More ED Patients, Less ED Specialists
Posted by WhiteCoat on November 21, 2007
Just read an article in Modern Healthcare referencing this article at the Center for Studying Health System Change (a .pdf copy of the article is here if the link goes dead). The latter organization could be a special interest group – I know little about them. But their article/survey is right on the mark regarding the availability of healthcare services in the emergency department. A summary states that
The diminished willingness of specialist physicians to provide on-call coverage is occurring as hospital emergency departments confront an ever-increasing demand for services. Factors influencing physician reluctance to provide on-call coverage include decreased dependence on hospital admitting privileges as more services shift to non-hospital settings; payment for emergency care, especially for uninsured patients; and medical liability concerns.
I work at a small rural hospital sometimes and that hospital does not have a lot of specialists available on staff to deal with emergencies. Often when there is an emergency, the specialists on staff at that hospital will just tell me to send the patient to the regional medical center. That statement translates into adding another $12,000 to the patient’s hospital bill (only about $2500 if an ambulance takes them).
The summary concludes by stating that
Many hospitals continue to struggle with inadequate on-call coverage, which threatens patients’ timely access to high-quality emergency care and may raise health care costs.
The system is cutting back on payments which makes specialty physicians less willing to care for patients who have no insurance and can’t afford to pay.
Trial lawyers may have good intentions in trying to hold healthcare providers accountable for every error that occurs in the care of patients, but according to this survey, the legal milieu may be having a secondary effect of reducing the willingness of specialty physicians to provide any emergency care.
I’ve watched more than one patient die in the ED while waiting for the helicopter to get there. It is an unfortunate part of the current healthcare system that where you live may significantly affect your likelihood of survival if you suffer a major trauma, a major stroke, a heart attack, or other similar emergencies.
Here’s a real-life example: I recently saw a patient in the ED at the small rural hospital. He had injured his hand at work using a power saw and cut the tendons in two fingers on his dominant hand more than a week prior to his visit. His boss was claiming that he was an “independent contractor” and therefore was not insured under workers compensation. None of the orthopedists would see him as a patient because his injury was “outside their specialty” (i.e. they were too afraid of getting sued for dealing with a complex hand injury). He went to the regional medical center and none of the hand specialists would see the patient because they were booked solid for months and the patient didn’t have any way of paying them. I went to the internet and looked up the numbers of some other hand surgeons 100-150 miles away and told him to try calling the hospitals where those physicians work. This poor guy is falling through the cracks and may very well end up with two non-functioning fingers.
We have to do something to fix this system.
UPDATE — 11/22/07
In the comments, Scalpel posted the question “how would you fix it?”
First of all, there’s no way I could top his 4-part masterpiece last month, so I won’t even try. But here are a couple of ideas that have been floating around in my head …
- Create county or regional specialty clinics where specialists MUST work at least one day per month in order to keep their state license. The specialists get paid a stipend by the state for staffing the clinic and for doing surgery if necessary. If the patient has insurance, the specialists get to bill on top of the state funding. Specialists don’t have to take patients in their offices if they don’t want, but they do have to treat patients in these clinics. At least this way patients have somewhere to go for specialty care.
- Any treatment rendered in these specialty clinics is partially or completely immune from lawsuits. People make a choice when seeking care – go to the specialists office, pay for care and wait or see a specialist in a public clinic who will do a reasonable job and accept the fact that your outcome may not be perfect. If you want the care to be available, you have to accept that doctors are human. This way, retired specialists could continue to practice in the specialty clinics a couple of days per month if they wanted. No worry about staff privileges, malpractice insurance, etc. But the care would be there.
As an aside, I’d even consider partial immunity for EMTALA-related care in general — including emergency physicians and hospitals. I’m sure that the response to this proposal is that it would turn all the physicians into malevolent agents of evil who go out of their way to harm any patient they don’t like under the shroud of civil immunity. Just have to roll my eyes at that one. - Federally-mandated real-time online tracking of hospitals available to provide emergency specialty services. If you have a patient that needs emergency psych care, you log onto a centralized internet database, type in your zip code, and the database gives you real-time tracking of the hospitals in your area that are available to accept psych transfers. No more wasting half your shift (when you could be treating other patients) making 50 phone calls to different referral hospitals hoping to find one that can take a patient. If the hospital has availability according to the database, they must take the transfer. You log in to the system, complete some basic patient demographics, and print out a form that will accompany the patient on the transfer. Once the form is printed, the database automatically changes to reflect one less open bed at the referral hospital. Upon printing of the form, notice is automatically sent to the referral hospital that a patient is coming from the referring hospital. The two hospitals then conference by phone for report.
