Obamacare 30 day Readmission Penalty

[Groove]

This asinine policy on penalizing hospitals for medicare reimbursement when they are re-admitted within 30 days of discharge is so incredibly ludicrous to me. Is anyone else getting pressure to discharge high risk patients due to re-admission concerns? I had a recent experience that is, I feel, an ill omen for future pressures we face as EM docs and all the more reason to stick to our guns. Let me throw this patient at you and see if anyone would have done differently.

Elderly pt in her 70s, s/p discharge 2 days ago who left with chest pain and is now back with chest pain. Demented but interval periods of lucidness and able to give you a decent history. I don't think it's really important to provide all the details of her presenting symptoms when you hear the rest, suffice to say...chest pain. S/P... get this... NSTEMI with cardiac arrest. Troponin? Marginally positive, but positive nonetheless. EKG with flipped Ts in precordium, similar to last EKG, no ST depression. PMHx?: Train wreck.

Technically this pt meets nstemi criteria. Resolving troponinemia? It doesn't follow any sort of logarithmic half-life curve, and might be related to any other number of things but are you seriously going to bet your chips on anything else considering her recent arrest and nstemi? Hellz, no.

I actually got significant push back from medicine and cards on this pt. Medicine wants me to discharge her from the ED. "She left with chest pain and the troponin is less than the last one we got (10 days ago)". Things got heated and I basically told him to discharge her himself which he, of course, did not do. Cards is concerned about re-admission wrist slapping by hospital administration and wants her boarded in the ED for another 6 hours for a repeat troponin. Ultimately, I get her upstairs with much gnashing of teeth and sticking to my guns on a pt I felt needed telemetry obs at the very least and medicare penalties be damned.

I really got worked up over this and although kept professional (I think), I was definitely fired up and galled that I was being pressured to d/c such a high risk patient with a positive troponin.

I feel this is an ill omen and I am suspicious that it's a sign of more to come in the future along with ridiculous requests to excessively board patients in the ED to avoid re-admissions, which... bad pt care aside, makes everyone's metrics look good except ours of course.

It's my day off and I'm still worked up over this. I blame suits and ties in Washington for coming up with hospital policies that make absolutely no sense.

Imagine, the hospitals that are going to end up penalized the most are the tertiary care/ high acuity hospitals where the pt population being discharged is a helluvalot sicker than the 50 bed hospital with no ICU an hour away in the middle of nowhere that transfers 50% of their pt's needing admission.

The whole thing is ridiculous to me.

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[two guys]

I understand the premise of the policy - to make sure folks don't get discharged earlier and without any type of bounceback protection (scheduled follow up visit, home health, a phone line to call and arrange outpatient eval, etc). That being said, it makes no sense to put the responsibility of preventing the bounceback on the EM provider. We didn't discharge the patient, we aren't experts at arranging the type of help they often need (home health, follow up visit, etc) and we have a shorter relationship with the patient than the originally discharging service.

This was a big deal where I used to work, not an issue at my current job. When it comes up, I always list the reasons above (I didn't discharge them, I don't have a social worker, and I don't know squat about home health) as why the discharging service needs to come see and dispo the patient. I've seen them discharge a handful with close follow up or a social work solution, but 90% of the time when the decision is theirs, they suddenly grasp the risk and impracticality involved and admit the patient.

As far as the political part of it. The suits don't have a medical license. If we keep doing whats right for the patient, the suits will use their lobbying powers to keep from losing any of their money. If we don't do the right thing and let them tell us how to practice medicine, they won't lose money and this rule will survive.

 

[Arcan57]

I understand the premise of the policy - to make sure folks don't get discharged earlier and without any type of bounceback protection (scheduled follow up visit, home health, a phone line to call and arrange outpatient eval, etc). That being said, it makes no sense to put the responsibility of preventing the bounceback on the EM provider. We didn't discharge the patient, we aren't experts at arranging the type of help they often need (home health, follow up visit, etc) and we have a shorter relationship with the patient than the originally discharging service.

