of rising Medicaid costs and falling revenues. In this latest speech, Dr. Kitzhaber pointed to the ever rising cost of health care in the US, and the fact that these expenditures have failed to achieve better health for Americans (relative to other economically advanced countries). John’s main point is that in order to save the country from drowning in health care debt, we need to redirect some of these expenditures from providing care to improving health, particularly through early intervention.

By early intervention I don’t mean the typical preventative care initiatives like mammograms and colon cancer screening and the like. Dr. Kitzhaber makes a very strong set of arguments for early intervention for children at risk, an investment with a huge potential payoff in terms of reducing the need for health care services down the road, and reducing other government and even private enterprise expenditures: in the criminal justice sphere; in social welfare programs; in failed educational efforts, and in lost productivity. John pointed to a remarkable study conducted by the CDC and Kaiser Permanente called the Adverse Childhood Experiences (ACE) Study that was able to identify young children who had certain experiences that were strongly associated with the risk of having subsequent social and health problems as adults. A predictive scoring method has been developed to facilitate the identification of these children who have suffered psychological stressors, and according to Dr. Kitzhaber, there are a wide variety of early social, economic, psychological and behavioral interventions that have been proven to mitigate these stressors and prevent these adverse childhood experiences. Investing in these interventions for children at risk could, according to Dr. Kitzhaber, reduce subsequent government spending for healthcare and welfare and criminal justice programs by billions of dollars.

Conservatives often scoff at the idea that spending on social welfare programs is worthwhile, as in their minds it just seems to perpetuate more spending. But what if spending on such programs were targeted to a very specific group of children and families that were at high risk of generating the most societal costs down the road, and by preventing such outcomes, not only reduce future spending on jails, mental health treatments, and health care services that could thus be avoided; but also improve productivity, employability, educational achievement, productivity, and the general wellbeing of the entire community. The examples John provides in his speech to explain how this would work, and why it is so hard to get current health care providers and policy makers to think outside the health care box to encompass targeted preventative health and social welfare services for at risk children that would hugely impact future spending, are both personal (the fruits of practice in the ED) and compelling. John hit the nail on the head with this thoughtful perspective on health care reform from a clinician turned politician who learned some key lessons in both careers. It is unfortunate that in this partisan climate, it will be difficult for a social democrat to get heard, even if he or she is speaking as a fiscal conservative.  I strongly suggest you go back to the link above to his speech and check out the video.

Ps  Thanks to Dr. Larry Bedard for forwarding this video.

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Hospital Staffing Contract Turnover
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Your staffing contract is terminated !

Your staffing contract is terminated !

You may have read about the breakup of Summa Health Systems and Summa Emergency Associates, a group of 55 emergency physicians and 20 PAs who had staffed the five emergency departments at Summa in Ohio for 40 years. The story has been in numerous EM magazines, ACEP and other medical society publications, and local newspapers. Although much has been written about the issues, conflicts of interest, and implications of such a rapid and hastily planned turnover of this hospital staffing contract; there are some underlying themes related to practice consolidation, growth imperatives, and the economics of hospital-based department physician staffing relationships that deserve further exploration. These considerations affect not only emergency physician groups that staff hospital EDs, but also anesthesiologists, radiologists, intensivists, hospitalists, and even trauma surgeons and internal medicine subspecialists. In fact, it is not just ED groups that have seen significant consolidation into large and very large CMGs (contract management groups); these other specialists have also been consolidating and growing and even coalescing into multispecialty CMGs. What is behind this consolidation? Why is there so much turnover in department staffing contracts? How is it impacting these physicians, their hospitals, and the cost of care? In an age where transparency in health care is almost anathema, it is difficult to answer these questions with certainty, but it is not unreasonable to speculate.