- Once a patient is discharged, referral hospitals would be required to update their availability information every 1-2 hours. Those that fail to meet given threshold for updating their availability lose some federal funding.
- To keep hospitals from just turning on the “red light” to prevent transfers, a significant amount of funding should be tied to bed availability. Referral hospitals don’t have to take transfers if they don’t want, but the less transfers they take, the less funding they receive. Those that don’t rely as heavily on funding have to pay a fine into the system to help fund the initiative.
Maybe the funding is tied to amount of patients treated or some other indicator, but there needs to be an incentive for treating patients and accepting transfers.
How’s that for a start?
Nurse K said
The weird specialty we can’t get coverage for is plastic surgery. What plastic surgeon would want to do hospital call for a crop of uninsured drunks who de-glove their face (yeeesh) or get their faces bashed in with baseball bats when they can do boobs and face lifts for pre-paid-in-full customers instead?
I think we have one plastic surgeon who does our hospital. Hand surgery, though, during normal business hours, we just send them to their offices the same day usually. Back before the hand surgery group moved, they’d sometimes send their own staff over to the ER to retrieve the patient and wheel him across the street to their offices. We’re lucky.
scalpel said
“We have to do something to fix this system.”
So how would you fix it?
Nurse K said
Please tell me YOU don’t personally find psych beds for patients, Whitecoat. That’s what a crisis social worker should be doing. Working on these people is a very complicated, time-consuming job because each hospital has different admission criteria, for one thing. For instance, one podunk psych facility will only take older patients who have had a physical and screening labs including EKG, TSH, CBC, Chem even when they have a long documented psych history. The crisis worker finds the bed, fills out EMTALA forms, calls for ambulance transport, deals with admission criteria, etc.
scalpel said
Excellent ideas…thanks for your response.
Dr. Galt said
“Create county or regional specialty clinics where specialists MUST work at least one day per month in order to keep their state license.” Have you ever read Ayn Rand’s Atlas Shrugged? Are physicians just the first of the producers of society to be yoked into indentured servitude (which, the last time I checked, was frowned upon by the US Constitution)?
WhiteCoat said
So Dr. Galt, lets hear your plan. It’s very frustrating when people just sit back and criticize new ideas and then contribute nothing to the solution.
If docs don’t want to give one day a month of their schedule to help less fortunate people, they don’t have to. But the state doesn’t have to license them, either. The docs are getting paid both a stipend and the insurance proceeds, so your “slavery” stuff doesn’t fly. Do you consider jury duty as slavery, also?
Cosmo said
I think number 2 in the solutions, above, is one of the best ways to fix the problem.
If doctors are staying away from the ED because of a fear of litigation, take away that fear. Offer some level of immunity from suit, whether it be outright immunity for ordinary negligence, a cap on damages (thus keeping malpractice premiums relatively low) or even the establishment of a fund to which malpractice claimants can apply for compensation.
Matt said
So you’d have clinics where doctors are forced to work to keep their state licenses? How would you like to be coerced into working somewhere or for someone you would prefer not. How would you like to be drafted into the army and sent to Guantanamo Bay to care for the troops and prisoners there? Force: the liberal’s inevitable answer to social problems.
WhiteCoat said
Matt,
You have persistently criticized other people’s suggestions to improve our failing system, but you have yet to provide any of your own solutions.
I’m neither a liberal nor a conservative. Enough with the ad hominem attacks – especially when you know little about my philosophy. My ideas are meant to be a pragmatic approach to a problem that is killing many patients and will kill many more. I’ve seen it happen in front of my eyes. You have not.
Forcing physicians to provide care for someone they would rather not? Happens all the time in an emergency department. It’s called EMTALA. I know, you lawyers can cherry pick the clients with money and refuse to represent everyone else, so you probably aren’t familiar with such a concept.