This was a big deal where I used to work, not an issue at my current job. When it comes up, I always list the reasons above (I didn't discharge them, I don't have a social worker, and I don't know squat about home health) as why the discharging service needs to come see and dispo the patient. I've seen them discharge a handful with close follow up or a social work solution, but 90% of the time when the decision is theirs, they suddenly grasp the risk and impracticality involved and admit the patient.

As far as the political part of it. The suits don't have a medical license. If we keep doing whats right for the patient, the suits will use their lobbying powers to keep from losing any of their money. If we don't do the right thing and let them tell us how to practice medicine, they won't lose money and this rule will survive.

This rule will survive regardless of what we do. It makes no sense for the health care payors to switch from FFS to paying for an episode of care if the hospitals can just collect for another episode by discharging the patient too early and then bringing them back in again. It's too big a loophole. If we stay strong on not inappropriately discharging patients then eventually the hospitals will have to come up with another solution. Unfortunately everyone is going to be acting in their own interests and hoping someone caves along the line.

If I'm a floor doc with hospital admin threatening to pull me off the call schedule if I don't get my LOS down, I'm going to discharge questionable cases. If some of them bounceback, I'm going to pressure the ED doc to send them back home. If I can get one or two to give in, then it starts becoming policy and docs holding the line will start looking "unreasonable". That being said it's not worth the risk to discharge them myself from the ED since family is already going to be pissed that I kicked them out.

If I'm hospital admin, my bonus is dependent on meeting metrics and playing hardball with the hospitalists regarding LOS is the most efficient way to save money. Effective social work or keeping a patient longer to allow for safe discharge both cost money. While theoretically a high profile bounceback could lead to discovery of documents that demonstrate a clear pattern of placing profits ahead of patient safety, in general there's enough ability to shift blame (rogue doc misinterpreted our policies) that you don't have direct exposure.

If I'm the ED doc, I'm right were I always am - cleaning up a mess I didn't make while keeping three sets of masters happy.

 

[erdoc00]

The business of medicine at work. Administrators and politicians just doing their best to put their self interests above everything else. And physicians are also to blame for letting it get out of hand because of our own financial interests, too. Our entire modern healthcare industry is one disgusting mess.

 

[Birdstrike]

This is just one of many reasons so many of us were against Obamacare. This is one of many "devils in the details." Just think of how many more of these surprises there are in those 2000 pages. It's just a matter of time before you have the news stories of sentinel events, and people dying, because someone refused to admit them on the 28th or 29th day to meet this metric. I think I posted something about this a couple of years ago, as this is not a new concept. It's no different than the HMOs trying to force out post-partum women 24hrs post delivery in the 1980's and 1990's. It took many deaths to get the very dangerous "policy makers" to change their own policies. The same will happen here. The more we have non-physicians making health care decisions, the more this type if thing will happen. Unfortunately Groove, I think you're right, that it is a sign of more to come.

 

[Silent Cool]

 

[Chip N Sawbones]

Dumb med student question here, but what's an S/P discharge? Dr. Google wasn't any help on this one.

 

[deleted547339]

Dumb med student question here, but what's an S/P discharge? Dr. Google wasn't any help on this one.

s/p stands for status post. It's traditionally used to mean after a surgery, but it is really used to just mean that something has already happened.

65yoWM with history of MI s/p CABG present with chest pain....

56yoAAF with hx of lymphoma s/p chemo....

You get the idea. Just means someone who was discharged.

 

[Siggy]

status post discharge.

 

[Chip N Sawbones]

Thank you.

 

[Alejandro]

Do Obs or CDUs count as part of the readmission? If not, then I imagine we'll start to see CDUs become even more prevalent, yes?

 

[TooMuchResearch]

If this pt was admitted for ACS again...isn't it actually a new problem? It's not like a CHF bounceback that wasn't thoroughly dried out the first time and lacked outpatient follow-up who is now back with the same/the next CHF exacerbation. It's a LOL who had ACS who has a separate event, also ACS. I thought the penalties were for bouncebacks for a select set of diagnoses.

 

[Arcan57]

If this pt was admitted for ACS again...isn't it actually a new problem? It's not like a CHF bounceback that wasn't thoroughly dried out the first time and lacked outpatient follow-up who is now back with the same/the next CHF exacerbation. It's a LOL who had ACS who has a separate event, also ACS. I thought the penalties were for bouncebacks for a select set of diagnoses.

