The $1000 Sprained Ankle

Why do we love sprained ankles in the ER? Why are we establishing Fast Tracks in our EMERGENCY departments in order to expedite these cases? Why don't we want them to leave without being seen and go somewhere else?

Because we can charge you over a thousand dollars for your sprained ankle, that's why. Here's how:

ERs make money by charging facility fees which are separate from the physician's (or PA's) billing. These fees are divided into 5 levels of care depending on how complicated the visit was. A basic triage with no prescriptions might be a level 1, whereas a cardiac arrest with multiple interventions is the highest level. Points are given for each intervention such as IV placement, medication administration, discharge teaching, etc., and the total number of points is used to determine the level of care (and therefore the ER charge).

At our facility, there is a big increase from a level 2 ($225) to a level 3 ($650) facility fee. After we've given you a pain pill, sent you off to X-ray, and applied a removable plastic splint to your sprained ankle, with one click on my electronic medical record I can increase your bill by over $400 - by ordering crutches and crutch training. For some reason, crutch training is worth several points, easily enough to catapult you into level 3 territory.

So after the cost of the X-ray, pain pill, plastic splint, and crutches are added to our facility fee, and once you receive your separate bills from the Radiologist for his interpretation of your X-ray and from me for evaluating and treating you, your charges are easily over $1000 for that sprained ankle. And you haven't even picked up your prescription yet.

That's why we love sprained ankles in the ER. You don't care, your copay is only $100. But maybe you should care.

Appropriate Billing and PA Utilization

I suggest that if a Physician's Assistant sees a patient independently in Fast Track or anywhere else, they should only be able to bill a maximum of 50% of the normal physician fee for that service. (UPDATE: this refers to insurance reimbursement and government programs; in a free market system, I of course believe they should be able to charge whatever the market will bear).

If a PA is directly supervised by a physician and the physician personally evaluates the patient or is physically present during the key portion of a procedure (and documents that fact) then they should be able to bill the full price. Just signing the chart is not sufficient. That is how we are required to supervise residents (some of whom already have their medical licenses and can therefore supervise PAs themselves). The requirements for supervision and documentation should not be less restrictive for PAs than for residents.

If a patient is not receiving the full service of a physician, then they (or their third-party payer) should not have to pay the full charge of a physician service. Because of the difference in training and experience, a physician's assistant does not provide the same level of care that a physician provides, even if the interaction appears to be superficially identical. So they shouldn't command the same fee.

In order to encourage physicians to still utilize and supervise PAs, I suggest reducing the liability of physicians who "supervise" essentially unsupervised PAs. After all, if the doc didn't see the patient, they shouldn't be liable (or only minimally so) for the PA's error. But PAs hardly ever make errors anyway, according to their supporters. When they are responsible for their own errors, I wager they will make even fewer.

If the theoretical numbers presented by Ten/Ten and Shadowfax are correct, a PA who was bringing in $160/hour would still bring in at least $80/hour under my system and still only cost $50/hour, so the physician groups would still make money pimping out their PAs with even less liability. Patients will have cheaper healthcare options, the costs of insurance will decrease, and the failure of the Medicare system will be delayed a bit longer.

Win/win/win. Everybody wins.

Just Say No to Fast Track

I hate the concept of Fast Track in the ER.

We've had an interesting discussion about the utility of PAs in these departments, but I have found that by establishing a fast track, we perpetuate the problem of non-emergencies clogging up the ER. If you build it, they will come.

Now I understand the argument that perhaps we should be moving to a new model that embraces our new status as "acute care" facilities rather than EMERGENCY departments. Maybe we should focus on meeting the needs of whiny demanding upper respiratory infection sufferers. Neither primary care physicians nor Urgent Care facilities are easily able to do so (at least in this area) because they are shackled by the same bonds - the inability to bill adequately for these low-level cases without a facility fee. That's why emergency department administrators like these patients - by turning a 99203 into a 99283 plus a several hundred dollar facility fee, level three patients are easy money for ERs which are already open anyway.

But as a strong supporter of the concept of appropriate triage, I don't agree with streamlining the dispositions of the lowest acuity patients in the EMERGENCY department. I'll be happy to see them when I'm done with the sicker patients. If we are appropriately staffed, it probably won't take too long. If the patients with runny noses and sprained ankles are in a hurry, they can go elsewhere. If I'm too busy to see them, I'm too busy to care about them.

