Getting Sued for the Homeless in the ER

[docB]

The ER, the EP and the hospital are all getting sued over this. The paper said that the diagnosis was “chronic homelessness.” The guy was booted out of the ER and died of respiratory arrest on the hospital lawn.

http://www.reviewjournal.com/lvrj_home/2005/Apr-07-Thu-2005/news/26237049.html

(BTW I have no personal knowledge of this case. It happened back in the 90s before I got here, at a hospital I don’t work for and I don’t know any of the people involved)

Clearly it sounds bad but it goes to show several things:
-The public has no idea about how the homeless clog the ERs with invented problems to malinger their way to free room and board.
-A family that lets its “loved one” roam the streets will be happy to pop up and sue if they think there might be money in it.
-You have to be really careful, especially as an ER doc, about what you write in a chart because it will be selectively edited and put in the papers by plaintiff’s lawyers.
-Even if you make an honest mistake and d/c someone who has no acute complaint and is stable on exam and they die your career is probably over.

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[spyderdoc]

The ER, the EP and the hospital are all getting sued over this. The paper said that the diagnosis was “chronic homelessness.” The guy was booted out of the ER and died of respiratory arrest on the hospital lawn.

http://www.reviewjournal.com/lvrj_home/2005/Apr-07-Thu-2005/news/26237049.html

(BTW I have no personal knowledge of this case. It happened back in the 90s before I got here, at a hospital I don’t work for and I don’t know any of the people involved)

Clearly it sounds bad but it goes to show several things:
-The public has no idea about how the homeless clog the ERs with invented problems to malinger their way to free room and board.
-A family that lets its “loved one” roam the streets will be happy to pop up and sue if they think there might be money in it.
-You have to be really careful, especially as an ER doc, about what you write in a chart because it will be selectively edited and put in the papers by plaintiff’s lawyers.
-Even if you make an honest mistake and d/c someone who has no acute complaint and is stable on exam and they die your career is probably over.

Pisses me off to see how the family, who didn't give a rat's ass about him being strung out on the street, is now sitting there looking all distraught....

 

[Apollyon]

Pisses me off to see how the family, who didn't give a rat's ass about him being strung out on the street, is now sitting there looking all distraught....

I called and emailed the guy who wrote the article about that same thing. Haven't heard back from him yet.

edit: checked my email just after I posted 5 minutes ago and the article author wrote back. He said that the guy had been estranged from his wife and added this:

"The idea that someone who didn't know an alleged victim is coming forward as part of a civil suit is something I unfortunately see quite a bit. "

I can forward you the email, if you'd like.

 

[southerndoc]

Gotta love our infamous American legal system. It's reputation is the most respectable of any legal system in the world (yea, right).

 

[NinerNiner999]

Then again, anyone condescending (and stupid) enough to put "chronic homelessness" as a diagnosis on a medical record... sigh.

 

[NeuroSync]

Then again, anyone condescending (and stupid) enough to put "chronic homelessness" as a diagnosis on a medical record... sigh.

Maybe the doc figured that no matter how it was coded, there wouldn't be reimbursement anyway.

Bad joke...sorry.

In all seriousness, a good point was raised. It is very important that opinions (other than medical, of course) and emotions be kept out of the medical chart. This includes opinions about the patients AND other staff member. Similarly, it is important to always be professional when communicating with patients and one another. Has anyone ever heard a provider or staff member say to a patient, "I don't know why [so and so] did that." I think that the bottom line is respect and not jumping to conclusions where we may not have full information.

 

[Sessamoid]

This is actually a case where malpractice award limits on non-economic damages (which Nevada just passed, but won't apply to this case since it was filed years ago) would actually probably prevent this lawsuit from ever coming to trial. The question of whether that is good or bad I won't comment on here.

The reason is that the patient was homeless. Future earnings are essentially zero. Costs of future medical care are exactly zero since the patient died. Those are generally the two largest economic components of a malpractice award IIRC (no personal experience myself except serving on a jury once). So the maximum potential award for this case if brought today in Nevada would be $350,000. I think it would be difficult to find a lawyer to take such a case unless a win or quick settlement were almost guaranteed.

 

[RexKD]

This case brings up an interesting point. How can a doctor write in a patient's chart information which conveys negative meaning without 1) insulting the patient 2) setting himself up for possible liability or board censure?

Are there certain euphemisms used which convey negative information indirectly?

