Archive for category Emergency Care

A Design For American Health Care

ahc_logo2What an opportunity!  A design for American Health Care that is badly needed, a blank slate, an open door, a blank check.  So what blogger could resist the obvious invitation.  First is the logo — I hope you like it.  No more Medicare, Medicaid, Indian Health Service, Veterans Administration, Blue Cross or United Health.

Who gets AHC?  Well, every US citizen.

How much does it cost?   The annual out of pocket cost is limited to just $1000.

Is there any paper work?  NO.  No paperwork, no bills, no EOB, and no insurance claims.

What do you need for healthcare?  Just your AHC card.

What is the price list?

  • Office visits:  $25
  • ER visits $50
  • Thirty day prescription $10
  • Surgery  $100
  • Hospitalization $200
  • Medical equipment $75
  • Medical devices $75
  • Ambulance $100

What is the national healthcare budget?  It’s set by congress.  Initially budget neutral at three trillion dollars (or whatever budget neutral at this time).

Where does the money come from?  Taxes.  Instead of insurance premiums it’s included in your taxes.

Do insurance companies go out of business?  No.  They process claims from healthcare providers, pharmacies, hospitals etc.  The person getting healthcare does not need to be involved with all the paperwork.

What government agency runs the program?  Medicare, under the AHC name.  Providers bill the claims processor and AHC pays the processor.

Is great American health research affected?  No.  This is a health care system.  Research is not health care and is outside the system.

Can people obtain health services, like for cosmetic surgery?  Sure.  Any services you want to purchase yourself outside AHC is fine.  But, you still pay the same taxes.  AHC does not pay for private care.

Are the States excluded?  No.  The States are responsible for managing AHC in their States.  The Federal Government sets the standards for the country.  The States make it happen.

Why would national costs be lower?  Because America as a country negotiates prices and because cost would be capped by the congressional budget for care.  The cost would be the same the first year.  Waste is a major problem — with better management of a system waste can be addressed.  Since about one half of US healthcare cost is consumed by waste there is lots of room for improvement.

What about poor people?  The deductible would be lower than $1000 — but because the deductible is low to begin with not many would need this help.

Now would be a good time for the applause.  Your humble blogger thanks you.

 

 

 

 

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Emergency General Surgery — dangerous and expensive

viewinsideabdomenEmergency general surgery (EGS) is common in the United States.  11% of surgical admissions require emergency surgery.  The statistics on EGS seem to create more questions than they answer:

  • The 11% of surgerys classified as EGS are associated with 50% of all surgical deaths.
  • Poor people who have EGS have a greater risk of death than average
  • Rich people who have EGS have a lower risk of death than average
  • Seven surgeries (removing part of the colon, removing part of the small-bowel, removing the gallbladder, operations related to peptic ulcer disease, removing abdominal adhesions, appendectomy and other operations to open the abdomen) accounted for 80% of the deaths and hospital costs related to EGS.
  • The cost of ECS in the U.S. is about 7 billion dollars per year.
  • EGS patients admitted by a surgeon have lower hospital costs than those admitted by a hospitalist.
  • Specific quality guidelines for ECS do not exist.

One might be tempted to say the diagnosis is so complicated nothing could improve the situation for patients.  However, this would be like the situation for pilots and passengers 30 years ago when major airliner accidents happened at least once a year.  The quality movement swept over the airline industry which is now is rated as one of the safest of complex human endeavors.  Those same measures need to be applied to EGS.

When an airplane has an emergency the crew pulls together and acts as a team.  They follow a procedure practiced many times.  They have simulators and tests.  If an engine fails, if there is a fire, if a landing gear fails there’s a procedure to follow.  Each pilot does not invent a procedure just because they are the pilot that day. Likewise, every surgeon should not invent a procedure just because they are the surgeon that day.

It would be easy to blame surgeons or the patients themselves for such dismal outcomes.  But, as people in the quality improvement department say:

IT’S NOT THE PEOPLE, IT’S THE PROCESS.

The first step is to acknowledge EGS is a process.  When a patient arrives in the emergency room with abdominal pain, low blood pressure, free air in the abdomen and a high white blood count there should be no barriers to evaluation an treatment.