No “force” would be involved with my suggestion. If physicians don’t want to work in a clinic, they don’t have to. But there would be some type of a negative consequence. Maybe they could provide on-call care out of their office one day a month. Maybe insurance/Medicare reimbursement rates get tied to the amount of charity care the physician provides. I’m open to other ideas.
Then again, maybe we do nothing so that if your family is involved in a car accident there won’t be a trauma surgeon or a neurosurgeon available at anywhere but the largest cities to care for you any more. We can bankrupt you by charging you $20,000 each for a helicopter flight to the trauma hospitals, then, when there is a bad outcome, you can turn around and sue the emergency physician who is doing his best to save your lives.
Perhaps you can enlighten everyone with some of YOUR ideas to solve the shortage of on-call specialists.
Or are you just going to spew more vitriol?
SmokeVanThorn said
No, it’s not “force,” It’s just thst bad things will happen to you if you don’t. Kind of like the way the IRS says that the income tax is “voluntary.”
I do med mal defense work and am currently defending a wrongful death claim against a specialist arising from a five minute phone call from an ER on the other side of the state on a Sunday night. The ER docs – you know, the guys who actually had the patient in front of them to examine and diagnose – have a statutory cap on their liablity, but my guy doesn’t. So complaints from the ER community don’t particularly resonate with me right now, but your suggestion to grant immunity to on call specialists would be a simple solution to the liability exposure disincentive. Trouble is, it would never get through a legislature given the influence of the plaintiff’s bar.
David Schwartz said
It’s really simple — allows doctors and patients to negotiate enforceable “will not sue” agreements. Allow patients to rationally trade off the potential for a jackpot lawsuit in exchange for better access to health care.
BladeDoc said
Just so you know where I’m coming from, I’m a trauma surgeon — the Lady Liberty of health care providers, you know, “Bring me your tired, your poor, your drunken drivers puking on their knees. I lift my silver scalpel by my bloody . . . ”
The entire health care “crisis” in access would go away if doctors, like EVERY OTHER business, could write bad debt off on their taxes. I.e. if patients have no ability to pay, the govt. writes off the cost at Medicare rates on the physicians taxes. Voila, every physician in the country would at least be willing to do 35% free care (i.e. to eliminate their tax burden). Add on some sort of limited liability for emergency care and the ED coverage imbroglio would be gone too.
I choose to practice where I operate on a lot of indigent patients and I do about 35% charity care by choice (e.g. last case this PM was a homeless, hep C cirrhotic with an incarcerated umbilical hernia) but I’ll only comply with FORCED clinic days when they make the trial lawyers give away a similar amount of time (and legal representation IS an actual enumerated right — unlike medical care). I’ll give up medicine first.
spongeworthy_us said
Simple solution: outlaw all for-profit medical insurance. The reason that medical treatment is so expensive is that insurers are in bed with the treatment providers. Treatment providers and insurers make more money on expensive procedures, equipment and facilities. This causes increased demand with no increased supply, a recipe for price inflation which is exactly what we have.
Take away the increasing demand and prices will stabilize. Demand will drop off if insurers are no longer making enormous profits and if the consumer is responsible for a greater share of the cost.
The idea that stopping lawsuits will appreciably reduce costs is hogwash. The idea that forcing providers to provide services when they wouldn’t normally will improve service or reduce cost is hogwash.
Anna said
Wow. Why is it that the “negative consequence” from a government mandate, as you propose, only applies to doctors? Why don’t you require patients to buy health insurance instead of forcing (and yes, it is forcing when you threaten to take away a man’s means to make a living if he refuses to comply) the doctors to provide service? Why don’t you advocate for insurance companies to no longer be exempt from anti-trust suits? Why not suggest that MICRA become a federal law? Instead, you want to force the very same people who are already unhappy with the system to become even more indentured to the system.
What is wrong with you liberals anyway? Do you really think that the doctors will be so happy to have these conditions placed on them – work once a month or else you won’t be able to practice – that everything will be hunkydory? There is such a shortage of doctors any more, as you know, and your solution is to make it even less attractive to practice medicine? Amazing.
And yes, the best way to counter an argument is to demand that your critics come up with their own suggestions because, after all, we can’t question your suggestions unless we come up with grand plans of our own.
WhiteCoat said
There are a lot of hangups about whether doctors should be subject to negative consequences for deciding that they do not want to treat patients.