 

[NeuroSync]

This is actually a case where malpractice award limits on non-economic damages (which Nevada just passed, but won't apply to this case since it was filed years ago) would actually probably prevent this lawsuit from ever coming to trial. The question of whether that is good or bad I won't comment on here.

The reason is that the patient was homeless. Future earnings are essentially zero. Costs of future medical care are exactly zero since the patient died. Those are generally the two largest economic components of a malpractice award IIRC (no personal experience myself except serving on a jury once). So the maximum potential award for this case if brought today in Nevada would be $350,000. I think it would be difficult to find a lawyer to take such a case unless a win or quick settlement were almost guaranteed.

I don't know...trial expenses are taken from the award first. Many plaintiff attorneys spend up to $150k on a case. So now the award is down to $200K. The lawyer will then take, on average, 35% of that. So the take home is $70k. I think a lot of bottom feeders would be happy with that, and the publicity for a case like that would be worth a lot, probably. The patient's family will then get $130k. After taxes, a big award is reduced to not a whole lot.

In England, it is considered unethical for a lawyer to take a case on a contingency fee basis. . .

 

[Febrifuge]

Are there certain euphemisms used which convey negative information indirectly?

Euphemisms are fertile ground for misunderstanding and creative interpretation, especially in the courtroom. Why do you need to put "negative information" at all?

See N'Sync's comment above; the point is well-taken. In the ideal, charts should contain nothing but objective findings, in clear and neutral language. In practice, it can be helpful to acknowledge the reality of the situation, but even that can be done with professionalism.

not helpful "DX: Chronic Homelessness"

better "PLAN (con't): discussed with pt that health situation can only be affected negatively by living on the street. Recommended pt take all available steps to obtain housing and support system. Offered referral to hospital social worker. Pt declined."

10 years working in customer service have made me ready for this part, at least.

 

[NeuroSync]

Euphemisms are fertile ground for misunderstanding and creative interpretation, especially in the courtroom. Why do you need to put "negative information" at all?

See N'Sync's comment above; the point is well-taken. In the ideal, charts should contain nothing but objective findings, in clear and neutral language. In practice, it can be helpful to acknowledge the reality of the situation, but even that can be done with professionalism.

not helpful "DX: Chronic Homelessness"

better "PLAN (con't): discussed with pt that health situation can only be affected negatively by living on the street. Recommended pt take all available steps to obtain housing and support system. Offered referral to hospital social worker. Pt declined."

10 years working in customer service have made me ready for this part, at least.

Exactly right...

See, Febrifuge? I CAN be serious.

 

[docB]

Interesting points. As someone said we don't have all the info. All we have is the plaintiff's laywers version (which the press used to generate the headline BTW ). Let's say the EP felt that the only reason for the pt's presentation was his homelessness. He wanted free food and bed. What's the diagnosis? Well adult check? Social issues? I run into the question of what diagnosis to assign to these people frequently. Is everyone saying that if I put "homelessness" that's inappropriate even if it is the reason for the visit? I totally agree with Febrifuge about the note but you can't write a note on the diagnosis line.

What if the comment "chronic homelessness" was not in the diagnosis but was just part of the assessment? Is it inappropriate there? I frequently note things in the chart like FOS and SOB which could be misconstrued. How paranoid should we have to be?

In answer to RexKD's question about how to convey negative info I actually know a doc once (who also had a JD) who wrote codes to himself in his charts. For example if he wrote that a patient had "presented himself" rather than "presented" it was a cue to him that he felt the patient likely had some mental illness in addition to his complaint.

 

[NeuroSync]

Interesting points. As someone said we don't have all the info. All we have is the plaintiff's laywers version (which the press used to generate the headline BTW ). Let's say the EP felt that the only reason for the pt's presentation was his homelessness. He wanted free food and bed. What's the diagnosis? Well adult check? Social issues? I run into the question of what diagnosis to assign to these people frequently. Is everyone saying that if I put "homelessness" that's inappropriate even if it is the reason for the visit? I totally agree with Febrifuge about the note but you can't write a note on the diagnosis line.

What if the comment "chronic homelessness" was not in the diagnosis but was just part of the assessment? Is it inappropriate there? I frequently note things in the chart like FOS and SOB which could be misconstrued. How paranoid should we have to be?

In answer to RexKD's question about how to convey negative info I actually know a doc once (who also had a JD) who wrote codes to himself in his charts. For example if he wrote that a patient had "presented himself" rather than "presented" it was a cue to him that he felt the patient likely had some mental illness in addition to his complaint.