  1. The goal is to have the patient in the operating room within 90 minutes from  crossing the ER threshold (T).
  2. Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
  3. Surgeon is in the ER to evaluate the patient by T + 30 minutes
  4. A decision for operation is made by T + 45 minutes.
  5. Pre-op antibiotics, fluids, and pressors are started as needed.
  6. Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
  7. Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
  8. Patient is transported to the operating room.  The opening incision is made by T + 90 minutes.

Such a process is obviously difficult.  First, the ambulance crew can not transport a patient with an abdominal emergency to a facility unable to deal with the problem, like a small rural hospital or an urban community ER.  This will require training of the ambulance crews and communication with a high level ER.

General surgeons and back-up general surgeons must be available within 30 minutes.  It’s a difficult life to be immediately available — the hospital is responsible to either pay surgeons to be on-call or to hire surgeons to stay in the facility.  Hospitalists are not an appropriate substitute to deal with an acute abdomen or even severe abdominal pain of uncertain cause.  A helicopter ride to a higher level facility is the best solution for patients with severe abdominal pain entering a facility not capable of following the above protocol.  The crazy practice of having a night-time hospitalist admit a critical surgical patient for a surgeon to see “in the morning” must come to an end.

Since the mortality rate of EGS patients is quite high the intensive care unit is the place they should go after surgery even if they seem stable in the operating room.  Complications are very common so early recognition and treatment is essential.  Returning to the operating room later may be needed and should not delayed.  Critical care consultation should be strongly considered.  Multidisciplinary rounding with critical care specialists, nurses, pharmacists, dietitians, and social workers is strongly advised.  Rushing to get the patient out of the hospital to a secondary level of care is a mistake since re-admission is fairly common.  The patient needs to be as stable as possible before discharge.  Hospitalization for 1 – 2 weeks is not uncommon.

The difference in outcome of EGS between rich and poor is not uncommon for many things in medicine and surgery.  Several factors are at play but probably the biggest is fear of big medical bills — if you can’t pay one would wait till the last moment.  Second, medical literacy — always a bigger problem for lower socioeconomic groups — if you think Tums or Rolaids will fix anything you might wait too long to go for help.  Finally, a negative bias toward Medicaid or “cash” patients — sometimes the finances determine whether a hospital will keep or transfer patients.  At midnight many cases seem to be too “hard” and must be sent to a referral hospital which wastes valuable time.

Since prospective research is difficult and time consuming (taking years or decades) a local and national registry should be utilized.  The diagnosis, the surgical approach and the outcome must be tracked to find the best combinations for the best outcome.  As best practices are identified surgeons and hospitals must quickly change protocols and surgical techniques.  U.S. healthcare can not stand the usual 15 years needed to implement new practices.

References:

If any nurse out there has a standard order-set for EGS please share it.

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Urinary Retention — 1 in 10 men over 70

urologybillboardOne ER visit is a red flag — more ER visits for the same problem become an example of  poor quality health care.

Urinary difficulty is something older men don’t like to talk about.  But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine.  Urologists are aware of this frequent problem — see the billboard story.  It is a serious problem;  in third world countries it may be fatal.

The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination.   Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.

The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter.  50% of men can then pass urine adequately (for a while).  The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?

A friend of this blogger landed in the ER a total of 4 times with urinary retention.  Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?

The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed.  Yes, own the problem, not turn off the phone and let the ER solve it.  Does that mean the urologist must be at the clinic 24 hours a day?  No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations.  An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.

The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP).  According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year.  This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.

A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?”  and “is there some alternative to the ER since you have already evaluated me?”.  At least find out how to get in touch with the on-call urologist!

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Cruise Ships and Illness — it’s not a hospital

helocopterIf you are really sick in the middle of the Pacific Ocean on a cruise ship the treatment options are limited.  The mid-Pacific is international water — there is no Coast Guard and there is no hospital helicopter to pick you up.  The ship can only go 20 – 30 mph so going somewhere in a hurry is just not possible.

The doctors on the ship do what they can and over the past 10 years shipboard medical capability has improved.  But, there is no CAT scanner, there is no cardiac catheterization laboratory and if you hit your head and get a hematoma on your brain you will probably die.  Remember, you are on a vacation ship, not a hospital ship!