I'm tossing this idea out to the community at large, so think well of me when you're picking out your superyacht.

HOME POINT OF CARE TROPONIN COMBINED WITH AUTOMATED 12-LEAD EKG VEST

Having chest pain that feels like your chronic angina but not sure? Sick of having to spend 12-24 hours in the hospital just to find out there's nothing fixable? Are you a hospital administrator looking to cut down on in-patient care while expanding into the lucrative field of niche home medical care delivery? Consider upgrading to the deluxe version which includes a "Lifevest" style AED add-on for arrhythmia prevention and a 6-pack of lovenox to make it through the weekend until your cardiologist is available. Combined with your existing home regimen of ASA, +/- Plavix, beta-blocker, and statin there's literally no reason to come to the hospital except a STEMI (dx'ed by vest with automatic call to 911) or cardiogenic shock.

 

[Silent Cool]

This asinine policy on penalizing hospitals for medicare reimbursement when they are re-admitted within 30 days of discharge is so incredibly ludicrous to me. Is anyone else getting pressure to discharge high risk patients due to re-admission concerns? I had a recent experience that is, I feel, an ill omen for future pressures we face as EM docs and all the more reason to stick to our guns. Let me throw this patient at you and see if anyone would have done differently.

Elderly pt in her 70s, s/p discharge 2 days ago who left with chest pain and is now back with chest pain. Demented but interval periods of lucidness and able to give you a decent history. I don't think it's really important to provide all the details of her presenting symptoms when you hear the rest, suffice to say...chest pain. S/P... get this... NSTEMI with cardiac arrest. Troponin? Marginally positive, but positive nonetheless. EKG with flipped Ts in precordium, similar to last EKG, no ST depression. PMHx?: Train wreck.

Technically this pt meets nstemi criteria. Resolving troponinemia? It doesn't follow any sort of logarithmic half-life curve, and might be related to any other number of things but are you seriously going to bet your chips on anything else considering her recent arrest and nstemi? Hellz, no.

I actually got significant push back from medicine and cards on this pt. Medicine wants me to discharge her from the ED. "She left with chest pain and the troponin is less than the last one we got (10 days ago)". Things got heated and I basically told him to discharge her himself which he, of course, did not do. Cards is concerned about re-admission wrist slapping by hospital administration and wants her boarded in the ED for another 6 hours for a repeat troponin. Ultimately, I get her upstairs with much gnashing of teeth and sticking to my guns on a pt I felt needed telemetry obs at the very least and medicare penalties be damned.

I really got worked up over this and although kept professional (I think), I was definitely fired up and galled that I was being pressured to d/c such a high risk patient with a positive troponin.

I feel this is an ill omen and I am suspicious that it's a sign of more to come in the future along with ridiculous requests to excessively board patients in the ED to avoid re-admissions, which... bad pt care aside, makes everyone's metrics look good except ours of course.

It's my day off and I'm still worked up over this. I blame suits and ties in Washington for coming up with hospital policies that make absolutely no sense.

Imagine, the hospitals that are going to end up penalized the most are the tertiary care/ high acuity hospitals where the pt population being discharged is a helluvalot sicker than the 50 bed hospital with no ICU an hour away in the middle of nowhere that transfers 50% of their pt's needing admission.

The whole thing is ridiculous to me.

@Groove ,
Given the changes coming down the pipe for medicine, would you recommend it as a career? What about compared to other options in health care?

thanx

 

[Birdstrike]

I'm tossing this idea out to the community at large, so think well of me when you're picking out your superyacht.

HOME POINT OF CARE TROPONIN COMBINED WITH AUTOMATED 12-LEAD EKG VEST

Having chest pain that feels like your chronic angina but not sure? Sick of having to spend 12-24 hours in the hospital just to find out there's nothing fixable? Are you a hospital administrator looking to cut down on in-patient care while expanding into the lucrative field of niche home medical care delivery? Consider upgrading to the deluxe version which includes a "Lifevest" style AED add-on for arrhythmia prevention and a 6-pack of lovenox to make it through the weekend until your cardiologist is available. Combined with your existing home regimen of ASA, +/- Plavix, beta-blocker, and statin there's literally no reason to come to the hospital except a STEMI (dx'ed by vest with automatic call to 911) or cardiogenic shock.