I think that the problem in this case was that there was an underlying medical problem that was missed, or at least not adequately addressed. By putting "chronic homelessness" in the diagnosis line, there is an assumption made that the underlying problem was missed and that there was a bias against this patient. That may or may not be true, but it sure wouldn't be tough to convince a jury of it. I wouldn't want to be grilled on that point. And if you do put something like that in the diagnosis line, you had better document a very good physical exam and review of systems. It's unfortunate that one must document to defend oneself in advance, but that seems to be the way it is for now.

 

[NeuroSync]

Also, Febrifuge has a good point: We can say the same things sometimes in ways that are not inflammatory. For example, the plaintiff attorney in this case reread three words in the chart, over and over, in varying order: "Filthy, dirty, and foul smelling." There are ways to describe this that will not come back to bite you. The description, I'm quite sure, was true. Yet it can be said in a way that seems more sympathetic and clinical. How about something like: "The patient's hygiene is consistent with homelessness." Everyone who works in the ED or the medical community will know exactly what you mean by that, yet it cannot be attacked so easily.

I don't know what the statistics are, but it seems like it is not so uncommon for a person with a pneumonia to be sent home and then die. The photographer at my wedding just had that happen to her S.O. I don't think that this EM doc's career is necessarily over because of this case. I guess it depends upon all of the surrounding circumstances, of which I am obviously unaware.

 

[RexKD]

From another article about this case:

"The Nevada Supreme Court in 2001 upheld the hospital's revocation of Meyer's privileges for one year after an investigation of Anguiano's case."

 

[docB]

I think that the problem in this case was that there was an underlying medical problem that was missed, or at least not adequately addressed.

We don't really know if the pt had any complaints that were not addressed. If the guy's complaint was "I'm hungry and I've got nowhere to go." like it usually is where I work then a chest xray and labs wouldn't be indicated. The question is if EP, or docs in general, should be liable for bad outcomes in people who presented for nonspecific or unrelated complaints. Or are we to be required to do a CXR and some basic labs on every pt? Should everyone get an EKG? How far should we go?

 

[NeuroSync]

We don't really know if the pt had any complaints that were not addressed. If the guy's complaint was "I'm hungry and I've got nowhere to go." like it usually is where I work then a chest xray and labs wouldn't be indicated. The question is if EP, or docs in general, should be liable for bad outcomes in people who presented for nonspecific or unrelated complaints. Or are we to be required to do a CXR and some basic labs on every pt? Should everyone get an EKG? How far should we go?

I agree that these are tough cases. The problem here was that this man really did need help. It is way easier to see after the fact. I don't think that you need to order a chest xray and labs if they are not indicated based upon the exam and patient interview. BUT, it IS clear that how we document can greatly influence the outcome of the case, at least from a legal standpoint. If the only complaint is hunger and homelessness, then it should be listed under the chief complaint. Also listed is an exam and review of systems. I DO think that there is a level of patient responsibility that people often forget to address and a good defense attorney always raises that issue.

In a related note, I liked the article about the NZ medical liability system in the recent ACEP News publication. I'm very curious to see how tort reform efforts shape up.

 

[Febrifuge]

Interesting points. As someone said we don't have all the info. All we have is the plaintiff's laywers version (which the press used to generate the headline BTW ).

well-said.

Let's say the EP felt that the only reason for the pt's presentation was his homelessness. He wanted free food and bed. What's the diagnosis? Well adult check? Social issues? I run into the question of what diagnosis to assign to these people frequently. Is everyone saying that if I put "homelessness" that's inappropriate even if it is the reason for the visit?

Tough one. I guess my attitude (speaking of course as merely the intellectual fetus of a hopeful future EP) is that at the end of the day, "homelessness" is not a concise and recognized medical diagnosis. As always, I also blame the insurance companies, in this case because you're forced to put something you can bill for, and thus you can't just say "no acute medical issues today" and be done with it.

It's a possible nursing diagnosis, maybe -- so one tangent to go off on is that it's a shame there's nobody in the NP world eager to launch a counter-offensive, and explain to the world that psychosocial issues can be as damaging as strictly medical ones. This is a darn fine illustration in some ways. But as someone said, that's setting aside the retrospectometer's finding of the pneumonia, so maybe this would not be the time.

