Wednesday, December 28, 2011

Proposed Law Would Allow Patients to Get Direct Access to their Laboratory Results

In September the Department of Health and Human Services, Centers for Medicare and Medicaid Services, and the CDC, proposed a rule that would allow patients access to their test results directly from the laboratory, rather than having to go through their physician.  There are pros and cons to this rule.  It could improve safety by allowing patients to have direct access o information that sometimes gets overlooked by medical providers.  It may help them make decisions about their medical care.  On the other hand, the patient may receive abnormal test results prior to discussing them with a medical provider and this  may cause them undue distress.  They may misinterpret results.  If the results are normal, it may discourage the patient from going back for follow-up care believing that since the results or normal, they have no medical issues.
More information can be found in the December 14th issue of JAMA.
Giardina, T., Should Patients Get Direct Access to their Laboratory Test Results?, JAMA, 306 (22): 2502-2503, December 14, 2011.

Tuesday, December 27, 2011

Appeal Filed to Block Law Prohibiting Physician Ownership of Hospitals

This is an update on a blog post I recently wrote about a provision in the Affordable Care Act that prohibits the creation of new physician owned hospitals.    In March a Texas Federal Court ruled that the provision was constitutional.  The plaintiffs, the Physician Hospitals of America and Texas Spine and Joint Hospital filed an appeal to the U.S. Court of Appeals, 5th Circuit and the Texas Medical Association and the Physicians Foundation filed amicus briefs to support the lawsuit.  Of note, this is the only lawsuit out of 24 filed challenging provisions of the Affordable Care Act that the Texas Medical Association has gotten involved with.
I will be keeping a close eye on the developments with this lawsuit.
More information can be found in the December 2011 issue of Texas Medicine:
Conde, C. Doctor and Owner, Texas Medicine (December 2011).

Original  Blog Post:

Sunday, September 18, 2011

National Ban on Physician Ownership of Hospitals

One of my goals in life was to own a hospital.  Thanks to a recent law passed by Congress, it doesn’t look like that is going to happen.  A part of the Patient Protection and Affordable Care Act prohibits physician-owned hospitals from obtaining a Medicare provider number (meaning they cannot bill and receive payment from Medicare or Medicaid, which is a large proportion of hospital income).  All existing physician-owned hospitals that were operating as of March 23, 2010 were grandfathered in (meaning the law won’t apply to them).  Physician-owned hospitals that were under development at the time of the law passing were allowed to proceed with development as long as they obtained their Medicare provider numbers before the end of the year.  After December 31, 2010, physician ownership and investment in hospitals was completely banned.  The grandfathered hospitals will also be banned from increasing bed numbers, operating rooms or increasing the percentage of physician ownership.
According to a recent Texas Medical Association article, physician-owned hospitals are safer and have higher patient satisfaction ratings; “a 2005 Department of Health and Human Services study…found physician-owned hospitals have lower complication and mortality rates, as well as higher nurse-to-patient rations, than do general hospitals….CMS patient satisfaction ratings…show 85.1 percent of patients gave physician-owned hospitals a rating of nine or ten on a scale of ten, compared with a national hospital mean of only 64 percent.”
I believe physician are the right fit for owning and running a hospital, especially those with business and/or legal training and experience on top of their medical experience

More information on this issue can be found in the August 2010 edition of Texas Medicine.  Ortolon, K., Quashing Ownership.  Texas Medicine, 106:8; 29 (August 2010).

Sunday, December 25, 2011

The Synthetic Drug Control Act of 2011

Last Month I wrote about the DEA making it illegal to manufacture or use bath salts.  Earlier this month, Congress passed the Synthetic Drug Control Act of 2011 which amends the Controlled Substances Act to place synthetic drugs (bath salts, synthetic marijuana, etc.) in Schedule 1.  The DEA definition of schedule 1 drugs is drugs that “have a high potential for abuse, have no currently accepted medical use in treatment in the United States, and there is a lack of accepted safety for use of the drug or other substance under medical supervision.”  The synthetic drugs join LSD, heroin, peyote, ecstasy and others that have been on the schedule 1 list for many years.

H.R. 1254: Synthetic Drug Control Act of 2011

DEA, Controlled Substances Schedules, Definition of Controlled Substances, http://www.deadiversion.usdoj.gov/schedules/

Saturday, November 26, 2011

Potential Solutions to the Drug Shortage Problem

Currently there are over 180 prescription drugs that are in a dangerously short supply.  These drugs include many important and lifesaving antibiotics, chemotherapy and cardiovascular drugs.
There are a few things the government is doing to try to tackle the problem. The Preserving Access to Life-Saving Medications Act of 2011 is a bill that is currently active that would require drug manufacturers to notify the FDA six months in advance of potential drug manufacturing interruptions. 
An additional problem with the drug shortage situation is that those manufacturers that do have the drugs are charging higher than normal prices for their drugs.  Evidence has been discovered that shows that five drug companies have charged seven to eighty times the regular prices of shortage drugs.  Since the discovery of this information, President Obama has issued an executive order that seeks to reduce this price gouging problem by asking the Department of Justice to examine price increases for shortage drugs to see if the increases violate the law.
I will continue to watch for developments on this issue.