You're way ahead of your time. This invention will be laughed at as absurd, then forgotten, only to be rediscovered at some point in the future and touted as genius by some penny pinching Medicare official who will try to make it a reality for "cost savings."

 

[EMIM2011]

You're way ahead of your time. This invention will be laughed at as absurd, then forgotten, only to be rediscovered at some point in the future and touted as genius by some penny pinching Medicare official who will try to make it a reality for "cost savings."

There are already places that are seriously working on this.

 

[Daiphon]

I'm tossing this idea out to the community at large, so think well of me when you're picking out your superyacht.

HOME POINT OF CARE TROPONIN COMBINED WITH AUTOMATED 12-LEAD EKG VEST

Having chest pain that feels like your chronic angina but not sure? Sick of having to spend 12-24 hours in the hospital just to find out there's nothing fixable? Are you a hospital administrator looking to cut down on in-patient care while expanding into the lucrative field of niche home medical care delivery? Consider upgrading to the deluxe version which includes a "Lifevest" style AED add-on for arrhythmia prevention and a 6-pack of lovenox to make it through the weekend until your cardiologist is available. Combined with your existing home regimen of ASA, +/- Plavix, beta-blocker, and statin there's literally no reason to come to the hospital except a STEMI (dx'ed by vest with automatic call to 911) or cardiogenic shock.

I'd kickstart this s*it.

 

[Old_Mil]

This asinine policy on penalizing hospitals for medicare reimbursement when they are re-admitted within 30 days of discharge is so incredibly ludicrous to me. Is anyone else getting pressure to discharge high risk patients due to re-admission concerns? I had a recent experience that is, I feel, an ill omen for future pressures we face as EM docs and all the more reason to stick to our guns. Let me throw this patient at you and see if anyone would have done differently.

Elderly pt in her 70s, s/p discharge 2 days ago who left with chest pain and is now back with chest pain. Demented but interval periods of lucidness and able to give you a decent history. I don't think it's really important to provide all the details of her presenting symptoms when you hear the rest, suffice to say...chest pain. S/P... get this... NSTEMI with cardiac arrest. Troponin? Marginally positive, but positive nonetheless. EKG with flipped Ts in precordium, similar to last EKG, no ST depression. PMHx?: Train wreck.

Technically this pt meets nstemi criteria. Resolving troponinemia? It doesn't follow any sort of logarithmic half-life curve, and might be related to any other number of things but are you seriously going to bet your chips on anything else considering her recent arrest and nstemi? Hellz, no.

I actually got significant push back from medicine and cards on this pt. Medicine wants me to discharge her from the ED. "She left with chest pain and the troponin is less than the last one we got (10 days ago)". Things got heated and I basically told him to discharge her himself which he, of course, did not do.

Our relationship with our hospitalists has really deteriorated over the past six months or so, I wonder if this is part of the reason. Just last shift one of them wanted me to board a patient in the ED and fix her lytes. but we get push back on everything so it may just be the culture of the inpatient team.

Sent from my Z10 using Tapatalk

 

[FutureInternist]

This asinine policy on penalizing hospitals for medicare reimbursement when they are re-admitted within 30 days of discharge is so incredibly ludicrous to me. Is anyone else getting pressure to discharge high risk patients due to re-admission concerns? I had a recent experience that is, I feel, an ill omen for future pressures we face as EM docs and all the more reason to stick to our guns. Let me throw this patient at you and see if anyone would have done differently.

Elderly pt in her 70s, s/p discharge 2 days ago who left with chest pain and is now back with chest pain. Demented but interval periods of lucidness and able to give you a decent history. I don't think it's really important to provide all the details of her presenting symptoms when you hear the rest, suffice to say...chest pain. S/P... get this... NSTEMI with cardiac arrest. Troponin? Marginally positive, but positive nonetheless. EKG with flipped Ts in precordium, similar to last EKG, no ST depression. PMHx?: Train wreck.

