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

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

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

http://www.ama-assn.org/amednews/2011/07/04/prsb0704.htm

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: 

http://www.cms.gov/HIPAAGenInfo/

http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/UCLAHSracap.pdf

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

Reducing Unnecessary Blood Tests By Telling Doctors the Cost, Katherine Hobson, http://blogs.wsj.com/health/2011/05/16/reducing-unnecessary-blood-tests-by-telling-doctors-the-cost/?mod=WSJBlog&mod=WSJ_health

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/

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

Judge Directed Negotiation-Another Solution for Medical Liability Reform

A new program known as "judge-directed negotiation" is being tested in New York as a way to solve some of the malpractice liability issues discussed earlier this month in this blog.  Under this program, Judges are involved in the cases from the start and actively suggest settlements.  This helps resolve malpractice cases years earlier, prevents lengthy appeals and allows those patients that truly have been harmed to receive compensation much earlier than usual.  This may be another notch in the tort reform belt that aids in reducing the malpractice crisis.  See this recent article in the New York Times for more information: http://www.nytimes.com/2011/06/13/nyregion/to-curb-malpractice-costs-judges-jump-in-early.html?_r=1&ref=todayspaper

We have a medical situation,Is there a Doctor or Nurse on the plane?

Ever been flying and hear the flight attendant announce overhead "Is there a Doctor or Nurse on the plane?"  Have you ever wondered what liability you have when you provide emergency medical assistance in this situation? Under the Aviation Medical Assistance Act, anyone (including physicians) that provides medical assistance on an airplane is protected from liability, as long as they did not act with willful or wanton misconduct (gross negligence).   Aviation Medical Assistance Act 1998 (H R 2843).

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

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 the 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?

Tort Reform

In my previous post I discussed medical malpractice.  The majority of malpractice claims (sixty-four percent) are either withdrawn, dropped or dismissed without any payment to the plaintiff.  In an effort to fix some of these problems, some states (California and Texas) enacted tort reform (some like to call it medical liability reform).    There is also current legislation to make tort reform national law (the Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act of 2011).  So far in areas where there is tort reform, states  have seen decreased the numbers of malpractice cases and a decrease in the cost of liability insurance, leading to increased numbers of practicing physicians in those states which helps relieve physician shortages.    However, there haven't been any clear indications that tort reform actually decreases the cost of health care, but it is still too early to tell the long term effects of tort reform.  I believe in the long run it will decrease defensive medicine leading to decrease health care costs.

For more information check out this article:  Medical Liability Reform: The Good, The Bad and The Ugly,

http://www.emra.org/emra_articles.aspx?id=43611&_cldee=cmI0QGJjbS5lZHU%3d

Medical Malpractice in the ER

Probably every doctor's worse fear (other than harming a patient) is getting sued, but overall, only 1% of total claims studied found a verdict for the plaintiff (29% of cases were settled with some payment to the plaintiff). 

Did you know that in the Emergency Department, only 19% of claims were actually attributable to Emergency Medicine physicians. 

The most common ED lawsuits involved acute myocardial infarction and appendicitis (missed diagnoses).  

To read more about this issue, check out a breif article I wrote in What's Up in Emergency Medicine:  http://www.emra.org/emra_articles.aspx?id=43544

The Litigators Lions Pit: The Top 10 Medical Malpractice Issues Every Resident Should Know

Why a Health Law Blog?

I am both a doctor and a lawyer so health and law both interest me.  I am presently an Emergency Medicine resident at the Baylor College of Medicine, but have a bit of a non-traditional background that got me to where I am today.  Before medical school I was a patent attorney (represented generic drug companies that were trying to get their lower cost drugs on the market).  Over the past few years I have become intrigued by various health law topics, went back to school (while in residency) and got a LL.M (Masters in Health Law).  Since then I have started writing on a few health law topics.  I am also interested in developing a Health Law curriculum for physicians, residents and medical students. One of my mentor's suggested that I start writing a Health Law Blog; it sounds like a great idea so I thought I would give it a shot.  I will post various Health Law topics, give my opinion and would like to hear others opinions on the topics as well.  Most of the topics may focus on Emergency Medicine related issues since that is what I deal with every day, but we will see what happens.  Any critique, comments or suggestions is welcome.