I wonder when Americans will see the folly of paying several hundred dollars a visit for non-emergent emergency care. Either directly via their overpriced cost-shifting "self-pay" charges or indirectly through their ever-increasing health insurance rates or their collapsing Medicare system, these patients will eventually be deterred, then another system will evolve.

The concept of Fast Track may seem like a functional solution to our current healthcare needs, but it covers up some ugly problems with our system... like putting a band-aid on a melanoma.

UPDATE: Thanks to Kevin for the link!

UPDATE: The Country Doc has similar concerns (and not only beat me to the punch, but found a couple of good articles on the topic).

Spider

It's creepy.

UPDATE: There's some spoilers in the comments, so don't read them yet, just watch it.

"Where Are All the Doctors?"

This is a guest post from commenter Helen:

I do have an issue. Where are all of the doctors? It seems that wherever I go there are Physician's Assistants, and the medical facilities seem to want us to think that they are doctors. What I mean by this is there is never any mention that they are not a doctor that they are a PA. They said "Deb will be in to see you soon". Deb walks in and introduces herself as Deb and never tells anyone what her title is. Many times when making an appointment we patients are never told that the PA will be seeing us. I have gone to several appointments and was never told that the professional that would be attending to my medical needs was a PA. I am a stay at home mom and my family is fully insured through my husbands employer. We are not medicaid or anything like that.

I seems to me that an appropriate use for the PA's would be for routine issues like Strep testing, pregnancy testing, UTI's, stitching patients after the Doc has seen them, diagnosing earaches all under the direct supervision of an MD. I live in Nebraska and the PA's are seeing the lions share of the patients. Many times with no physician anywhere in the building. I had to take one of my infant twins to the pediatrician for a puzzling symptom. A PA came in (without telling us her proper title). I knew something was different about her from the other physicians in the practice. There wasn't the expert presence that I usually felt with the other doctors. She did procedures and ordered expensive tests that were way off base. I came home and looked her up and I saw that she was a PA. Later I went back and saw our physician and she looked at the symptoms and gave a very reasonable explanation about what was going on. Those tests that the PA ordered were not even close to being necessary. She also left the main cause untreated.

Why are PA's running the show? Where are all of the doctors? Why are we as consumers and patients being conditioned to accept a PA as a doctor? I am in a mom's group, and most of the moms think PA's are pretty much the same as doctors. Many think the PA's are as competent and knowledgeable as doctors. Then why don't we just call the PA's doctors? When my daughter cut her finger the doc saw her and the PA came in and did the stitching. That seems like an appropriate use of a PA. There are PA's in offices where the are no medical doctors in attendance. Aren't PA's supposed to be working under direct supervision of a physician? (I know the was no doctor there because I asked).

I am not a medical professional. I am a consumer and I am at the mercy of the medical community. They tell me what they want, I have to see who they want, and often I am given no information about the type of care I am going to receive.

Helen

UPDATE: a report of more midlevel infiltration in the fields of Dentistry, Radiology, and EMS (courtesy of DocV)

Recertified

I passed my board exam, thank God.

Once again, I get to claim that I am "board certified." Not by the right board, mind you, but in the dysfunctional world of emergency medicine, despite the perpetual manpower shortage that we face, the powers that be would rather not know if I could pass their test. It doesn't matter; any certification will do. When I chose this path long ago, I knew that some doors would always be closed to me, but I correctly predicted that there would be plenty of back doors to sneak in. And there are. I'm blessed to work with a great group of docs in an amazing hospital. It's a dream job.

With my solid record in the trenches insufficient to the task, the pencil-pushers are now appeased for 10 more years. As a measure of quality, I must say I found the examination lacking, but it is what it is. Just another box to check off, but not one that I feel was necessary or adequate to prove my ability. In that sense it's a hollow victory, but a victory nonetheless.

Despite the gloom of another winter, the colors look a little brighter today. Tonight, champagne.

Why PAs and NPs Don't Help

I've worked with an assortment of physician assistants and nurse practitioners in various ERs, and while some of them were wonderful clinicians, I found that they weren't all that beneficial to the cause. Our group no longer employs them.

These midlevel providers are typically good competent at procedures, so having them sew up a laceration or drain an abscess while you crank through a few patients can be helpful in clearing the waiting room. But procedures are big money-makers in the ER, so unless the doc personally supervises the assistant, he is losing money if the PA does the procedure. Many docs commit fraud by saying they personally supervised the procedure when they really just looked at the results afterward (if that). And it's uncomfortable to me to make a paying patient settle for the services of a PA when they are paying for my services. And it's REALLY uncomfortable when their results are suboptimal.