Trapp, D., Obama Targets Prices of Shortage Drugs, American Medical News, November 21, 2011.
Current Drug Shortages, FDA, November 23, 2011, http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm

Sunday, November 13, 2011

Update on Judge Directed Negotiation in Medical Liability Lawsuits in New York

       A few months ago I wrote about a new pilot program in effect in New York in which judges lead negotiation in medical liability cases as opposed to having them go through the traditional litigation process.  Over 1,000 cases have gone through the program and so far the results have been positive. 
        Since implementation of the program medical liability payments and settlements have decreased,  and the expenses spent in defending medical liability cases has declined.  The average time cases are completed has declined from three years to nine months.  Doctors that are found to have no responsibility in the cases are weeded out within the first six months of the program (in traditional liability cases these doctors cannot be removed from lawsuits until after the discovery process which can be more than a year after the case is filed).
        It seems that this may be another solution to dealing with the medical liability crisis.  I will be keeping a close eye on the progress of this program.

Gallegos, A., Cutting Costs From the Bench, American Medical News (November 7, 2011).

Saturday, November 12, 2011

Stanford University Program Offers Apology and Financial Compensation to Patients Affected by Adverse Events-Since then Liability Premiums and Numbers of Claims Have Dropped

       Stanford University has developed a new way to deal with high liability payments by creating a more transparent and patient centered approach to dealing with adverse events.  In this new program, they identify adverse events that have been reported by physicians or patients within 90 days of its occurrence.  Investigations are made, and if the event is determined to have been avoidable, the patient and or family is contacted with the results, an apology is made and compensation is discussed. 
       According to Stanford, liability claim frequency has dropped 36% since implementation of the program in 2007 and they estimate that they have saved $3.2 million in annual premiums since the program has been established.  It seems like this may be a good thing to identify adverse events early, holding physicians accountable, apologizing and rectifying the situation when possible.

O’Reilly, K., Stanford Cuts Liability Premiums with Cash Offers After Errors.  American Medical News (November 7, 2011).

Friday, November 11, 2011

Washington State Lifts Limits on Medicaid Patient ER Visits

      A few months ago I wrote a blog post about Washington State implementing a law starting October 1, 2011 that limited the amount of ER visits for Medicaid patients to three visits a year.    Many physicians, including myself felt it was extremely dangerous to place these limits on patients.  The  Washington State chapter of the American College of Emergency Physicians, Seattle Children's Hospital, Washington State Medical Association, and the Washington State Hospital Association filed a lawsuit challenging this.  Yesterday the Court lifted the limit on the ER visits.

      Of note,  when they looked closer at the numbers they discovered that 97 percent of Washington's Medicaid clients did't even exceed three ER visits a year. "They blamed a "small, but expensive group" of patients for running up large numbers of visits.  Some of those patients have more than 100 visits a year, often for chronic conditions and a need for painkillers, officials said."

Read more:

State lifts three-visit ER limit for poor patients
 
http://www.seattlepi.com/local/article/State-lifts-three-visit-ER-limit-for-poor-patients-2263234.php#ixzz1dRdxibdJ

Sunday, November 6, 2011

Is it Okay for Physicians to Prescribe Medication to their Family and Friends?

Before the ink is even dry on your medical school diploma, you have family and friends asking you for medical advice and asking you to write a prescription.  But I have often wondered, is it okay to write a prescription for a friend or family member?  According to the Texas Medical Board, it is not illegal to do so, but physicians must be aware that doing so poses some risks.  In a recent article, they caution that friends and family must be treated like any other patient, and an adequate history and medical assessment must be obtained.  They also caution that it would be a good idea to maintain medical records on these individuals and your interactions with them.  In addition, the Texas Medical Association Board of Councilors advised that it is ethical to treat family and friends.  They also believe that medical records should be maintained, but they do note that in “urgent or episodic situations” that it may not be practical to do so.
            There is one important caveat however.  The Texas Medical Board absolutely prohibits physicians from writing prescriptions for controlled substances (e.g., narcotics) to family, friends or even themselves unless there is an emergency situation.  Physicians can prescribe a small amount of controlled substances for a 72 hour period in emergency.
            So if you are a physician in Texas, it is okay to prescribe medication to family and friends, but be aware of the possible need of maintaining medical records and be extremely cautious about prescribing controlled substances to family and friends (better yet, don’t do it at all).

Conde, C., Treating Your Own:  It’s Legal, But It Can Be Risky, Texas Medicine (October 2011).


Saturday, October 29, 2011

Accountable Care Organizations

As a part of healthcare reform there has been a lot of talk about the creation of Accountable Care Organizations, but what exactly are they, why are they so controversial, and what is their potential impact on the delivery of Emergency Medicine? 

Under the Affordable Care Act, ACOs have been created as a new payment model under Medicare.  There are also have pilot programs to extend the payment model to Medicaid and private insurance.  The goal of ACOs is to create a hospital and provider network that would provide care with quality and cost saving initiatives and CMS and the providers would share the cost savings.  The goal is to provide high quality care with reduced cost using a more integrated delivery approach and more aggressive quality monitoring.