How about positive consequences for agreeing to treat patients, then? Tax credits? Ability to write off bad debt (I like that idea)? Higher insurance/Medicare reimbursements? There are a lot of ways to get to reach the same goal which is greater access to care.
Smoke, I find it interesting that you are vilifying the ED physician in your case. If you as a lawyer were forced to provide legal advice to every client who came to your office (as ED physicians are required to do with EMTALA), a client you never met before asked you for advice about setting up a trust, you called a colleague “across the state” who was an expert in trusts, that colleague gave you the wrong advice, you relayed that advice to the client, and the client suffered, would you expect to shoulder all of the blame? ED physicians aren’t experts in every field. Why should they be responsible when they rely upon the advice of experts who know more about them on a given subject?
David, your idea would be a simple solution, but I don’t know whether “will not sue” agreements would be valid for negligent acts. If you agree not to sue an airline before getting on a plane, should it apply if the pilot was flying drunk?
I like BladeDoc’s idea a lot and think that could be a good carrot instead of the stick that I was suggesting. The only problem I see at first blush is how to keep unscrupulous docs from writing off $1000 for a visit from an indigent patient. Perhaps tie amount of write-offs to the amount collected in cash for a similar visit from a non-indigent patient?
Spongeworthy, you’re on the right track about insurance, but insurance companies don’t like paying for high-tech procedures any more than the patients do. Docs order the test for various reasons (financial reasons cannot be one of them due to Stark laws) then insurers try to keep from paying for the test. Insurance makes its profit by charging high premiums and then paying out less for care.
Anna, I’d like to make everyone purchase health insurance so we could spread out the risk. What do you do with the millions of people who can’t afford insurance? I wasn’t aware that insurance companies were immune to anti-trust suits. How would making insurance companies liable for anti-trust actions improve access to care for indigent patients, though?
I still find it ironic how so many people find it offensive to use a “stick” instead of a “carrot” to accomplish goals. No one seems to realize that emergency physicians (and I am one) get beaten down with a stick called “EMTALA” every day they treat patients in the emergency department – evaluate the patient or be subject to a $50,000 fine and loss of ability to participate in Medicare program. I always looked upon my job as the ability to help people who couldn’t find help anywhere else.
Come to think of it, a carrot probably would be nice every now and then.
Deoxy said
Spongworthy,
Your idea has already been tried AND FAILED. There are significantly large chunks of this country (at least one whole state, for instance) whose ONLY med-mal insurance providers are non-profits (most of them doctor-self-insurance groups), because the private firms have all left (because there’s no profit to be had). Go look at how those gruops are doing, and you’ll see that insurance greediness plays an insignificant part in this mess.
Go do a little reading on what a single lawsuit costs, both in money and in emotional distress, and then do a little more reading about the odds of getting sued (essentially, all doctors get sued, and the relationship betwen lawsuits and bad care by the doctor is almost non-existant).
Much of the cost of medicine is actually driven by MORE medicine; that is, we consume more services that we used to, because there are more services to be had (classic example: when you have a heard attack, dying is much cheaper than being treated – 50 years ago, well, you just died and saved a lot of money).
Shortage of doctors willing to cover the ER, etc, is driven prrimarily by fear of litigation.
spongeworthy_us said
Deoxy, you miss my point. My idea has never been tried – the movement of private firms out of the “unprofitable” areas of the country is a negative byproduct of “free-market” system we currently have. Again, my idea is to outlaw profit-based medical insurance. When and where has that ever been tried? The answer is never.
I’ve already done more than a little reading about medical lawsuits and the odds of getting sued – after all, I used to work for a medical insurer. Actually, the cost and the odds of getting sued are relatively small with respect to the enormous amounts of money being made in the for-profit insurance business. If there wasn’t so much money to be made and if the for-profit medical insurers weren’t already making gobs of money, wouldn’t they have abandoned the business? Absolutely they would have. But they haven’t, so I’m forced to conclude that the cost and the odds of getting sued are simply a business cost to the for-profit medical insurer, something to be risk-managed, and something which contributes to the fact that while we in the US spend more than any other country in the world on health expense, we have something like the 30th or 40th worst resulting health and longevity. Take the massive profit-taking out of the picture and we might have a fighting chance and righting that imbalance.