When a person is seriously ill and near a port (75 miles) a helicopter pick-up is possible.  Or, when the ship is in port an ambulance pick-up is possible.  Then what?  If you are in a third-world country the hospital you go to might not be much better than the ship.  If you are stable enough you might be able to take an airline flight home.  Otherwise, you might hire a med-evacuation flight — but plan to spend $50,000 unless you have insurance to cover it.

If you are seriously ill you can not stay on a ship — once the ship docks you will be taken to the closest hospital — even in  Guatemala.

The number of elderly people on cruise ships is huge.  The big cruise ships carry between 2,000 to 8,000 passengers.  During almost every week-long cruise on one of those ships someone gets sick and is taken off the ship, usually at port.  And, every year several people die on cruise ships.

Medical care on a cruise ship is very expensive.  Medications are very expensive.  A cast placed on a broken arm is very expensive.  If you are quite elderly or have significant health problems you need travel insurance and med-evac insurance.  Or perhaps, just skip the cruise instead.  Remember, regular health insurance or Medicare will not pay for cruise ship medical care.

Cruise ship doctors usually have experience with diarrhea, dehydration, colds, pneumonia, urinary tract infections, sea-sickness, cuts, bruises and broken or dislocated extremities.  The ships all have communication equipment and doctors can contact specialists anywhere in the world.

Despite access to a world of medical information the ship has limited medications and no major surgical capability.  In some respects, there is no need to do complicated tests because there is not much that can be done!  Why do a brain scan if you can’t do brain surgery!

So, caveat emptor — buyer beware.

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Something Less than an Ambulance — will it fly?

ambulanceER doctors never ask the question but often think: “Why did you call an ambulance for a sore throat?!”  The trip costs at least $1000 and stands a chance of not being covered by insurance.  The ambulance crew feels bad they don’t have a more appropriate option but if you call an ambulance — you get an ambulance.

Kaiser Health News reports the South Metro ambulance company in a suburb of Denver Colorado is trying a new service.  An ambulance that is basically an ER in a box.  Equipped with lab tests, bandages, sutures and a few medications they go to a home to treat a problem rather than transport a person to the ER.  It costs about $500 — at this point, it is something insurance will not cover.

Here are two extremes:

  1. A single parent picks up their child from a family member after working 2 jobs at fast food restaurants.  The parent just got the jobs after 3 months of being unemployed.  The primary care doctor’s office is closed and the parent is expected at work in about 7 hours.  But, the child has a fever and a sore throat. The bus they usually catch to go to the hospital does not run after 8 PM.  The parent calls an ambulance.
  2. A woman drops a martini glass and cuts her finger.  Her husband thinks she needs stitches but he has some after hours stock trading to do before bed.  He tells the butler to call an ambulance and get the problem resolved.

The first case is common for Medicaid families.  No resources, no car, and not much to lose by calling an ambulance.  But, something to gain by not missing time at a new job and it helps the child on both counts.  The ambulance and ER visit may cost Medicaid over $1000.  But, during the day a visit to primary care might only cost $50.

The second case is crying for concierge care.  The family has the cash to pay for someone to come to the house and put a few stitches in a finger.  But, instead the problem clogs up the ER that should be dealing with heart attacks and car wrecks.  Again, if the problem happened earlier in the day a primary care office or urgent care clinic could have solved the problem.

One could see Medicaid having a fleet of mobile treatment units just to limit the financial losses in the ER.  Actually, a good idea.  Both cases might have solved their problems by taking a taxi to an urgent care clinic — if one was open.

Will the “ER in a box” find a place? — at least a place where someone will pay them?  The idea leans toward the concierge model.  No insurance is going to pay for an ambulance when a taxi will work.  No insurance company will pay extra just for the convenience of one patient.

Nice idea, but it’s not likely to fly financially.

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Clinic of Last Resort — the ER

erdoorDeath can be caused by not having a car.   If a sick person does not have transportation the effects can be serious.  And, lack of insurance makes the problem worse.