ACOs may have some conflict with the traditional practice of Emergency Medicine in several ways.  First, physicians will become employees of ACOs.  Traditional Emergency Medicine doctors have the choice in some states to work as independent contractors.  Being an independent contractor allows them to provide access to care without a conflict of interest and without outside influence. 

ACOs may also conflict with laws in some states that prohibit the corporate practice of medicine. The CPM laws prohibit a hospital (or non-physician entity from directly hiring physicians).  CPM laws are designed to protect the physician patient relationship from conflict of interest, allowing doctors to be hired as independent contractors and to do what is best for the patient without undue influence. 

Although ACOs goals ares to to provide high quality integrated care at a lower cost, we will have to wait and watch closely to see what the overall effect truly will be.

New Affordable Care Act Tools Offer Incentives for Providers to Work Together When Caring for People with Medicare (October 20, 2011)   http://www.healthcare.gov/news/factsheets/2011/10/accountable-care10202011a.html

Fisher ES, Shortell SM (2010). Accountable Care Organizations: Accountable for What, to Whom, and How. JAMA 304 (15): 1715–1716.

Friday, October 28, 2011

Pre-Existing Condition Insurance Program (PCIP)

          As a physician, one of the things that frustrates me is when people are denied health insurance or are forced to pay extremely high premiums because they have a "pre-existing" medical condition.  Now, as a part of the Affordable Care Act, children and adults that have a preexisting medical condition and have been without health insurance for the past 6 months are eligible for insurance through the Pre-Existing Condition Insurance Plan (PCIP). 
          In order to be eligible for the PCIP, one must be a US citizen, or be residing in the US legally.  The individual also needs to provide a letter from a physician stating that they currently have a medical condition, disability or illness or that they had one within the past 12 months.  So far over 35,000 people have enrolled in the PCIP.
          This is a transitional program that will be available until 2014.  After 2014, people with pre-existing conditions will be eligible for health insurance through insurance exchanges.  Also after 2014 it will be illegal for insurance companies to deny people health insurance coverage or charge higher premiums because they have a pre-existing condition. 


More information on this topic can be found at these links:
Pre-existing Condition Insurance Plan.  https://www.pcip.gov/

Sunday, October 23, 2011

In Addition to Bath Salt Drugs Being Illegal, the DEA now has made the Synthetic Stimulants Used to Make the Bath Salt Drugs Illegal As Well

Last Month I wrote about Bath Salt drugs being made illegal by the DEA (see a copy of that blog post below).  Now the DEA is taking it one step further and specifically banning the three synthetic stimulants Mephedrone, 3,4 methylenedioxypyrovalerone (MDPV) and Methylone that are used to make Bath Salt drugs.  The DEA used its emergency scheduling authority to control the three synthetic stimulants making possessing and selling these chemicals, or the products that contain them, illegal in the United States. 
More information can be found at this link:  Chemicals Used as "Bath Salts"  Now Under Federal Control and Regulation, http://www.justice.gov/dea/pubs/pressrel/pr102111.html.
My Original Blog Post:
Patients in Emergency Departments across the country have been presenting with overdoses of a fairly new drug called “Bath Salts” (psychoactive bath salts).  Bath salt drugs actually have nothing to do with the chemicals that you may use in your bath, they are actually synthetic drugs  (methylenedioxypyrovalerone,  mephedrone and methylone).  These chemicals inhibit norepinephrine–dopamine reuptake and act as central nervous system stimulant.  According to the New England Journal of Medicine, these drugs can cause extreme sympathetic stimulation and profoundly altered mental status. “The sympathetic effects may include tachycardia, hypertension, hyperthermia, and seizures, and deaths have been reported. Altered mental status presents as severe panic attacks, agitation, paranoia, hallucinations, and violent behavior (e.g., self-mutilation, suicide attempts, and homicidal activity).”Bath salts were legal until recently when the DEA made them illegal. As of September 7, 2011, possessing and selling these chemicals or the products that contain them are both illegal in the United States for at least 1 year while the DEA and the US Department of Health and Human Service gathers more information.  The DEA is using its emergency scheduling authority to temporarily control bath salt drugs.   More information about this new law and about bath salts can be found at these links:http://www.medscape.com/viewarticle/749304http://www.nejm.org/doi/full/10.1056/NEJMc1107097

Thursday, October 20, 2011

Physicians May Violate HIPAA by Using Mobile Devices to Communicate with Patients

Many doctors use their mobile devices (Blackberry's, iPhones, etc) to communicate with patients.  However, you should be aware that using these devices to exchange protected health information (PHI) is covered by HIPAA.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law that was enacted to establish  national standards for electronic health care transactions and also address the security and privacy of health data.  Hospitals, medical offices, medical providers, HMOs and health care clearinghouses may only use or disclose protected health information (PHI) for treatment, payment and health care operations.  Users of these devices to share protected health information must have specific administrative, physical and technical safeguards (e.g., encryption) in place to protect patient privacy.

