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Eat what we kill, which tracks RVU closely (unless different partners are getting different payer mixes somehow).
Every quarter we see every penny that comes in and goes out of the practice.
Assigning patients from the waiting room
Started by TheTruckGuy
Every quarter we see every penny that comes in and goes out of the practice.
Got it.. Just allows potential abuse. no system is perfect. curious the reason not to move to RVUs which alleviates a lot of issues in my opinon.
It’s completely backwards and upside down. All the negatives, eg a faux history and physical exam leading to shotgunning labs and imaging, without any of the throughput benefits.
We do 50/50 rvu based and hourly. I think it works out quite well. Old group I worked for was pure rvu for partners and I think it led to a really negative working environment. Plus there such a negative psychological strain when you have a slow night. Pure hourly only works if everyone is a hard worker, otherwise too subject to people playing games.
Seems strange to do collections based vs rvu based, although I imagine it all ends up being equal in the end (but honestly, if your in an SDG, it all,basically works out in the end regardless). Is it just simpler for your billing company?
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I was never a fan of RVU centric compensation models. It turned everyone into cut throat cherry pickers who would snipe 10 patients from WR but never go see them so they could get "their numbers". Low volume meant you'd be making zero money on that shift and led to lots of stress and monthly fluctuations in pay. You got super resentful at the other docs competing for patients. I also hated having to think about all that stuff every time I'd see a patient where you are trying to figure out how you can milk the chart for maximum RVUs.
The decision predates me (and is perhaps 30yr old at this point). I think originally it was easier; literally whatever comes in for Dr X goes to Dr X. May even have been cheaper overhead originally.
Adding the RVU layer would in theory control for payor type and complete lack of payment, assuming a physician was savvy enough (and the department busy enough) to cherry pick BCBS cases as opposed to Medicaid patients as another data point to to chose from, on top of cherry picking level 4 chart with an ankle split instead of a strep throat.
Working where we do, the uninsured rate is very low, which helps keep things even. As well, if you work for a few years and see a few thousand patients your payor mix will go to group average.
We aren’t a true SDG but operate (esp financially) as close to one as we can.
It requires a proper group culture to not have anyone behaving in a cut throat manner. It can be hard to establish. I think a smaller stable group (and the current overly busy EDs…) can help this.
I get less worried about up coding behavior in EM with current coding regs. Everything is level 4/5/cc and honestly it’s typically better to just discharge a 4 and churn another patient than to come up with something stupid to move the 4 to a 5. It encourages good charting. It encourages putting splints on. Maybe it encourages documenting your POCUS (not a lot of money there). It encourages proper OBSV documentation and CC charting.
I typically worry more about stupid upcharging in other procedural specialties to be honest.
Literally sitting next to another attending right now who is putting her name on WR patients, calling consults on them, and attempting to transfer from the WR.
I'm like....why?
Huge liability, pisses off the nurses, creates confusion w the consultants. For wut? 4 RVUs?
I'm like....why?
Huge liability, pisses off the nurses, creates confusion w the consultants. For wut? 4 RVUs?
I cant call this little b!tch behavior because I’ve never had any female physicians I work with pull this crap so far,l in my 15 years, but have known several doctors who happen to be male (at least 6 or 7 I can think of) pull this behavior. I won’t say whether it applies to other fields but your assertion about this being a gender issue for doctors doesn’t really make any sense with the reality I’ve seen (and believe me there are both male and female physicians I’ve had issues with)
EM in general is huge liability we got hit for emtala for not putting orders on waiting room patient. It’s not like once they are registered you aren’t liable it’s just now everyone in the dept gets hit
EM liability is just stupid. You're expected to see a patient that you know next to nothing about, in a crowded, noisy, distracted environment and diagnose and treat their potentiially life threatening illness with 100% accuracy, all with a smile, and without pissing off anyone..
They ****** us over during COVID by cutting our hours and having us do all sorts of stupid **** like remdesivir infusions to make the hospital $$$, and now that society is back to the "go to the ER for anything" norm, we're cooked.
Waiting room medicine is bull**** and we should have never accepted this. Like how did this happen lol. Because the hospital prioritizes elective replacements of pawpaw's hip, we have to board medical admissions? **** That. And people still matching to EM in droves lol.
As long as the law "community" says we're liable as long as someone is on the property, we're skrrood. It's just a game of musical chairs, with massively painful consequences for whomever is left without a chair when the music rarely stops.