Sure there are now more services to be had – that’s what is to be expected from and what inevitably happens with a “free-market”, profit-driven approach to this sector. But don’t confuse that with better services or better resulting health. And, finally, maybe if the driver wasn’t profit, which leads to “cost-cutting”, which leads to cost-cutting, which leads to mistakes, there wouldn’t be so many lawsuits.
True example – a member of our church recently went in for prostate cancer surgery and was sent home 2 days after surgery, which is a ridiculously short amount of time and would never have been contemplated if the motive for the insurer wasn’t profit. Of course, he went home, had complications and had to be re-admitted a few days later to deal with it. Now if he winds up dying, the doc and the insurer absolutely deserve to be sued. Maybe when they get sued enough times for that kind of slipshod, slapdash, profit-driven “medicine”, when it finally starts hitting them hard enough in the only place it seems to have an effect – the pocketbook – they might start thinking about providing quality care instead of high profits.
Do you understand how modern-day health insurance works? It doesn’t really seem like it.
spongeworthy_us said
Another thing that removing the profit motive from the health insurance picture is that it would enable the emergence of a kind of universal health care coverage that many, though possibly not all, in the US believe we should have. I am among those who believe universal health coverage is something we should have in the US, even though I personally have never been un-covered in my 47 years, which I recognize is pure luck on my part.
It just does not seem right that for all practical purposes unless you are independently wealthy or permanently employed, you cannot have affordable health coverage in this country. And there’s really only one reason for that, which is the profit-making of health insurers and providers.
Once upon a time, before the advent of for-profit insurance providers, the purpose of all insurance was to spread risk of loss among a large heterogeneous population, making the insurance affordable to all and reducing (not eliminating) the risk of massive losses to any individual. Somewhere along the line when insurers figured out there was all kinds of money to be made, they decided to weed out the high risks by refusing to cover them for many different reasons, the most common being the so-called “pre-existing condition”, so while they continued to collect premiums from most of the subscribers, those who were most likely to cause payouts were prevented from participating at all.
This was and is a great deal if you happened to be employed or independently wealthy but pretty much sucked if you weren’t. So maybe what I’m saying is not necessarily that medical insurance for profit is the problem, but rather their ability to pick and choose their customers is. If anyone in this country in any physical condition could go to any medical coverage provider and bind coverage at the same per-subscriber rate as anyone else, then I would be fine with them pulling any profits they could, because the ones who send their insureds home 2 days after major surgery would soon be out of business.
Sure, I know what you’re thinking and probably getting ready to post: that’s communism; that’s not free markets; that’s not what made America great.
You’re probably right. But the health care industry is in my opinion the best example among many that prove, the collapse of world-wide communism notwithstanding, that free markets are not perfect markets. As long as there is profit motive in health insurance there will be victims of the health care industry, those who treated unfairly and those who are unable to participate.
SmokeVanThorn said
WhiteCoat – I am not vilifying anybody – I leave that to plaintiff’s counsel. My point was to give a concrete example of the way that the legal system gives the consultant very strong incentives NOT to get involved.
As for ED docs not knowing everything, Florida recognizes this fact and limits their liability, while denying any such protection to a physician who can’t examine the patient and is relying on someone “who doesn’t know everything” for information.
And another disincentive is ED docs who are reflexively defensive and anxious to point fingers at their consultants. I am grateful that I don’t have to deal with such attitudes in the matter I’m handling.
If you weren’t intending to bust on ED physicians, then I apologize that I got the wrong vibe from your post.
I agree that the current system creates disincentives to care. If the specialists took a stand and refused call due to liability concerns, policy would quickly change. ED physicians don’t have that luxury.
I also have seen first hand that the ED physicians aren’t the only ones who jump to point fingers at other physicians. It works in reverse, just as often. Having a good attorney to nip actions like that in the bud helps a lot.
SmokeVanThorn said
Fair enough – and you are certainly correct that ED docs aren’t the only ones to point fingers. In fact, I’ve never had that happen.
There are real problems in Florida caused by the fact that there are limits on recovery from some physicians and no limits as to others. In my experience, this issue has not arisin with ED docs, only with physicians who are employees of state agencies and therefore have a sovereign immunity cap of $100,000. The statutory change requiring that med mal liability be apportioned on the basis of relative fault may alleviate this problem.
Interesting discussion – I’ll be back to read more of your blog.
The doctor who wasn’t there said
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