More information on this issue can be found at the links below:

The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).  http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

Healthcare Providers May Violate HIPAA by Using Mobile Devices to Communicate with Patients, ABA Health eSource (October 2011) http://www.americanbar.org/content/newsletter/publications/aba_health_esource_home/aba_health_law_esource_1110_barrett.html

Saturday, October 1, 2011

Hospital Liable for Assault of one Patient by Another Patient Under the Doctrine of Premise Negligence

A court in Tennessee recently held that a hospital can be held liable for patient safety, not under the doctrine of medical negligence, but under general premise liability, i.e., failure to keep the environment safe for a patient.  This ruling comes from a 2010 case in which a woman who was admitted to a psychiatric unit for hallucinations was assaulted in the shower by a male patient.  The court held that the facility did not have appropriate safeguards in place to protect their patients from assault.
The bottom line, hospitals and medical professionals are responsible for keeping their patients safe. 

More information on this topic can be found on the amednews website: Hospital can be sued in man's alleged attack on another patient.
http://www.ama-assn.org/amednews/2011/08/29/prca0829.htm.

Friday, September 30, 2011

Washington State Chapter of ACEP Files Lawsuit Challenging New Law that Would Limit Medicaid Patient ER Visits

This an update to my recent post about Washington State proposing to limit the amount of ER visits for Medicaid patients to three visits a year starting October 1, 2011.  Yesterday the Washington State chapter of ACEP filed a lawsuit challenging this.  I will be keeping a close eye on the outcome of this lawsuit.  More updates to follow!


Original Post: 

Washington State has approximately 1.1 million of their residents covered by Medicaid and two thirds of these are children.  In 2003, President Bush passed a law allowing states to limit access to ER's for Medicaid patients.  Since then, a few states have enacted such laws.    In an effort to lower the cost of health care, Washington State is proposing limiting the amount of ER visits Medicaid patients can make in a year.  They plan to only allow for three “non-emergency” visits per year.  If the patient makes more than three visits, the state will not pay the hospital for any services provided for after the third visit.  They estimate that they can save up to seventy-six million dollars over two years. 

They have a fifteen page list of nonemergency conditions.  However, some of the conditions they include as non-emergent include hypoglycemic coma, asthma attacks, abdominal pain, some types of bleeding and other potentially dangerous medical conditions.     Crises from chronic conditions like Sickle Cell anemia are included in the list as well. The person that developed this list is not a physician, and said the list was not intended to be used to make health care decisions or payments.  In fact, he has stated that the list was actually created to help officials find out where patients have trouble accessing primary care and help figure out if particular programs work well. 

It is extremely dangerous to place these limits on patients.  It may deter a patient bringing their child in with an asthma attack, because it is going to be labeled as non-emergent.  This can cause many deaths.  Even things that are truly non-emergent, can become emergent.  For patient that needs a medication refill or has lost their prescription, and cannot get an appointment with a doctor to get a, sometimes going to the ER is their only solution to get access to potentially life-saving medication.  Although ER overcrowding is a problem, deterring patients from seeking medical care is not a proper solution to this problem. 

Anyone else have a problem wtih this?  What do you think?

Wednesday, September 28, 2011

Limiting ER Medicaid Patient ER Visits: A Way to Curb ER Overcrowding, or a Dangerous Limitation of Access to Medical Care

I am reposting this blog entry I wrote a few months ago because the AMA recently published an article on this topic and I would like see if any of followers of this blog have any comments.  The new law discussed in this blog will take effect on October 1st of this year in Washington State.

Washington State has approximately 1.1 million of their residents covered by Medicaid and two thirds of these are children.  In 2003, President Bush passed a law allowing states to limit access to ER's for Medicaid patients.  Since then, a few states have enacted such laws.    In an effort to lower the cost of health care, Washington State is proposing limiting the amount of ER visits Medicaid patients can make in a year.  They plan to only allow for three “non-emergency” visits per year.  If the patient makes more than three visits, the state will not pay the hospital for any services provided for after the third visit.  They estimate that they can save up to seventy-six million dollars over two years. 

They have a fifteen page list of nonemergency conditions.  However, some of the conditions they include as non-emergent include hypoglycemic coma, asthma attacks, abdominal pain, some types of bleeding and other potentially dangerous medical conditions.     Crises from chronic conditions like Sickle Cell anemia are included in the list as well. The person that developed this list is not a physician, and said the list was not intended to be used to make health care decisions or payments.  In fact, he has stated that the list was actually created to help officials find out where patients have trouble accessing primary care and help figure out if particular programs work well. 

It is extremely dangerous to place these limits on patients.  It may deter a patient bringing their child in with an asthma attack, because it is going to be labeled as non-emergent.  This can cause many deaths.  Even things that are truly non-emergent, can become emergent.  For patient that needs a medication refill or has lost their prescription, and cannot get an appointment with a doctor to get a, sometimes going to the ER is their only solution to get access to potentially life-saving medication.  Although ER overcrowding is a problem, deterring patients from seeking medical care is not a proper solution to this problem. 

