Archive for November, 2012

Real Life ER Visit — Some Pitfalls

One winter afternoon Mr. C was at his health club  enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed.    In the past, any nosebleed would go away with some pressure but this was different, the bleeding  just would not stop.  Driving his car was out of the question.  Fortunately, another health club member offered him a ride to the ER.  On the way they passed an urgent care clinic but did not stop.  They were concerned the urgent care clinic might not be able to stop a nosebleed.   The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.

Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room.  After 20 minutes a nurse evaluated him and took his blood pressure.  His nose continued to bleed and 30 minutes later a doctor arrived.  He put drops of epinephrine in the nose followed by a nasal pack.  The bleeding stopped, he was given an antibiotic  pill (ciprofloxacin), he  rested a few minutes then his wife took him home.  A few days later his wife removed the packing as directed.  Problem solved — at least the bleeding problem.

He eventually got a statement from his Medicare (MC) supplemental insurance company.  

Item Charges MC Allowed Out-of-Pocket
Facility charges $3,569.05 $310.92 $0
Procedure (30903) $681.00 $139.85 $0
epinephrine 4 drops $204.60 $0 * $204.60
ciprofloxacin 500mg $50.82 $0 * $50.82
TOTAL $4,505.47 $450.77 $255.42

* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge.  What Medicare does not allow supplemental insurance will not allow either.  So, the patient has to pay.

Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55   (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45                       (charged 110 x cost)

See the reference on nosebleeds (epistaxis).

Could there have been another way?  Less waiting and less cost?  Perhaps.  Consider the following alternative scenario:

A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP).  The patient was instructed to go to an urgent care center.  Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on).   The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50).    The charges and out of pocket expenses for the urgent care visit were as follows:

Item Charges MC Allowed Out-of-Pocket
Procedure (30901) $275 $94.32 $0
epinephrine nasal $20 (est) $0 $20.00
ciprofloxacin 500mg $0.50 $0 $0.50
TOTAL $270.50 $94.32 $20.50

It is important to note there is no “facility” charge at the urgent care.  Only hospitals can charge for use of the facility.  Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies.  In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.

The bottom line:  At your next visit with your PCP discuss how they want you to handle minor and major emergencies.  In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room.  Use urgent care centers rather than the ER if possible.  Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy.  If your PCP is aware of an urgent problem they will likely follow up when needed.

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Observation Unit — Between ER and Hospital

Laura Landro of the Wall Street Journal reported on a growing trend in US hospitals.  The trend is the “Observation Unit”.  In hockey terms it is the penalty box where hospitals put patients they can’t send home but can’t admit, at least for a few hours.

The origin of this idea may have come from English hospitals.  Those hospitals run at almost 100% occupancy.  So, when a patient from the ER needs to be admitted there is a delay to wait for a room.  Those patients  get put in a big room next to the ER with several gurneys, a few nurses,  and lots of curtains (the observation unit).  The patients do get tests and treatments but they wait for a room.  As it turns out, some of the patients get better and don’t actually get admitted — they go home — the rest eventually go to a hospital room.  In England hospital care is free and the hospitals don’t have to worry about insurance or Medicare rules that separate  outpatient and inpatient charges.

US hospitals have plenty of beds available but US hospitals do have to worry about insurance and Medicare rules.  Care is not free and if a hospital makes a mistake (like admitting for indigestion) they don’t get paid.  And, if a doctor makes a mistake and sends a patient home who should have been admitted (for a heart attack) they could be in legal trouble.  Consequently, unlike the English hospital that needs to hold patients to wait for a bed the US hospitals need to hold patients because of red tape and legal worries!  It’s hard to tell which is worse.

The Wall Street Journal article puts a positive spin on the “new” idea:  “when operated efficiently observation units have been shown to reduce health-care costs and improve treatment”.  Obviously there is a balance of forces between the Hospital that makes money and the insurance company that looses money with each admission.  Regulators try to develop rules to speed evaluation and treatment so some patients can go home safely without a hospital admission and the huge associated costs.  Any patient who can bypass the hospital will also avoid the risk of hospital errors and exposure to hospital acquired infections.

Patients have two main concerns:

1) Getting the right care the first time and not coming back sick.   The unit may provide a little longer time to get test results and see if treatment is working which is good unless unnecessary tests are being done.
2) Minimizing out of pocket cost.  A person without insurance would get a lower bill by avoiding the hospital but having both the cost of observation and hospitalization is a real possibility.   The current trend for insurance  is to shift a higher percent of outpatient charges to the patient compared to inpatient charges.  So, depending on what a person’s insurance covers, there might be higher out of pocket expense for using observation.

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Satisfaction VS Quality

The following is extracted from data presented by the Dartmouth Atlas.


Data about high ranking academic medical centers is plotted above.  On the vertical axis is the patients rating of their experience at the hospital — the higher the percent the better.  On the horizontal is the rate of a severe infection complication of tubes put in the veins (which should be taken out periodically) — the lower the rate the better.  The hospitals in the lower right have the highest rate of undesirable “line” infections AND the lowest rating by patients.  The hospitals in the upper left have the lowest rate of such infections AND the highest satisfaction.

The point is:  the hospitals are all over the map (poor reliability).  Worse yet, patients seemed to give some hospitals high marks for poor performance.   To be fair, very few patients actually get line infections so the negative effect on overall satisfaction is small.  It would be interesting to evaluate  satisfaction of patients who had line infections (if they survive).

So, you say, hospitals need to work harder.  That would be true but where are the guidelines for removing these problematic vascular catheters?  The CDC and others describe how to care for the catheters but leave it to “judgement” when to take them out.  The problem is “judgement” is not conducive to reliability.

Make a rule and follow the rule!  Sure there are exceptions, like it’s the last vein the patient has — judgement is when you state why you are not following the rule.  The specter of malpractice litigation is here.   Although the rule of law is doctors are not held responsible for a well considered judgement (which later may prove to be wrong) it often does not work that way in court.   So,  a good defense would be that a national guideline was followed — if it existed.

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