An EM friend of mine got named in a case in which the triage nurse ordered testing in his name. The kicker was that he was not even on shift that day. He eventually got dropped, but still had to give a deposition, etc.
They weren't appropriately dropped. They had to go all the way to deposition which likely took at least 2 years. Plus the added stress. Now they have to disclose this whenever they apply or reapply for credentials. They should have never been named. Insanity.
I hate everybody.
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This was from a doc not even working. If he was on shift, he would not have been dropped. Not only the stress but the time commitment it takes. Just not worth it to assign yourself or have someone assign you to a pt you never saw. Never do this. Never Never do this in a bad medmal state.
I must be old bc when I was in the PIT, no doc would ever assign themselves to triage pts no matter how busy. We have 6-8 hr waits and I NEVER even looked at the triage board.
Regarding this, I believe I have been told that once someone presents to hospital property seeking help, we are liable. If someone has a bad outcome in the waiting room. I have even heard if someone has a bad outcome in the parking lot on the way in. It’s been a reason we have been told to always at least have eyes on what’s in the WR. Is there truth to this?
100% truth from what I've seen
A doc in my ex-group got sued when someone fell over and died in the WR. Patient checked in with abdominal pain, was triaged with normal vitals, and went back out to wait for a room. Stable entire time, then AAA ruptured in WR and died.
Her lawyers pressured her hard to settle, apparently too much of a chance to lose. You are the physician of record. If not in the WR, then when you go out and run the code.
I don't agree with any of this but the world we live in isn't necessarily the world we want
In the US, we can be liable for anything. But there is a giant leap from being liable from a pt in the WR vs a pt you put your name on.
Not to lawyers. Very short, in fact.
I highly doubt this. I have been on MEC making decisions on care quality. If a doc put their name on a WR pt, and pt crashed in the next hr, he would be crucified. If the pt was in the WR for an hr and crashed, the nurse/procedure would be crucified.
As to a med mal case, no one can convince me that every ER doc working would be sued b/c they happened to be working. But a doc with a name on a pt who crashed could, and likely will be sued.
I kind of liken a physician being sued for a waiting room patient that they have zero interaction with, i.e. no name on them, no EKG read, etc., as the nurses who use the “but muh license” argument. Could it happen? Of course, this is America, home of the frivolous lawsuit in and out of medicine. The real target will be the hospital. If you sign up for them, go see them, and order stuff then that patient is your responsibility like any other roomed patient that you’ve seen. I have no problem throwing in orders on waiting room patients if we have the staff to get things moving but it’s rare we have a truly sick patient sitting in the waiting room for long. Of all the things that I can worry about on shift, being sued because of a bad outcome in the waiting room for which I have had no interaction with doesn’t even pop up on my radar. It doesn’t change what I do or don’t do so there’s no reason for me to stress over it.
It's like the pts that shows up at 0755, when shift change is at 0800. Dr Smith gets his name on the chart. Dr Jones starts at 0800, sees the pt, pt sues, and Smith and Jones both get named.
Em is still high liability this patient when roomed will spend hours in the waiting room with nothing done so sepsis or a perf appendicitis is on you.
Also for people saying seeing patients in the parking lot Emtla applies 250 yards from the hospital
Gramma falls 245 yards away
I check for cameras
Move 6 yards further
Continue sandwich
The hospital is liable. You’re mostly liable only if you’re their physician or the only one available. I’m
Can you show me one case report where a doc working in the ER was sued without his/her name being on the chart?
I get that anyone can sue anyone at anytime BUT I highly doubt any lawyer would take up a case like this. Sure they could name every single person worked in the ER that day but they get dropped.
If there was precedence for a doc who happened to be in the ER and sued/lost, then you are essentially saying a doc who went off shift 30 min before a bad WR pt outcome happened is kind of ridiculous.
Now having my name on the chart eventhough I didn't see the pt is quite a different story.
I will again repeat this that I would never let anyone assign a pt to me that I did not see/aware of. Anyone who lets someone randomly assign your name is quite crazy.
Kaiser Northern California auto-assigns patients to physicians as soon as they register in the ED, at least they did at the site I used to work at.
If I were a patient, I would much rather be seen in the ED waiting room sooner by a physician than wait hours and hours to be seen later in a room/bed. We can all agree it is suboptimal, but it's better for pt and satisfaction and more importantly MUCH better for patient care. I've picked out some real sickies from our waiting room that might have crumpled if let to sit for hours and hours before moving back to a room.