Technically this pt meets nstemi criteria. Resolving troponinemia? It doesn't follow any sort of logarithmic half-life curve, and might be related to any other number of things but are you seriously going to bet your chips on anything else considering her recent arrest and nstemi? Hellz, no.

I actually got significant push back from medicine and cards on this pt. Medicine wants me to discharge her from the ED. "She left with chest pain and the troponin is less than the last one we got (10 days ago)". Things got heated and I basically told him to discharge her himself which he, of course, did not do. Cards is concerned about re-admission wrist slapping by hospital administration and wants her boarded in the ED for another 6 hours for a repeat troponin. Ultimately, I get her upstairs with much gnashing of teeth and sticking to my guns on a pt I felt needed telemetry obs at the very least and medicare penalties be damned.

I really got worked up over this and although kept professional (I think), I was definitely fired up and galled that I was being pressured to d/c such a high risk patient with a positive troponin.

I feel this is an ill omen and I am suspicious that it's a sign of more to come in the future along with ridiculous requests to excessively board patients in the ED to avoid re-admissions, which... bad pt care aside, makes everyone's metrics look good except ours of course.

It's my day off and I'm still worked up over this. I blame suits and ties in Washington for coming up with hospital policies that make absolutely no sense.

Imagine, the hospitals that are going to end up penalized the most are the tertiary care/ high acuity hospitals where the pt population being discharged is a helluvalot sicker than the 50 bed hospital with no ICU an hour away in the middle of nowhere that transfers 50% of their pt's needing admission.

The whole thing is ridiculous to me.

This was in place way before ObamaCare

 

[Silent Cool]

Curious what the EP docs think:

Have you entertained owning a free-standing ER? Why or why not?

 

[Arcan57]

Our relationship with our hospitalists has really deteriorated over the past six months or so, I wonder if this is part of the reason. Just last shift one of them wanted me to board a patient in the ED and fix her lytes. but we get push back on everything so it may just be the culture of the inpatient team.

Sent from my Z10 using Tapatalk

Why are you getting push back on everything? Is their compensation model hourly rather than RVU? Did the hospital stop subsidizing them for self-pay patients? Is anyone thinking about a CDU?

 

[NinerNiner999]

This 30-day bounce back rule is also designed to motivate hospitals to create more robust outpatient options for their patients - which is another goal of obamacare. Home health visits, CHF clinics, COPD evaluations will become more prevalent to reduce readmissions. From the ER side, over time, these resources will be put in place to reduce the number of returns, and it will slowly come to fruition. Patient dispositions to alternative facilities (such as rehab facilities and LTAC's who have the capability to manage these cases) will also become more prevalent. Observation stays will become frowned upon because, in addition to lower reimbursement, there is a higher individual responsibility for patients to pay for their own stay, which hurts inpatient satisfaction scores. And the wheels goes round and round...

 

[Birdstrike]

This 30-day bounce back rule is also designed to motivate hospitals to create more robust outpatient options for their patients - which is another goal of obamacare. Home health visits, CHF clinics, COPD evaluations will become more prevalent to reduce readmissions. From the ER side, over time, these resources will be put in place to reduce the number of returns, and it will slowly come to fruition. Patient dispositions to alternative facilities (such as rehab facilities and LTAC's who have the capability to manage these cases) will also become more prevalent.

With that statement, you seem to have quite a bit of faith in the "policy maker" types to make the system actually work properly. They sure as hell haven't done it so far. My view is that they're just winging it as they go along and their ability to cause major unintended adverse consequences of their poorly thought out policies, cannot be underestimated. I just hope doctor pay stays strong, otherwise there will be a mass exodus from the profession of Medicine. No one in their right mind, would put up with this level of nonsense, without being assured they'll be paid extremely well. Otherwise, it's just not worth the stress, debt, sleeplessness, liability and other garden variety bullsh¡t.

Edit: Some of you might be surprised to hear me says this, but I think doctor salaries are going to be just fine. In fact, I think they are going up. I count on the incompetence of the politicians and policy makers to fail just as miserably at reducing doctors salaries, which they give lip service to, as they have at containing all other healthcare costs. These are the same people who haven't been able to keep the national debt under $17,000,000,000,000 ($17 billion). We as doctors are a smart group, and I think we'll do just fine in maintaining our salaries. You might have to change locations or practice settings more than once or twice in a career to do so. Look at MGMA, doctors salaries are going up, not down. I think the frustrating nonsensical regulations and requirements will go up, but I think salaries will hold. Just my opinion. I could be wrong.