Instead, you could use the assistants to see the minor stuff while you do the procedures. So when you get done with the laceration repair, maybe you have the PA ready to present two or three kids with colds. But when you look at the census, you see that you have a septic nursing home resident that needs to be seen NOW, and a drunk guy on a backboard that needs to be seen next. So either you are going to have to commit fraud by signing the charts of the kids with colds so you can get them out the door (and bill for their visit) without personally evaluating them, or you could make them wait until you have seen the sicker patients first before doing a quick evaluation on them (like you would do without a PA), or you could delay your evaluation of the sicker patients in order to move the meat (not likely).

Instead, you see the septic NH resident, you let the PA see the drunk guy on the backboard, and the kids with colds wait longer, like they would without a PA. But you still have to go around and see everyone anyway, and if you are a good doctor it won't take you much longer than it would have without a PA. The door to caregiver time for the minor stuff is decreased, but the time in department often isn't. And the annoying interruption factor is significantly increased. When you've got a department stacked with sick patients, the last thing you want to deal with is a PA standing there trying to present a kid with a sore throat to you.

That's why PAs and NPs don't really help.

Job Security

From a recent analysis:

The number of physicians with board certification in emergency medicine is unlikely to meet the staffing needs of U.S. emergency departments in the foreseeable future, if ever. In the December issue of Academic Emergency Medicine, the investigators report finding that staffing every emergency department with board-certified emergency physicians does not appear to be feasible, given their projections for the field.

Having at least one board-certified emergency physician present in all U.S. hospital emergency departments at all times would require 40,000 physicians with such training, indicating that only 55 percent of 2005 demand was being met. Under the intermediate-scenario projection, it would not be possible to meet the goal until 2038, and under the worst-case scenario, the goal could never be met. Even if no board-certified emergency physician ever died or retired, 100 percent staffing of all emergency departments with board-certified emergency physicians would not happen for more than a decade.

via NCEMI

Quote of the Day

"Why do we pay doctors big salaries to do what a nurse practitioner could easily do? Honestly I think that a nurse practitioner could easily handle what comes into an ER if they specialized in emergency medicine."

That's a bold statement.

Toxic Tampon Sydrome

Most ER visits for "retained tampons" are no big deal really. Half the time there isn't even a tampon in there at all, and most of the rest are easily removed and really not as gross as one would expect.

Except this one.

As soon as I walked into the room, I knew this was the real deal. The whole room smelled like a dead rat that had been stuffed in an old gym shoe and allowed to bake on the driveway in the summer sun. It made my eyes water, and she hadn't even gotten undressed yet.

You really feel like you've done someone some good when you pull something like that out of them.

Mmmm, Bacon!

It's not only delicious, but this dish actually reveals what your coronary arteries will look like after eating it. Or is that a dissecting aortic aneurysm? Hard to tell.

Serve with biscuits and gravy, and a Lipitor.

via Ace.

Snowtime in Texas

The last time it snowed here was Christmas Eve 2004. That should make driving to work interesting. I've got almost an inch of fluffy white goodness on my car right now.

The Hello Kitty Hospital

If I owned my own hospital, all the nurses would have to wear Hello Kitty scrubs. Taiwan beat me to the punch.

"Describing the objectives of the hospital, (the director) said: "I wish that everyone who comes here, mothers who suffer while giving birth and children who suffer from an illness, can get medical care while seeing these kitties and bring a smile to their faces, helping forget about discomfort and recover faster."

Me too, Mr. Tsai. Me too.
But my blog genderanalyzer just took a serious beating.

via Ace.

UPDATE: Not everyone likes the idea, according to Dr. Rob. I think they should have to stay in the Dora the Explorer hospital then.

TV on the Web

I don't watch much TV, except for sports, but I enjoy watching Family Guy and SNL clips on the internet. While surfing around, I found this website that has quite a few full-length episodes of a variety of TV shows, so you might want to check it out. Here's another one.

I don't have any financial interest in those websites or anything else I ever recommend to you. Enjoy.

The Quickie

Toward the end of a shift, an enterprising ER doc sometimes looks to take one last uncomplicated patient before going home. We call these patients "quickies."