I agree with comments however regarding likely higher liability. No perfect solution to overcrowded and under-resourced/staffed EDs. As usually, we the ED physician get hosed if something bad happens.
Legal Exposure if Patient Is Not Reassessed in ED Waiting Room
In this article we cover Legal Exposure if Patient Is Not Reassessed in ED Waiting Room. Stay up to date on the latest in healthcare news and online…
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Legal Exposure if Patient Is Not Reassessed in ED Waiting Room
In this article we cover Legal Exposure if Patient Is Not Reassessed in ED Waiting Room. Stay up to date on the latest in healthcare news and online…
Well there you go
In addition to the person I actually know sued in this context
What should be is not always what is
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Spoken like a true administrator. Waiting room medicine is a disservice to the patient and not better for their care. Why not meet them out in the parking lot?
Ha! We did that during Covid.
We can agree that the best for their care is to be quickly roomed and seen by a physician ASAP in a bed.
Didn't read in detail. Hospital sued, makes some sense. ED doc sued, makes little sense to me but what was the result of the lawsuit against the doc? Anyone can be sued, but the case result is what matters against the ED doc.Legal Exposure if Patient Is Not Reassessed in ED Waiting Room
In this article we cover Legal Exposure if Patient Is Not Reassessed in ED Waiting Room. Stay up to date on the latest in healthcare news and online…
I think WR medicine is crazy but sometimes it is just necessary. I mean if the whole department is holding admissions, then you have to do what you have to do. Yeah, go out to the WR and see/assign yourself.
But Sorry, I am not allowing anyone to put my name on a pt without my knowledge. Once they assign you, you essentially gave them informed consent that it is your patient.
Not going to debate this anymore, but the younger docs appear to do whatever the hospital wants.
Covid was essentially a mass casualty disaster in some places but should not be the norm. During normal times, seeing pts in the WR is just giving the C suite more ammo to do treat you as a lap dog.
C suite meeting - The old ER docs would never see pts in the WR. These new docs are great, they will do anything anything. They are seeing pts in the WR without complaints. Lets see if they will allow us to auto sign pts to them without their knowledge. Hey boss CEO man, they didn't like autosign but they are really not complaining much. Boss CEO man, "Great, lets see if they will be willing to see them in the bathroom. We have a large bathroom down the hall that has private stalls. Lets label that WR extension Rooms 1-15. If that works, we can start doing appointments and auto assigning them. These ER docs are great......."
And to think our SDG said no to covering floor EKG reads, central line placements, doing ER patients triaging. Some of you guys have really given up.
Know of two cases:
1. Doc sued for signing an EKG on a patient he didn't take care of (who didn't have a cardiac abnormality -- his EKG was normal)
2. Pediatric ER doc sued because he was on call for an adult patient that he never saw and was never even in the adult ER at the time patient was seen
#2 was dropped. #1 not sure (think it's ongoing). Even with #2 dropped, he has to list that on credentialing applications.
#2 dropped because there was never a relationship, similar to if I was working in the ER and someone died in the WR.
#1 signed an EKG creating a pt/provider relationship. He opened himself up for liability. Hospital asked our SDG to sign in patient EKGs, we said no go. This is more similar to me signing my name on a WR pt and he crashes before I could see him. I never signed my self to a pt in the ER unless I am going to see him immediately.
I would be interested in any cases that went to trial and the doc lost because he was working in the ED and a WR patient had a bad outcome without any pt/provider relationship.
Getting sued is the same outcome for most doctors as losing a lawsuit stress and having to list it. Can anyone give an example of an EM physician losing assets we know that one georgia doctor got sued for tens of millions but he has yet to actual lose money and that case is pending.
Who has had their EM job options limited by lawsuits?
Who has had their EM job options limited by lawsuits?
Why not go to their home? Shhhh don't give them ideas...
There is a solution.
Hire nurses. Open up beds. Smooth the surgical schedule.
Very very simple.
WR medicine is crazy, but never necessary. This is a failure of the hospital.
Agree that younger docs just do whatever. I know newer grads staying 3-4 hours late.
Getting sued successfully and getting named in a suit are the same feeling. If you lose, insurance pays. It's going through the process that is painful. I've been sued twice -- dropped both times -- but the entire process was very stressful and honestly I didn't care what the outcome was as I went through 90% of the process.