 

[Groove]

Arcan, LOL.

SilentCool: Yes, I'd absolutely welcome students to pursue medicine with the same enthusiasm that I'd welcome any company to join me in the midst of say.... open ocean dog paddling, surrounded by sharks, or say... swimming across the Amazon being chased by flesh hungry pirañas. The kind of desire for companionship fueled by a strong self preservation instinct where I'm really glad you're there with me, but at the same time... I secretly hope you can't swim. Oh, I kid... But seriously.... jump in already.

Niner, medicine is even more pressured from a metrics standpoint as ever and hospitals are teetering on record admissions and LOS. They rush them out the door as soon as possible and hope/pray that they don't return. In theory, a policy maker assumes that the incentive to avoid a re-admission would be a strong enough impetus to provide all of the outpatient care and follow up that you describe, but it's simply not a strong enough incentive. Quite honestly, I'm not sure the co$t of investing outpatient care, adequate follow up, additional manpower to say... call the pt and check on them, etc.. has not remotely proven to reduce moneys lost in re-admission penalties, at this stage of the game. If this strategy were even remotely effective it will take years to notice any change. I certainly have not noticed anything different from my standpoint other than to observe medicine complain about the egregious numbers of their census, LOS or 30d re-admission rates. The irony in this particular pt was that she had been in the hospital over a month and they were anxious to get her home. Discharging a pt s/p arrest/nstemi during hospital course WITH active chest pain on the day of her discharge? Bad idea, dude. No nurse to call and check? Again, poor thinking. +Troponin on return to ED? Let's call it bad discharge planning and just plain bad luck. Either way, any policy can look good on paper. Effective policy should not only look good on paper but have the precedence of proven effectiveness in implementation. Obamacare can't even claim the former unless you're a socialism zealot squinting with your "mind's bad eye" through a pair of welding glasses at a hopeful scenario of how this will all play out.

 

[Groove]

Our relationship with our hospitalists has really deteriorated over the past six months or so, I wonder if this is part of the reason. Just last shift one of them wanted me to board a patient in the ED and fix her lytes. but we get push back on everything so it may just be the culture of the inpatient team.

Sent from my Z10 using Tapatalk

The irony is that many of these guys don't understand the big picture. What are some primary metrics that these guys are "judged" by through a hospital administrator's eyes? LOS? 11a d/c? 30d re-admissions? ALL of their metrics are improved by virtually any "soft admit", not that I'm advocating "soft admissions", but chest pain rule outs are a perfect example. Dehydration in an elderly pt with AKI and some mild lyte abnormalities would be another, etc.. I mean, I send a lot of these home but certainly a sig number of these could come in overnight.

I've gotten push back on a few soft admits in the past (though I don't usually admit many of these) but I actually had the medicine director in the ED one day who sidled up and said, in so many words "hey man.... any chance we could get a few more soft admits? It really makes our numbers look better...."

In my case, I actually don't have a lot to complain about in that I have a competing "hospitalist group" who will take admissions at the drop of a hat and are hunting for almost any and all business. These guys roam through the ED every other week shaking hands and letting us all know that they are here to help in any way whatsoever. Whenever I need these guys, I make one call. Name, diagnosis, where I'm sticking them. Click. I put in quick bridging orders and make the appropriate consultations and they see them later. Easy as pie. If I ever have problems with our primary admission team, I always go to these guys as it's so incredibly pain free and refreshing.

 

[Birdstrike]

Curious what the EP docs think:

Have you entertained owning a free-standing ER? Why or why not?

I have entertained it. Haven't done it.

 

[Groove]

Curious what the EP docs think:

Have you entertained owning a free-standing ER? Why or why not?