What if the comment "chronic homelessness" was not in the diagnosis but was just part of the assessment? Is it inappropriate there? I frequently note things in the chart like FOS and SOB which could be misconstrued. How paranoid should we have to be?

Ay, there's the rub. My pie-in-the-sky solution would be to legislate better rules about the disclosure and use of medical records in legal proceedings. Create a situation where the lawyers can't info-dump juries into submission with scary jargon and codes, and then pick out the few words that are most quotable and damaging. More practically, I guess you get a defense expert to drone on about the niceties of how charting is done in that community.

 

[NinerNiner999]

Perhaps this case exemplifies the very challenge of practicing medicine in our country. Regardless of patient disposition or outcome, if a law suit (or even a mere investigation) is put forth, every letter, dot, slash, and circle on a medical chart will be scruitinized for accuracy, connotation, and prima fascia presentation. If it is written clearly and in correct professional terminology little can be left to interpretation. Perhaps equally important is that which is not written, such as lab values, events, patient demeaner/acivity, procedures, etc because if they are not documented they never occurred. Further, events/progress notes written on the nursing chart that are not written on the MD progress note may also be disregarded if the MD did not document it him/herself. One might imagine a plaintiff's attorney carefully choosing which parts of the discordant documentation would best suit the case. We truly have a difficult challenge with malpractice law in this country, and the only weapon we have to reduce our liability is precise documentation, which can be impossible at times in a busy setting.

 

[NeuroSync]

Perhaps this case exemplifies the very challenge of practicing medicine in our country. Regardless of patient disposition or outcome, if a law suit (or even a mere investigation) is put forth, every letter, dot, slash, and circle on a medical chart will be scruitinized for accuracy, connotation, and prima fascia presentation. If it is written clearly and in correct professional terminology little can be left to interpretation. Perhaps equally important is that which is not written, such as lab values, events, patient demeaner/acivity, procedures, etc because if they are not documented they never occurred. Further, events/progress notes written on the nursing chart that are not written on the MD progress note may also be disregarded if the MD did not document it him/herself. One might imagine a plaintiff's attorney carefully choosing which parts of the discordant documentation would best suit the case. We truly have a difficult challenge with malpractice law in this country, and the only weapon we have to reduce our liability is precise documentation, which can be impossible at times in a busy setting.

You couldn't have summed this up better, Niner. Even something so simple as clocks being different in different rooms, causing times documented on charts during codes to be different, have caused major litigation problems. Standard of care was met -- absolutely -- yet there was a question of a delay.

I think my point about documenting a thorough exam on everyone you see in the ED was said better by you: If you dont' document it, it didn't happen. So if the only thing on the chart was a diagnosis of chronically homeless, the doc is in serious trouble.

Until there is a penalty associated with bringing a frivolous lawsuit (i.e., forcing plaintiff's attorneys to pay all defense and court fees), there will always be those lawyers out there who just file to see what happens and if they can make a quick buck. It's even worse for military doctors. Although they cannot have personal liability, they CAN be listed on the National Data Bank, so when they get out, they DO pay personally. And when a claim is filed against the military (dependents and retirees can sue, active duty cannot), the military lawyer must provide the entire medical record (usually for free) and start an investigation. If the investigation reveals an error, then negotiations are started to try to settle the case. Most of the government attorneys are lazy and are interested in getting a quick dispostion, rather than doing the right thing and defending the providers vigorously (as the professional ethics of law requires). So by just filing a shotgun type claim, a lawyer can walk away with a LOT of money. But even if nothing comes of it, they have lost only a few hours of their time. Good gamble, huh?

Another possible solution has come from some astute defense attorneys with insurance firms (med mal, or course). It is their POLICY to vigorously defend all law suits and to never settle. This FORCES the plaintiff attorney to shell out (out of pocket) well over $100k usually, and it will take many years to recover it, even if they do win. What this does is forces the bottom feeders out of the game. I think it's a good idea, and I would make sure that the insurance company that covers ME has such a policy.

 

[Sessamoid]

Many plaintiff attorneys spend up to $150k on a case. So now the award is down to $200K. The lawyer will then take, on average, 35% of that. So the take home is $70k. I think a lot of bottom feeders would be happy with that, and the publicity for a case like that would be worth a lot, probably. The patient's family will then get $130k. After taxes, a big award is reduced to not a whole lot.