A new study reported in Health Affairs  finds closure of inner-city ER facilities causes more deaths.  Poverty, advanced age, immigrant status, and lack of insurance were correlated with the increased mortality.

Poor people count on the ER as the clinic of last resort — our health system is designed that way — call an urgent care clinic and ask what services are available — “it depends on your insurance” is the answer — “you better go to the ER” is the advice if you have Medicaid or don’t have insurance.

Why wait until the last minute?  Because, there is always hope the health problem will get better, the chest pain will subside, the blood in the stool will stop or the arm weakness will vanish.  Once the heart attack hits, the bleeding is worse,  or the whole side of the body is paralyzed  the chances of death are much higher.

If you don’t have money one of the greatest concerns is NOT getting admitted — how do you get home, how do you pay for outpatient medications and how do you pay for the ambulance ride ($1000)?  The logic is simple: wait until you are REALLY sick.

The ambulance-to ER-to-operating-room is usually a very profitable supply-line of patients, so lots of resources have been lavished to make the system work.  If the ambulance-to-ER system brings diabetes, pressure ulcers and urine infections it drains a hospital’s resources, and finally leads to ER closure.

A good health system would provide transportation, guaranteed urgent care, medications and transportation home for a low-cost package price.  The unloading of the ER might actually save the ER, save patients with true emergencies, and save poor patients who get care earlier.  Wow — and what if that urgent care center was right next to the ER so if there really was an emergency it could be handled.

But no, all that would require planning and a health system where hospitalization was an overhead expense, not a profit center.  So, the only viable solution in the US:   include vouchers for ER visits with Cadillac  purchases or golf club memberships.

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Freestanding ER — the microhospital

microhospital

What is a freestanding emergency center?  And, is it something good for patients or not?  Michael Booth reported on the spread of this concept in Colorado in his article in the Denver Post “The parent of metro Denver’s Exempla to open four micro-hospitals” (4/14/13).   The feature that separates a simple urgent care clinic and a microhospital is the presence of a few patient rooms intended for short term “observation”.

These microhospitals exist to make money.  They are not charity operations or an improvement on hospital care or low cost options.  Patients with a high deductible insurance plans do think of the cost.   And such facilities may be less expensive than a hospital emergency room but more expensive than an urgent care center and much more expensive than a primary care office.

Urgent care clinics are much less expensive than a hospital sponsored emergency room because they are not allowed to charge the “facility fee” — the fee allowed by Medicare and insurance companies to compensate hospitals for special equipment and staff  for very sick patients.  Any facility that must own expensive diagnostic equipment does shift the cost to all that visit even if they don’t use the equipment.  Also, there is the tendency to over-utilize high tech equipment (because it makes money for the clinic).

What about those observation rooms?  They are very expensive and usually billed by the hour ($50-$100 per hour) plus a cost for medications that may be astronomical.  An observation room is helpful to provide time (at the patients expense) to wait for test results or to see if treatment is working (like for nausea).    Generally, if a patient does not have a condition that warrants full hospitalization they should be able to manage at home.  There are some social situations that prevent a patient from going home in which case outpatient observation may have a place — but not one that insurance will always cover.

Insurance companies vary in what they will pay for outpatient observation — often they exclude medication costs.     If  a patient has to take an ambulance ride it is best not to go to a freestanding ER because a second ambulance ride to an actual hospital may be needed.  Ambulance transport usually costs between $600 and $2000 — not something to be duplicated.

The notion that microhospitals have providers present 24/7 is of course true.  But those providers are ER doctors who have work to do in the emergency area, they work in shifts, and ER doctors are not accustomed to hospital type care — they are not hospitalists or surgeons or specialists as might be found at a true hospital.

People need to have primary care providers.  A primary care doctor may see someone with acute illness fairly soon (like the same day).   Often that is soon enough and certainly at much lower cost than any outside microhospital.  But, if the provider is busy or not available urgent care or microhospital care are substitutes.

Are microhospitals good or bad for patients?  They probably have little place in outpatient care.  If a patient has a condition that medically requires intravenous medications or oxygen then hospital care is probably better and safer.  A lower cost option for some people  is care at an urgent care center that does not have all the overhead cost of a hospital facility.

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