As have I.. I think you have a reasonably safe confidence in ROI as far as business ventures go but it would require analytics based on region/state/payor mix/location/legislative-policy risks and extrapolations over a variety of business/market stress scenarios to ensure productivity. There's companies that you can hire to run all the numbers and I looked into it a few months ago but I'm just not at the point where I'm ready or willing to go through the requisite headaches. If you stand back, as long as you don't absolutely hate EM, the money is good....like really good, right now. It would take a sig amount of time to turn a business venture into a sig profit and by the time you'd be seeing profits far exceeding your salary as an EM doc, you would quickly be reaching a point where the business side of things is requiring more and more of your time and so you'd likely gravitate away from clinical medicine. For some, that's the ultimate allure. For me, I honestly enjoy clinical medicine too much right now. I have a colleague who is getting part time into a cosmetic boutique shop and is going to do laser lipo, etc.. a couple days a week and see how it goes. I would say the same goes for him... if it turns out to be successful, he'll likely go full time towards that side of things but he'd ultimately largely give up life as he knows it as an EM doc. There's nothing wrong with that, of course. I think freestanding EDs are inherently profitable with the right payor mix and location. That being said, all it would take is one swift legislative hammer impacting reimbursement rates at these locations to quickly put many of them out of business. I keep reading about anxiety surrounding future medicare reimbursements at "freestanding" EDs that are not attached to hospitals and some doubt over their future ability to charge at their current rate which is much higher than urgent clinic/outpatient, etc..

That being said, I've had quite a few colleagues who have urgent care clinics or other health care related businesses on the side and I'm assuming they must be fairly profitable though I have no idea. I know one of my colleagues who opened an urgent care clinic months ago and tells me it hasn't really turned a profit yet but he has hope.

 

[GeneralVeers]

Niner, Obamacare has many "goals", almost none of which have been achieved so far. Yes the 30-day re-admission rule is "supposed to" make sure that people get better outpatient care to prevent re-admissions, however the reality is that it's just another sneaky way they have of denying payments to hospitals and providers. That is the crux of it. We have expanded Medicaid, and reduced the amount of money that insurers can make on people with pre-existing conditions, but there is no more money to provide the care which has been legislated. All of the seemingly well-intentioned rules and quality metrics, are simply designed to say: "Oops, sorry. You didn't follow the rules on one of our arbitrary, non-scientific metrics, so we aren't going to pay you.". It is a form of rationing in all but name.

 

[Birdstrike]

Niner, Obamacare has many "goals", almost none of which have been achieved so far. Yes the 30-day re-admission rule is "supposed to" make sure that people get better outpatient care to prevent re-admissions, however the reality is that it's just another sneaky way they have of denying payments to hospitals and providers. That is the crux of it. We have expanded Medicaid, and reduced the amount of money that insurers can make on people with pre-existing conditions, but there is no more money to provide the care which has been legislated. All of the seemingly well-intentioned rules and quality metrics, are simply designed to say: "Oops, sorry. You didn't follow the rules on one of our arbitrary, non-scientific metrics, so we aren't going to pay you.". It is a form of rationing in all but name.

It's all a stupid game. Why do you think hospitals charge $7 per Tylenol and most doctors who can refuse crappy low-paying insurance like Medicaid, refuse to take it?

It's to play this stupid reimbursement game these people have set up, to get paid. They make one stupid rule, and the players find a way around it.

Check mate.

The other fraud being perpetuated is this line you keep hearing, "Fee for service will end. Soon you'll be payed not for your service but for 'quality.'"

It's the biggest load of horse---- I've ever heard. You will continue to perform your physician services and in return you will receive a fee. Sure, they can add some penalty if you don't meet some pointless metrics, but eliminating fee for service is impossible.

Anyone taking about that is mindlessly following the herd, or dreams for a utopia where doctors are payed on some mythical basis no one has invented yet, where they can do one surgery per year and get pay more than the guy who does one thousand because his one surgery was of better "quality" than the guy who did 1,000. Horsecrap! If you don't pay (a "fee") for someone's work ("service") no ***** is going to do any work ("services") at all!

Just think in reverse....No one's going to pay you for not performing "services", are they? Make my words. This "end of fee for service nonsense" is just that, nonsense and they know it. It's just their way of adding more and more metrics, social goals and feel good initiatives to your requirements, to make it look like they're fixing the problems we have to advance their political careers.