You're assuming they win, which is generally not the case. Most med mal cases are lost by the plaintiffs. So a "bottom feeder" would have to have pretty deep pockets and very little risk aversion to take a questionable case that he'll easily have to shell out $100,000 out of pocket to process on the relatively slim chance of netting perhaps $70,000. So the choice is, PROBABLY lose $100,00 to $150,000 versus SMALL POSSIBILITY OF WINNING $70,000. Vegas was built with the dollars from suckers who took those kinds of bets.

Lawyers that foolish won't be practicing long.

 

[NeuroSync]

You're assuming they win, which is generally not the case. Most med mal cases are lost by the plaintiffs. So a "bottom feeder" would have to have pretty deep pockets and very little risk aversion to take a questionable case that he'll easily have to shell out $100,000 out of pocket to process on the relatively slim chance of netting perhaps $70,000. So the choice is, PROBABLY lose $100,00 to $150,000 versus SMALL POSSIBILITY OF WINNING $70,000. Vegas was built with the dollars from suckers who took those kinds of bets.

Lawyers that foolish won't be practicing long.

Yes. The assumption was a win. Something over 90% do not win...

 

[NeuroSync]

That is of cases that do not settle, though. And how many settle totally depends upon who is defending you. Some will want to settle quickly to get rid of the case. Others have, as I said, a policy of NEVER settling cases. Settling may be a quick fix, perhaps, but you still go into the data bank if there is is a dollar settlement. I would want the insurance company that represents me to have a no settle policy.

 

[NinerNiner999]

That is of cases that do not settle, though. And how many settle totally depends upon who is defending you. Some will want to settle quickly to get rid of the case. Others have, as I said, a policy of NEVER settling cases. Settling may be a quick fix, perhaps, but you still go into the data bank if there is is a dollar settlement. I would want the insurance company that represents me to have a no settle policy.

Of course, while 90% of cases that actually do win, I would guess that 90% of the cases filed bank on the assumption of a quick settlement (that's how most bottom-feeders support their take home profit...)

 

[NeuroSync]

Of course, while 90% of cases that actually do win, I would guess that 90% of the cases filed bank on the assumption of a quick settlement (that's how most bottom-feeders support their take home profit...)

Exactly right. There are LOTS of suits filed, but very few go to trial. That 90%+ number is JUST trial numbers. It doesn't cost much to put out the bait and see who bites.

 

[toughlife]

Exactly right. There are LOTS of suits filed, but very few go to trial. That 90%+ number is JUST trial numbers. It doesn't cost much to put out the bait and see who bites.

I keep up with the effort for malpractice reform all over the US. I read the Washington State medical Society is gearing up for a fight at the polls against the WA trial lawyers regarding tort reform (proposition i330 vs. i336). Glad to see people are finally starting to do something there.

Link: http://capwiz.com/wsma/state/main/?state=WA
http://www.yesoni330.org/

 

[NeuroSync]

I keep up with the effort for malpractice reform all over the US. I read the Washington State medical Society is gearing up for a fight at the polls against the WA trial lawyers regarding tort reform (proposition i330 vs. i336). Glad to see people are finally starting to do something there.

Link: http://capwiz.com/wsma/state/main/?state=WA
http://www.yesoni330.org/

Interesting link, Toughlife. I have always thought that it would be the doctors who will join together to get some positive changes in health care. Not only is it an intelligent group, but they are generally well-intentioned people. The problem has been that, for the most part, doctors want to be doctors, and they have wanted to wash their hands of the business side of medicine and of the politics involved. It is certainly not the politicians (i.e., trial lawyers, in large part), nor is it the insurance company administrators who know what is best in terms of patient care. At some point, when all of the facts are out on the table, the trial lawyer lobby will no longer be able to cliam that tort reform merely hurts "victims" of bad doctors and that it will do absolutely nothing to lower the costs of medicine.

I forget where I read it, but someone posted an article about doctors in a certain area refusing to treat trial attorneys or their families. I laughed. I couldn't do that, but I laughed. I'm sure that when the tables were turned, those lawyers were not so tough.

 

[docB]

Here's an update:
http://www.reviewjournal.com/lvrj_home/2005/Apr-15-Fri-2005/news/26297466.html
Fortunately the hospital was cleared. I don't know about the doc. It's taken 10 years to get to this. Imagine having a case like this hanging over your head for that long. I noticed that the article about the hospital winning the case still closed with a quote by the plaintiff's lawyer about how wrong it is. And this article says that the comment about "acute homelessness" was in the records and not the diagnosis as the previous article had implied. It's also likely that the autohors don't know the difference.