Anyone else have a problem wtih this?  What do you think?

Sunday, September 18, 2011

National Ban on Physician Ownership of Hospitals

One of my goals in life was to own a hospital.  Thanks to a recent law passed by Congress, it doesn’t look like that is going to happen.  A part of the Patient Protection and Affordable Care Act prohibits physician-owned hospitals from obtaining a Medicare provider number (meaning they cannot bill and receive payment from Medicare or Medicaid, which is a large proportion of hospital income).  All existing physician-owned hospitals that were operating as of March 23, 2010 were grandfathered in (meaning the law won’t apply to them).  Physician-owned hospitals that were under development at the time of the law passing were allowed to proceed with development as long as they obtained their Medicare provider numbers before the end of the year.  After December 31, 2010, physician ownership and investment in hospitals was completely banned.  The grandfathered hospitals will also be banned from increasing bed numbers, operating rooms or increasing the percentage of physician ownership.
According to a recent Texas Medical Association article, physician-owned hospitals are safer and have higher patient satisfaction ratings; “a 2005 Department of Health and Human Services study…found physician-owned hospitals have lower complication and mortality rates, as well as higher nurse-to-patient rations, than do general hospitals….CMS patient satisfaction ratings…show 85.1 percent of patients gave physician-owned hospitals a rating of nine or ten on a scale of ten, compared with a national hospital mean of only 64 percent.”
I believe physician are the right fit for owning and running a hospital, especially those with business and/or legal training and experience on top of their medical experience

More information on this issue can be found in the August 2010 edition of Texas Medicine.  Ortolon, K., Quashing Ownership.  Texas Medicine, 106:8; 29 (August 2010).

Saturday, September 17, 2011

Is Compassionate Dialysis Really Compassionate?

A large amount of patients present to our county ER with a chief complaint of needing dialysis.  These patients are undocumented residents that can only receive compassionate dialysis (meaning they only can receive it when they get very ill, not on a schedule).  I wondered, why can't these patients receive dialysis on a scheduled basis and wouldn't it be more cost effective and better for the patients to receive scheduled dialysis rather than showing up at an ER every time they needed dialysis?

Patients that are US citizens with End Stage Renal Disease qualify for Medicare or Medicaid through the End Stage Renal Disease Program that was enacted in 1973. However, undocumented residents cannot received any federal funding for dialysis.  In 1986 as a part of the Consolidate Omnibus Budget Reconciliation Act (COBRA),  the use of federal funds for covering undocumented residents for non-emergency services, like dialysis was prohibited.  Some states use state funds to provide for scheduled dialysis (California, Massachusetts), while other states (Texas) do not.  So patients in the states that do not provide funds for scheduled dialysis (like Texas), are left to present to the ER multiple times a week to determine if they are ill enough to receive dialysis.  The annual cost of scheduled hemodialysis is about $72,000.  However, this cost of compassionate/emergency dialysis is more than $200,000 annually. Compassionate dialysis also is bad for the health of the patient.  It has been noted that when comparing scheduled dialysis to compassionate dialysis, the later results in more ER visits, more hospitalization.

In my opinion it would be more cost effective, better for the patient, and better for community as a whole if there was universal coverage for patients with End Stage Renal Disease so that they may receive scheduled dialysis.  Over the next few years, millions of people will be eligible for health insurance.  Because of the existing shortage of primary care doctors, as more people receive health insurance, it is likely that more people will be trying to see primary care doctors.  The people that can’t get an appointment with a primary care doctor will likely go to the ER if they need to for treatment.  ER overcrowding is already a serious issue and will likely get worse.  It likely would help alleviate some of the strain on the ER by providing undocumented citizens scheduled dialysis so they don’t have to come to the ER multiple times in a week in order to try to get dialysis.

More information can be found in this recent New England Journal of Medicine article--Raghavan, R., Nuila, R., Survivors-Dialysis,  Immigration, and U.S. Law, NEJM 2011;364:23: 2183-85.

Friday, September 16, 2011

Tort Reform in Texas: Fear that Reform will be Overturned?

Most Texas physicians discuss how the medical liability climate has improved for the better since the advent of tort reform.  However, according to the Texas Medical Association, there has been an ongoing fear that the 2003 reforms will be overturned.  There has been a fear that the $250,000 cap on noneconomic damages will be attacked in attempt to raise the cap, attach a cost of living adjustment to the cap or even create an exception to the cap for those that will not get a significant amount of money in the form of economic damages (lost wages).  There was also some fear that the willful and wanton provisions that apply to professionals who provide care in the emergency setting will be changed to apply only to Good Samaritan situations. 
It is believed that the expected attacks on existing tort reform laws did not occur the last session as a result of the November general election.  However, physicians in Texas will be watching closely this session to see if any changes are made in the Texas House of Representatives, in the court system and also in the federal system (The HEALTH Act).

More information can be found in the September 2011 issue of Texas Medicine.