If you get sued once or twice, it won't be an issue unless you were careless with something. If you have three or more, it's going to raise red flags and might not only prevent a job offer, but may prevent a credentials committee/med exec from credentialing you from a hospital. Don't get credentialed at one, and you have to not only report the litigation but you also have to report the credentialing denial. Don't get me wrong. Three suits being dropped probably won't prevent you from being credentialed, but three dropped suits plus a successful one might. At some point red flags are going to be raised, and some hospitals and contract groups are going to ask if it's worth hiring you or if they'd be better off taking the next person who has applied for the same position.
So just getting named in litigation has potential for serious consequences. For those that are nonchalant about it because it wasn't carried until the end, I can assure you it has real consequences.
2nd shift as an attending. Picked up a pt in the last hr that needed an LP. Stayed past close to 3 hrs and unpaid. Fixed this real quick. I prob average 80% out within 15 min of my shift ending. 10% within 30 min. 10% within an hr. Maybe stay past an hr twice a year. Never stay past 2 hrs.
I have a laundry list of tricks to prevent from staying late. One of my best ones was when a few hospitalists took an hr or more to call me back. I gave them 15 minutes and I just texted them to call my cell for report.
I’m sure it does affect you if you’re getting sued multiple times in a short period of time. But I would have legitimate concerns about any physicians who is getting sued that much in a short period of time because that is at least a couple of standard deviations from normal. Average is once every 30,000 patients I believe.
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Having sat on med exec and done a lot of credentials, particulars matter.
3-4 suites where the explanations make it clear the MD had near-zero issues require a little review but haven't been an issue in my experience. ESPECIALLY if the applicant is known personally or regionally by members of the committee. Things like "patient slipped and fell while inpatient, MD/Hospital sued, MD dropped" or "Patient had wrong Rx due to EMR issue, sued MD/RN/Hospital and dropped MD" just didn't really interest committee members, as they know how the sausage is made.
4 suites that allege patient abandonment and all resulted in settlement would require some review, especially if they were in a short window of time.
Specialty and practice location ALSO play into this; my non-EM colleagues at my hospital seem to get the minefield we operate in...
3-4 suites where the explanations make it clear the MD had near-zero issues require a little review but haven't been an issue in my experience. ESPECIALLY if the applicant is known personally or regionally by members of the committee. Things like "patient slipped and fell while inpatient, MD/Hospital sued, MD dropped" or "Patient had wrong Rx due to EMR issue, sued MD/RN/Hospital and dropped MD" just didn't really interest committee members, as they know how the sausage is made.
4 suites that allege patient abandonment and all resulted in settlement would require some review, especially if they were in a short window of time.
Specialty and practice location ALSO play into this; my non-EM colleagues at my hospital seem to get the minefield we operate in...
what’s wild to me is that we (as in physicians) intimately understand the ridiculous nature of our malpractice system and have control over the real downstream consequences, yet let it, and all of its secondary effects persist. It doesn’t need to be this way.
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Hypothetically, yes being listed hurts but in reality it’s just not the case. I doubt that you would have any issues working if you get dropped from 3 to 4 suites also credentialing actually looks at what happened being named can just be probability as doctors win 80-90 percent of cases that go to court.
I personally know OB/GYN’s who are on national news for a case and had no issues with getting credentialed. I just don’t see this in real life at all. It also wouldn’t makes sense since most hospitals are desperate to fill.
You are more likely to get in trouble for sexual harassment claims. Doctors who can't practice EM anywhere is very rare I have never heard of it personally. You would be more likely to lose things in divorce or lose credentialling from issues from a divorce than being named in a lawsuit with no gross issues.
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As a close colleague who sat on a state licensing board for years told me--
90% of the issues they saw that led to loss of license or severe curtailing of privileges were either sexual relationships with patients or substance issues-- and the later wasn't just a basic addiction issue, those get (at least a chance) at rehab. It was using their license to supply substances, often in exchange for sex.
My director was named because a nurse did a triage protocol ekg on a patient - on a night shift - which he hasn’t worked in at least 15 years - he was also dropped but it took 2 depositions somehow …
When you realize it's mostly loser non-contributing patients/families going after a scratch off lotto ticket and unscrupulous lawyers taking on cases because they know medmal insurers are skiddish and quick to settle, it all makes sense.
Yes, the case of the missed PE in the tachycardic and hypoxic patient exists; but this is the exception.
Exactly!