There are many reasons why hospitals and hospital systems change staffing contractors. There are certainly both downsides and upsides to making this change, for all concerned parties, including the patients; and you would expect the wise hospital CEO to carefully weigh these considerations before pulling the trigger. The CEO (and the incoming physician group) will likely point to precipitating factors like: poor patient satisfaction ratings; inability of the group to mentor (or get rid of) underperforming members of the group; complacency, poor operational metrics, or a failure to adopt continuous improvement strategies; poor relations with nurses; the need for a group with more sophisticated management tools; or greedy doctors. The group that gets ousted will likely point to: failure of the hospital to adequately staff the department; excessive boarding of ED admissions in the department; unreasonable expectations; unwillingness to subsidize a financially stressed practice; coercive contracting by the hospital; demands that the group take on financially unsupportable practice lines; or a greedy hospital C-suite. Money isn’t always the primary issue, but it is often a significant consideration. Consultants are sometimes asked to weigh in on the issues, either in an effort to rehabilitate the group, or to provide the CEO with cover. In almost every such case I have witnessed, one or both parties become intransigent, or can not find a way to hear or be heard; and as a consequence families are disrupted, patient care is sometimes compromised, reputations may be disparaged, revenues are almost always adversely affected for both parties, careers upended or even ruined, medical staffs assailed, and nursing staff pulled in every direction. This is not always true, of course: some transitions are welcome and needed, and some threatening RFPs turn into opportunities for reinvigorated relations between hospital and group. There is another factor besides the negotiation between hospital CEO and physician group, however, that frequently has bearing on the outcome.

In these contract issues, there is almost always a third party, or several, waiting in the wings to assume responsibility for staffing and running the vacated department. Why are these groups so willing to assume the often rigorous and even distressing job of stepping in to a new hospital to replace an existing group? And if the existing docs were so bad or intransigent or complacent, why is the new group often allowed to hire these same docs to staff the department under new management? Often, as in the Summa situation, the new group has to substantially subsidize the practice, at least for a time, in order to replace what the group leaving may have taken years to develop, including not just qualified physicians, but also accounts receivable, billing services, support staff, PAs and NPs, and typically most important, leadership. The new group may even have to bend the rules a bit, risking: inexperienced physicians quickly hired; hurried credentialing; malpractice related to poor coordination of care in unfamiliar consulting, follow-up and referral arrangements; and even pulling staff from established sites and jeopardizing those contracts. The underlying factor that motivates most of these groups taking over staffing contracts is the growth imperative.

To put it another way, these groups need to bring in new docs from which they can extract revenue in excess of compensation. Different CMGs do different things with this revenue, but they all need it. Some, like CEP America, the group I worked with for 30 years, redistribute this ‘excess revenue’ as a bonus to partners who have moved through the partnership track. This is a way to compensate those partners who have contributed their time and effort to building their practices and reinvesting in their partnership. CEP America is fairly egalitarian in this distribution, with a limited year partnership track and all full partners owning the same equity slice. Other groups distribute this excess revenue to a very limited number of equity holders, or use other methods to inequitably distribute these funds, such as charging inordinate fees for billing services owned by a small portion of the group. Still others must feed the hungry maw of Wall Street or other investors, in the process of exchanging the future revenues (in excess of compensation) of future employed physicians in return for equity multiples of stock or bonuses or payouts to a small number of physician entrepreneurs who ‘built’ the group.

If the CMG stops growing, the bonus or stock value or distributed equity dries up, or is held to replacement rates as older docs retire. A few CMGs really try to grow selectively, and preferably through mergers with other groups that have similar, usually democratic, business models. Others see failing contract groups as fair game, often justifying this by citing their better patient outcomes or leaner management, or more sophisticated support systems or medical directors. Some CMGs are so motivated by this growth imperative that they become predatory, aggressively pursuing new contracts at the expense of not just the replaced group’s physicians, but at the expense of the entire specialty. This ‘excess’ revenue imperative has also resulted in escalating physician charges, aggressive claims coding and collection tactics, and employee exploitation. What I do not understand is why hospital CEOs haven’t caught on to this. Ultimately, it can’t be good for business. Perhaps if the average hospital CEO held their job for more than a couple of years, they would be thinking longer term, and invest in helping their existing contract staffing group succeed.

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