Thursday, September 15, 2011

HEALTH Act (Help Efficient, Accessible, Low-Cost, Timely Healthcare Act of 2011), National Tort Reform

The HEALTH Act is in essence National Tort Reform or Medical Liability Reform that is based on liability reforms adopted by Texas and California.  It places caps of $250,000 on non-economic damages (pain and suffering) and caps punitive damages at $250,000 or twice the amount of economic damages.  The provision also considers each party’s liability in direct portion to responsibility, limits attorney contingency fees, and sets the statute of limitations at 3 years after the date of injury manifestation or 1 year after the injury is discovered.
The bill was sponsored by Rep. Phil Gingrey, MD (R, Ga.). Two House committees have approved the bill, up next is a vote by the full House.  However, President Obama has said he will not approve capping damage awards.

More information can be found here:

Tuesday, September 13, 2011

Bath Salt Drugs are Now Illegal in the United States

Patients in Emergency Departments across the country have been presenting with overdoses of a fairly new drug called “Bath Salts” (psychoactive bath salts).  Bath salt drugs actually have nothing to do with the chemicals that you may use in your bath, they are actually synthetic drugs  (methylenedioxypyrovalerone,  mephedrone and methylone).  These chemicals inhibit norepinephrine–dopamine reuptake and act as central nervous system stimulant.  According to the New England Journal of Medicine, these drugs can cause extreme sympathetic stimulation and profoundly altered mental status. “The sympathetic effects may include tachycardia, hypertension, hyperthermia, and seizures, and deaths have been reported. Altered mental status presents as severe panic attacks, agitation, paranoia, hallucinations, and violent behavior (e.g., self-mutilation, suicide attempts, and homicidal activity).”
Bath salts were legal until recently when the DEA made them illegal. As of September 7, 2011, possessing and selling these chemicals or the products that contain them are both illegal in the United States for at least 1 year while the DEA and the US Department of Health and Human Service gathers more information.  The DEA is using its emergency scheduling authority to temporarily control bath salt drugs.   
More information about this new law and about bath salts can be found at these links:
http://www.medscape.com/viewarticle/749304
http://www.nejm.org/doi/full/10.1056/NEJMc1107097

Monday, September 12, 2011

Missed Myocardial Infarction Held to Constitute Willful and Wanton Negligence in Texas


     As a part of Tort reform in Texas, in order to find a physician providing emergency medical services guilty of negligence, the claimant must show that the doctor acted with willful and wanton negligence. Willful and wanton negligence is defined as gross negligence. Plaintiffs must prove that ER doctors acted with conscious indifference, or gross negligence, rather than simple negligence. This is extremely difficult to prove and is one of the primary reasons for the decrease in medical malpractice cases against emergency medicine physicians in Texas. However, recently a Texas court held a hospital liable for willful and wanton negligence for a missed MI. This is a rare precedent in Texas since the enactment of Tort Reform. 

      An elderly woman with history of diabetes and hypertension presented to ER with chief complaint of chest pain, chest discomfort and chest tightness. She was triaged as level 3 (low severity level), given albuterol nebulizer treatments and discharged home with a prescription for captopril. She he died at home the next day, autopsy reported that cause of death was MI (severe atherosclerotic disease was seen).  It was later determined that during her brief stay in the ER, she had 2 EKGs done (one EKG was reported normal but the other showed a Septal Infarct).

  The treating physician settled out of court and the hospital was found liable for negligence.  The court found that prematurely discharging a patient with chest pain, improperly interpreting EKG results, and prescribing medication without first determining the effect it will have on the patient’s cardiovascular system constituted willful and wanton negligence (gross negligence).
 
More information on this case can be found here: http://www.beaumontenterprise.com/news/article/St-Mary-s-found-negligent-in-ER-death-737829.php

Rates of Malpractice Lawsuits Against ER Doctors

       A recent article in the NEJM evaluates the numbers and size of malpractice awards among various specialties. Although there is a common misconception that ER doctors get sued a lot more than other specialties, this study shows that this is not true. ER doctors are actually sued at the same rate as the average physician. According to this study, the specialties associated with the highest malpractice rates include Neurosurgery, Cardiothoracic Surgery, General Surgery, OB/GYN, Orthopedic Surgery. The specialties associated with the highest payouts include Pediatrics, Pathology, Neurosurgery and Obstetrics.

       In summary they found that in low risk specialties, 36% of physicians were projected to face their first claim by the age of 45 years, as compared with 88% of physicians in high-risk specialties. By the age of 65 years, 75% of physicians in low-risk specialties and 99% of those in high-risk specialties were projected to face a claim. 55% of physicians in internal medicine and its subspecialties were projected to face a malpractice claim by the age of 45 years, and 89% by the age of 65 years.

In contrast, 80% of physicians in surgical specialties (including general surgery) and 74% of physicians in obstetrics and gynecology were projected to face a claim by the age of 45 years.