If they truly decide to stop paying a fee for my services I'd be ecstatic because I will no longer provide any services. I'll just sit on my butt and do whatever that is they they are going to pay for! As if paying for "services" is somehow demeaning, uncivilized, outdated and not uppity-progressive enough.

"Hey Birdstrike, how come you're sitting on your rump only seeing one patient per shift?"

"Oh dude, haven't you heard. They don't pay for 'services' anymore. I'm not going to waste my time doing all those procedures and 'services'."

"Then what the hell are you going to do?"

"Quality bro. They don't pay 'fees' for 'services' anymore. They only pay for 'quality.' I'm just sittin' hear doing 'quality.' That's how they do it now."

It's complete garbage and your physician "leaders" are buying right into it, because going against the grain puts their cushy non-clinical 9-5 jobs in jeopardy.

 

[GeneralVeers]

Birdstrike, you have just outlined why every government program inevitably failed. When you pay people for doing nothing, and don't incentivize work, the results are predictable. We have the evidence right in front of us: The VA system. You pay me a salary, and I am not going to stay late for shifts, I am going to see EXACTLY the median number of patients per shift that everyone else sees, and I certainly won't participate in any hospital committees. Why do we think that government-run healthcare (the VA) which is an epic fail is going to work on a broader scale for all of society? When watching the news all I hear from politicians is how they want to "fix" the VA. That is the wrong answer. The right answer is to disband the VA system entirely, fire all of the government employees, and give all the veterans private insurance. It would actually save money.

I am salaried right now, but as a "locums" who likes my current job (I've been working at it for a year) I know I can be fired at any time for any reason, so I work hard to keep my employment.

 

[Birdstrike]

Birdstrike, you have just outlined why every government program inevitably failed. When you pay people for doing nothing, and don't incentivize work, the results are predictable.

Exactly. You can't end fee for service without entire government control and without outlawing private practice entirely. Even the ACO model, touted as the magical savior that will somehow eliminate the profit motive while still allowing profits hasn't done it. It is a gimmick that will fail. This guy nailed it:

“There’s lots of activity, but it’s unclear what’s really going on...[and] it hasn’t led to a significant change of the culture and financial incentives that doctors and hospitals are working under,” Berenson says. “The ACO has the incentive to save money, but hospitals and doctors are still under fee-for-service, (FFS)” he adds, “so it seems too minimal a change” to show a serious intent to transform healthcare delivery. - See more at: http://managedhealthcareexecutive.m...uch-can-they-really-save#sthash.G447QJqf.dpuf"

Ultimately, there's no real way to motivate people to save money, if you're going to pay them less money to do it. It's ludicrous. Even if you take the profit motive from the physicians, the hospitals, ACOs and insurance companies themselves being businesses in every sense of the word, will do everything they possibly can to maximize their profits.

There's no frickin' magical way to trick people into doing anything else but getting payed for the work they do, and if they don't, they're not going to do any such work. They're going to move along to somewhere they can get paid as much as possible for their services ("fee" for "service.")

We have the evidence right in front of us: The VA system. You pay me a salary, and I am not going to stay late for shifts, I am going to see EXACTLY the median number of patients per shift that everyone else sees, and I certainly won't participate in any hospital committees. Why do we think that government-run healthcare (the VA) which is an epic fail is going to work on a broader scale for all of society?

It will not. You watch. The VA will clean up it's act long enough to get the media lens out of their faces then back to business as usual. Human nature is what it is. Fed Ex beats USPS every time. It may be more expensive to send a package, but much more effective, and Fed Ex gets my money every time I need to be sure my delivery gets there and fast.

The right answer is to disband the VA system entirely, fire all of the government employees, and give all the veterans private insurance. It would actually save money.

In the mean time, it serves as a great example of what we should not model ourselves after: Government Healthcare in the truest sense of the words.

I am salaried right now, but as a "locums" who likes my current job (I've been working at it for a year) I know I can be fired at any time for any reason, so I work hard to keep my employment.

Absolutely. It's the same if you're a physician in private practice. If you're not a good employee, your boss goes broke. When the boss is you, the result, most doctors in private practice are going to work very hard.