 

[juddson]

This is actually a case where malpractice award limits on non-economic damages (which Nevada just passed, but won't apply to this case since it was filed years ago) would actually probably prevent this lawsuit from ever coming to trial. The question of whether that is good or bad I won't comment on here.

The reason is that the patient was homeless. Future earnings are essentially zero. Costs of future medical care are exactly zero since the patient died. Those are generally the two largest economic components of a malpractice award IIRC (no personal experience myself except serving on a jury once). So the maximum potential award for this case if brought today in Nevada would be $350,000. I think it would be difficult to find a lawyer to take such a case unless a win or quick settlement were almost guaranteed.

Every word of this is 100% correct. BTW, everything you said about the homeless man applies as well to a dead child.

Judd

 

[NeuroSync]

Here's an update:
http://www.reviewjournal.com/lvrj_home/2005/Apr-15-Fri-2005/news/26297466.html
Fortunately the hospital was cleared. I don't know about the doc. It's taken 10 years to get to this. Imagine having a case like this hanging over your head for that long. I noticed that the article about the hospital winning the case still closed with a quote by the plaintiff's lawyer about how wrong it is. And this article says that the comment about "acute homelessness" was in the records and not the diagnosis as the previous article had implied. It's also likely that the autohors don't know the difference.

"Attorneys for Anguiano's loved ones, however, were mortified at the verdict." That sentence should read, "Attorneys for Anguiano's children were horrified when they learned that after ten years of thinking there would be a big payoff...there was nothing."

I think ten years to resolve a case like this is not unusual. But it can be even more extreme, because while most states have a statute of limitations, this is "tolled" for certain patient populations such as children. It can also be tolled and begin only when it is discovered (or should have been discovered) that there was an error. So it is possible, for example, for an OB/GYN to be sued many, many years later by a child he or she delivered.

 

[RichL025]

Every word of this is 100% correct. BTW, everything you said about the homeless man applies as well to a dead child.

Judd

Err, Judd:

Doesn't a "dead child" have quite a significant level of "future earnings" that can be factored into a damage award ?

 

[Sessamoid]

Err, Judd:

Doesn't a "dead child" have quite a significant level of "future earnings" that can be factored into a damage award ?

A dead child has no proven earning capacity, only a hopeful and projected one. No valued skills, nor education, except for the rare case of child actors and models (of which I have heard of one such a successful tort case).

 

[docB]

I was at a get together the other night with a lot of non-medical people and I had something reiterated to me that I've known for a long time. Laypeople think that the government pays the hospitals and doctors when they treat the indigent. I was answering all the usual questions about wait times and why we can't just meet people in the lobby to refill their prescriptions and so on when we started talking about how the homeless, the addicted and the crazy clog the system. 90% of the people there, smart, educated people, thought that if I treat a homeless guy I will eventually get a check from Uncle Sam. We need to do some better public education.

 

[Jeff698]

We need to do some better public education.

Or convince Uncle Sam to put his money where his unfunded EMTALA mandate is.

Like that will happen.

Take care,
Jeff

BTW, I saw a B2 billion dollar bomber fly over Galveston as part of an airshow today. I had to wonder how many EMTALA patients could have been funded for what it took to fly that plan at an airshow (much less build it).

 

[Sessamoid]

Or convince Uncle Sam to put his money where his unfunded EMTALA mandate is.

Like that will happen.

Take care,
Jeff

BTW, I saw a B2 billion dollar bomber fly over Galveston as part of an airshow today. I had to wonder how many EMTALA patients could have been funded for what it took to fly that plan at an airshow (much less build it).

Quite a few I imagine. The administration just asked for $81,000,000,000 more for supplies in Iraq. That would buy a hell of a lot of health insurance. At a generous $200 per month, that would insure almost 34 million Americans for a whole year for health care.

 

[Sessamoid]

Laypeople think that the government pays the hospitals and doctors when they treat the indigent.

This has been my experience as well. Many of them are astounded when I tell them that neither I nor the hospital gets any money for seeing them. In LA county that's not technically true, as there is a small fund that compensates a small percentage of indigent care. IIRC it doesn't even cover the malpractice expense of seeing those patients, but it's a couple bucks better than nothing I guess.

 

[southerndoc]

This has been my experience as well. Many of them are astounded when I tell them that neither I nor the hospital gets any money for seeing them. In LA county that's not technically true, as there is a small fund that compensates a small percentage of indigent care. IIRC it doesn't even cover the malpractice expense of seeing those patients, but it's a couple bucks better than nothing I guess.