This is a link to this article:
http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

Friday, July 29, 2011

Dispelling the Myth of Emergency Department Health Care Spending

Emergency Departments are often blamed for increased health care spending.  However, upon investigation Emergency Departments only account for 3% of health care spending annually.  In addition, Emergency medicine physicians only account for 4% of all physicians, yet 70% of Emergency Department visits are by uninsured physicians and we see 124 million patients each year.  Emergency Departments are closing at an alarming rate, however the need for emergency visits have increased and will increase even more as health care reform is further implemented.  Emergency Departments are vital to the community and provide medical care at a low fraction of health care spending.  See this website for more information: http://www.acep.org/Content.aspx?id=45294

Cybermedicine

With the widespread availability and use of the internet in today’s society, the internet has begun to facilitate the use of the internet by physicians to communicate with patients, including the use of the internet for online medical consultations (aka, Cybermedicine).  However, many doctors are consulting with patients that they have no established relationship with and have never examined.  These doctors are diagnosing ailments, providing a treatment plan, and in some situations, prescribing medication. Diagnosing and treating a patient that you have never examined can be very dangerous, and can place the doctor in a significant potential for malpractice liability. At this point it is even uncertain whether malpractice insurance will even cover the physician practicing medicine in this way. 
             Because regulation of the practice of medicine is largely governed by states, there is no uniform law regarding the legality of Cybermedicine. In Hawaii, patients can visit with a physician that they never met before via the internet, the physician can diagnose the patient's illness and provide the patient with a prescription.  In other states, like Texas, this practice is only allowed if the patient and the physician have an established physician-patient relationship.  Some states do not have any laws covering Cybermedicine.    
            Reimbursement of Cybermedicine services is also a complicated issue. So far Medicare and Medicaid do not reimburse for Cybermedicine services.  In addition, only a few private insurers offer reimbursement.  For those patients and physicians with established relationships, Cybermedicine may be a cost effective method of lowering medical costs.  However, if physicians will not be reimbursed for providing these services, they have no incentive to participate. 
            Overall, online medical consultations may be an efficient, cost-effective way of enhancing an established physician-patient relationship and for certain medical conditions. 
To read more on this subject, take a look at this article:  Cybermedicine: What You Need to Know, http://www.americanbar.org/content/dam/aba/publishing/health_lawyer/health_mo_premium_hl_healthlawyer_v23_2306.authcheckdam.pdf

Emergency Department Waiting Times Posted on Billboards

Hospitals have begun to post their Emergency Department waiting times on billboards, on the internet and even via text messages.  In New Jersey, a hospital has an electronic billboard with waiting times on the New Jersey Turnpike near the Holland Tunnel.  The billboard posts the average wait time from entering the door of the ED to the time the patient sees a medical provider (their current claim is an average wait time of less than 30 minutes).  Although some argue that posting waiting times will help cut backlogs because people with less urgent problems will drive farther to a hospital with a shorter wait time, others argue that it is a marketing strategy used to attract less urgent patients that can be seen and discharged quickly.  Some even argue that it is luring patients from competing hospitals.  I personally believe that it may deter patients that are really ill from waiting if they feel that the wait is too long.  In addition, just because a patient may get into a bed quickly doesn’t mean they will get seen quickly and doesn’t mean that you will get better care.  I wrote an article on this topic recently and it generated some interesting debate on Facebook.  Here is a link to the article:  Emergency Department Waiting Times: A Solution to ED Overcrowding or a Deterrent to Patients? 
http://www.emra.org/emra_articles.aspx?id=43622&_cldee=cmI0QGJjbS5lZHU%3D

Tuesday, July 19, 2011

FDA Releases Proposed Guidelines for Regulation of mHealth Technology (mobile apps)

Last week I wrote about mHealth technology and FDA regulation and the murkiness of such regulation.  Finally, the FDA has released a set of proposed guidelines, of what mobile apps will be subject to FDA regulation.  They include:
·         Mobile apps that are an extension of a medical device by connecting to the device for purposes of controlling the device or displaying, storing, analyzing, or transmitting patient-specific medical device data. Examples include remote display of data from bedside monitors, display of previously stored EEG waveforms, and display of medical images directly from a Picture Archiving and Communication System (PACS) server, apps that provide the ability to control inflation and deflation of a blood pressure cuff , apps that control the delivery of insulin on an insulin pump by transmitting control signals to the pumps from the mobile platform.
·         Mobile apps that transform the mobile platform into a medical device by using attachments, display screens, or sensors or by including functionalities similar to those of currently regulated medical devices. Examples include attachment of a transducer to a mobile platform to function as a stethoscope, attachment of a blood glucose strip reader to a mobile platform (e.g., cell phone)  to function as a glucose meter, or attachment of electrocardiograph (ECG) electrodes to a mobile platform to measure, store, and display ECG signals.
·         Mobile apps that allow the user to input patient-specific information and output a patient-specific result, diagnosis, or treatment recommendation to be used in clinical practice or to assist in making clinical decisions (Offer suggestions about a patient's diagnosis or treatment).  Examples include mobile apps that provide a questionnaire for collecting patient-specific lab results and compute the prognosis of a particular condition or disease, calculate dosage for a specific medication, or provide clinical recommendations that aid a clinician in making a diagnosis or selecting a specific treatment.
People have up to 90 days from publication of the proposed guidelines to submit comments and suggestions.
Draft Guidance for Industry and Food and Drug Administration Staff - Mobile Medical Applications. http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm263280.htm#5


Monday, July 18, 2011

West Virginia Court Upholds Constitutionality of Non-Economic Damage Caps

In 2003, as part of tort reform, West Virginia enacted damage caps of $250,000 for non-economic damages (damages for pain and suffering).  This award increases to $500,000 for certain cases like wrongful death, loss limb).  Recently, a claimant appealed a ruling that granted him damages based on this law.  During this appeal, the claimant argued that this law violated equal protection laws granted by the constitution.  The court denied the appeal, upholding the law as constitutional.  This ruling sets a precedent for other states, upholding the constitutionality of the caps.