Sometimes, what looks like a quickie really isn't, so one has to be careful.


PATIENT 1
Chief Complaint: sprained ankle (Great, send them
back!)

Nurses note: pt c/o twisted ankle and vaginal discharge for one week. (Never mind.)


PATIENT 2
Chief complaint: UTI (perfect!)

Nurses note: pt c/o burning with urination, lower abdominal pain, and vaginal discharge for one week. (Never mind.)


PATIENT 3
Chief complaint: migraine (Hmmm...migraine or pelvic, tough call)

Allergies: Toradol, Compazine, Reglan, Haldol, DHE, NSAIDS, etc. (Ka-CHUNK! back in the rack!)


PATIENT 4
Chief complaint: 6 weeks old, feverish (Maybe just a worried mom, lets look at the vitals)

Initial vital signs: Temp 98.4 (Winner!)

I enter the room to find a sick kid with a repeat temp of 102 who required a sepsis workup and a transfer to another facility, causing me to stay an hour after my shift ended. Oh well, at least the right patient got seen first.

In reality, quickies are generally not worth the effort. They aren't financially rewarding for us because of their low acuity, they aren't medically satisfying because they usually don't really need to be seen in the ER anyway, and they don't do much to decompress the waiting room since they are just as quick for the next guy. I've become more a fan of leaving on time than seeing another sore throat.

Medicare Med Refills in the ER

As more and more patients become eligible for Medicare and realize that many primary care physicians are refusing to take Medicare, these patients will be forced to turn to the ER for their primary care and their med refills. And we will see them over and over and over again, which will not only clog up the ER but hasten the bankruptcy of the failing Medicare program.

But what bothers me the most are the med refills.

The Cardinal Rule

photo credit

ER Tech dude: "Doc, I got a lady on the phone who wants to know if she should bring her kid in to be seen."

Me: "For what?"

ER Tech dude: "The kid drank out of a water fountain and then Mom noticed that there was a dead bird in it."

Me: "Is she sure it wasn't a bat?"

ER Tech dude: "Was it a bat, ma'am?" ... (listening) ... "Nope, it was a cardinal."

You can't make this stuff up.

Turkey Sausage Gumbo

Good way to get rid of the leftovers.

1/2 cup flour
1/2 cup corn oil
one red onion
1 cup chopped celery
one green bell pepper
leftover turkey, shredded
any sausage (I only had little smokies, unfortunately)
chicken broth
cajun spice (I use Tony's)
minced garlic or garlic powder

Shred the turkey, cut the sausages into bite-size pieces, chop the veggies, set aside. Constantly whisk the flour and oil in a large cast iron skillet over medium to medium-high heat using a metal whisk until the roux becomes the color of milk chocolate (this takes around 20 minutes). Don't burn it. Turn off the heat and allow to cool a bit, whisking occasionally. Stir in some of the chicken broth, then transfer to a large pot with the rest of the broth, heat to boiling, stir well then turn down the heat to medium low. If you are going to cook the gumbo slowly over a couple of hours, just dump everything else in the pot and stir occasionally. If you want to eat quicker, then stir fry the veggies and garlic in a little oil for a couple of minutes to soften them first. Add cajun spice to taste, and add a little gumbo file (if you have any) right before serving. Spoon over steamed white rice.

ER Doc Assisted Mukasey After Collapse

Next year, she'll get a better table:

Dr. Lisa Cooper, an emergency room doctor in Houston...got a chance to use her skills on U.S. Attorney General Michael Mukasey when he collapsed on Nov. 20 while giving a speech in Washington, D.C.

The Coopers...were at a Federalist Society banquet last Thursday night, where Mukasey was speaking. Mukasey collapsed at about 10:15 p.m. after talking for about 15 or 20 minutes. (Dr.) Cooper ran up to the stage from their table at the back of the room, and she treated him until paramedics arrived about 30 minutes later. She also rode with Mukasey to the hospital in the ambulance. Mukasey left the hospital the next day, and Justice Department officials characterized his illness as a fainting spell.

(Dr. Cooper) apparently was the only doctor in attendance at the banquet.

The ER is Not Burger King

You wanted socialized medicine, well here it comes. Everyone gets the same burger, like it or not. You're going to have to wait, and you can't have it your way. You get a generic burger out of the pile, same as everyone else, and no, you can't have extra ketchup. You'll get used to it, onions and all.