The majority of hospitals in Georgia are also reimbursed for indigent care, but at a drastically reduced compensation. Hospitals are reimbursed, but not physicians.

 

[RichL025]

The majority of hospitals in Georgia are also reimbursed for indigent care, but at a drastically reduced compensation. Hospitals are reimbursed, but not physicians.

I'm military, so I've never much wondered about this topic before now... but how does reimbursement for indigents matter? Most of the job offers I've seen for EPs specify an hourly wage. Are you saying that there are some positions where the EP will be billing per-patient like outpatient medicine or something?

And if the EP is paid per-hour, then by definition isn't the hospital footing the bill?

 

[southerndoc]

I'm military, so I've never much wondered about this topic before now... but how does reimbursement for indigents matter? Most of the job offers I've seen for EPs specify an hourly wage. Are you saying that there are some positions where the EP will be billing per-patient like outpatient medicine or something?

And if the EP is paid per-hour, then by definition isn't the hospital footing the bill?

Yes, you are correct. If the hospital is paying per hour, the EP is employed by the hospital, then the hospital is footing the bill. However, it's impossible to continue paying someone if you aren't getting reimbursed. No money coming into the hospital means no money to pay the EP, which means the hospital either is forced to pay lower wages or is forced to close its doors.

Most EP's, however, are employees of contracted groups or companies. Patients who do not pay cut into their revenue, which means less pay for EP's sometimes. In most cases, it means not enough EP's. Some EP's might see 4 patients/hour instead of the national average of 2. Instead of having money to hire an additional EP, the original EP is forced to see more patients at the same wage.

So reimbursement does affect hourly workers.

 

[docB]

And if the EP is paid per-hour, then by definition isn't the hospital footing the bill?

Southerndoc is exactly right. There are EM groups out there that work on strictly fee for service. They get paid only what money is collected by their billing. Any group that tells you you won't get paid until after your first 90 days is probably on this system. If you work for one of those groups and you see nothing but indigents for a shift guess what? You just did a shift for free.

I work for a contracted group. We get paid hourly and also have an efficiency incentive to see more patients. Everything in this system is based on hours worked and RVUs generated (if you don't know what RVUs are read loosely as "patients seen"). I can see a shift full of indigents and I'll still get paid but my group loses $. My system basically spreads the cost of seeing the homeless over the 30 docs in my group so no one gets stuck all by them selves. If we were seeing paying patients instead of the homeless we would make a lot more money.

We talked about this in a thread called "The cost of treating the homeless" or something like that. I'll bump it.

 

[Febrifuge]

Does RVU = "revenue valuation unit" or something similar? If so, never ever let a malpractice attorney hear the term. They have no innate sense of irony and would surely roast you over the coals for using such Orwellian terms (even though I understand it's probably more fair and compassionate not to rank patients in strict terms of their illnesses when it comes to billing and compensation).

 

[Jeff698]

If you work for one of those groups and you see nothing but indigents for a shift guess what? You just did a shift for free.

And wouldn't it be great if that shift actually was free in both directions, ie no money earned but no money spent either? As opposed to the money you have to spend for malpractice insurance to see those indigent patients?

Take care,
Jeff

 

[docB]

Does RVU = "revenue valuation unit" or something similar? If so, never ever let a malpractice attorney hear the term. They have no innate sense of irony and would surely roast you over the coals for using such Orwellian terms (even though I understand it's probably more fair and compassionate not to rank patients in strict terms of their illnesses when it comes to billing and compensation).

RVU= Relative Value Unit in terms of the work of the physician. It does not refer to the relative value of the patient (although that's an interesting idea). It's essentially a way to compare the work that a doc does to that of other docs. For example doc A sees 3 complicated chest pain patients and doc B sees 6 ankle sprains. Doc B saw twice as many patients as Doc A but their RVUs will be about the same because a level 5 generates about twice as many RVUs as a level 3.
For everyone in school and early in residency I'd say don't sweat this billing and RVU stuff. Just know that it's out there and you'll learn about it someday. For senior residents try to pick up as much as you can. Bug your faculty about how documentation affects billing (by affecting the RVUs per patient). Especially talk to any faculty who are in private practice. The academic guys are often insulated from the revenue whirlpool to some degree. For most of you you should get to know this as your paycheck will soon depend on it.