For more information, see the following links:

W.Va. Supreme Court OKs State's Cap for Non-Economic Damages in Case
http://statejournal.com/story.cfm?func=viewstory&storyid=102008

West Virginia High Court Upholds Noneconomic Damages Cap

Saturday, July 16, 2011

Increased Enforcement of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) in order to Protect Patient Medical Records

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law that was enacted to establish  national standards for electronic health care transactions and also address the security and privacy of health data.  Hospitals, medical offices, HMOs and health care clearinghouses may only use or disclose PHI (protected health information) for treatment, payment and health care operations.  The reason for its creation was the growing number of organizations involved in care and processing of medical claims, the growing use of electronic technology and the increasing ability to collect highly sensitive information.  HIPPA privacy standards were enacted to restore trust, and make business associates directly accountable under HIPPA.
Two years ago, HIPPA breach notification obligations were developed (if there is a breach of the HIPPA rules, the organization bust notify the Department of Health and Human Services.  Since then, the Department of Health and Human Services, Office for Civil Rights, had six settlements (four within the past year), for violation of the privacy and security rule.  The most recent settlement was $865,500 against UCLA Health System. UCLA Health System employees were accused of violating the Privacy Rule by improperly accessing the protected health information of patients, including several celebrities who filed complaints with HHS.  In addition to paying the $865,000 fee, UCLA Health System entered into an agreement with OCR requiring it to revise its HIPAA Privacy and Security policies, submit them to OCR for approval and present the revised policies to all employees who access PHI and all new employees within 30 days of HHS approval of the Policies.

Links to more information: 

Tuesday, July 12, 2011

US Healthcare Spending Outpaces Other Countries

The United States spends more on health care than any other country per capita with similar patient outcomes.  In 2009 Healthcare spending in the U.S. accounted for 17.4% of the nation’s total economic output. But why are health care costs so much higher n the US than in other states? 
Studies have shown that health care in the United States involves a lot more procedures.  In addition we insist upon using the newest technology (even if it hasn’t been proven that the newer is better).  We are a high-tech society.  The U.S. has more MRI and CT scanners than all other countries except for Japan (and in Japan they have access to cheaper CT and MRI’s).  We also buy our new technology earlier when it is more expensive while other countries will wait. 
In order to curb health care spending in England, they created the National Institute for Health and Clinical Excellence (NICE).  NICE` evaluates new drugs, medical devices, diagnostic techniques, and surgical procedures, determines whether treatments are clinically effective,  compares them with relevant and current alternatives, and determines whether they are cost-effective and advises the National Health Service whether they should provide coverage for those services.
Another small step in lowering health care spending may be to be more aware of the costs of tests that are ordered.  A recent study showed that by merely giving doctors a list of the cost of laboratory tests they are ordering helps to reduce ordering unnecessary or duplicative tests.
Two recent articles on this topic can be found here:
U.S. healthcare spending far outpaces other countries,  Noam N. Levey, http://www.latimes.com/health/boostershots/la-heb-health-spending-20110630,0,4003574.story?track=rss

Got a Medical Question....there is an app for that...

Does your patient have a medical problem or question?  The chances are that they have gone on the internet or used an mobile phone application to get more information.  In additon, many emergency departments and physicians use various mobile phone technology in their medical practice.  Mobile Health technology aka mHealth is becoming prevalent as our society become more technolgically advanced.  What most don't know is that most mHealth technology and apps are regulated by the FDA.

More information can be found in this article:  mHealth: A Descriptive Analysis of the Technology that is Changing the Practice of Medicine   http://www.emra.org/emra_articles.aspx?id=43536

A blog on this technology can be found at http://www.imedicalapps.com/

Monday, July 11, 2011

Minimal Decrease in Low-Severity Emergency Department Visits in Massachusetts after Implemention of Health Reform

A recent study shows that the level of low-severity ED visits in Massachusetts has decreased slightly and overall ED use has increased since its implementation of health reform in their state in 2007.  This is the opposite of what was proposed when their health reform was enacted (it was believed that overall ED visits and low-severity visits would decrease).  Some believe that there is still not enough primary care available for the newly insured and that others have not changed their habits yet and still use the ED for primary care visits.  I feel that it still too early to see the effects of health care reform and that eventually the numbers of lower severity visits to ED's will decrease when (and if) more primary care providers are available to see the patients.   A link to the article on this subject can be found here: http://www.sciencedaily.com/releases/2011/06/110606142555.htm