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?

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 1^st 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?

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).

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.

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.

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:

http://www.ama-assn.org/amednews/m/2011/07/25/gsb0725.htm

http://www.ama-assn.org/resources/doc/washington/hr5-summary.pdf

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

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