Medicaid and ED Use

[Mad Jack]

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Don't feed the bears. Nothing that says you have to feed someone during a 2-4 hour ED visit. Just say no like you do for narcotics. If you don't want the patient back, do what is legally and ethically required and no more.

We are legally required to hold drunks until they are under the legal limit because of state laws, so a lot of our regulars who come in blowing a .34+ end up staying a good long while.

 

[TooMuchResearch]

If only we could stop our frequent flyer drunks from coming back every night.

The number of times they scream for a nurse to heat up their free food, laying in a comfortable hospital stretcher with fresh sheets as they bask in the heat paid for by others...

If they keep coming back, perhaps you should consider discharging them after you evaluate them and not feeding them.

 

[TooMuchResearch]

We are legally required to hold drunks until they are under the legal limit because of state laws, so a lot of our regulars who come in blowing a .34+ end up staying a good long while.

Are you legally required to check a blood alcohol level?

 

[Mad Jack]

Are you legally required to check a blood alcohol level?

If they're admitted for alcohol intoxication, yeah. Used to just get bumped off to police drink tanks, but too many diabetics died in police custody because they appeared drunk, so a law got passed that anyone who appears to be intoxicated goes to a hospital instead of jail.

 

[Psai]

If they keep coming back, perhaps you should consider discharging them after you evaluate them and not feeding them.

I do that all the time. It's the other guys that are the problem.

One of our frequent fliers threatened to **** the bed and I'm like go ahead but you're getting discharged without a clean set of clothes

 

[The White Coat Investor]

We are legally required to hold drunks until they are under the legal limit because of state laws, so a lot of our regulars who come in blowing a .34+ end up staying a good long while.

But you're not required to feed them. At any rate, that's not the 2-4 hour visit I'm talking about.

 

[Mad Jack]

But you're not required to feed them. At any rate, that's not the 2-4 hour visit I'm talking about.

I doubt the suits would be down with that, unfortunately. "Patient" satisfaction was numero uno, plus they made shiatloads of Medicaid and state money off of them in exchange for fifty cent turkey sandwiches.

 

[The White Coat Investor]

I doubt the suits would be down with that, unfortunately. "Patient" satisfaction was numero uno, plus they made shiatloads of Medicaid and state money off of them in exchange for fifty cent turkey sandwiches.

Your admin cares about your satisfying drunks? Time for a new job.

 

[GeneralVeers]

Does a diagnosis of "alcohol intoxication" weed them out from getting a survey? After all someone who's intoxicated can hardly remember accurately the "patient experience".

 

[EMDOC17]

Does a diagnosis of "alcohol intoxication" weed them out from getting a survey? After all someone who's intoxicated can hardly remember accurately the "patient experience".

I would actually hope the happy drunks got a survey. Most likely they are drunk again and would give me a positive review. The angry drunks not so much so I guess it evens out.

 

[MSmentor018]

I was referring to the Medicaid population. And I'll dig up the psychological research on it later. But unless your friends were dealing drugs, one doesn't make thousands on welfare.

you have no idea. ever seen see'em with smart phones, tattoos, nice sneakers, or a family of 4 here for the flu eating mcdonalds during the exam? that stuff isn't free. you're obviously not going to get rich and unless you work under the table your monthly income is capped. that's the whole premise in the last 8 yrs, to elevate and level the playing field in for all socialeconomic status. ha! this quote is just from the SSI website, california unemployment. throw in a couple of kids (or foster a kid)

"While SSI is a federal program (administered by the Social Security Administration), and the federal government pays a standard base rate of $733 per month, most SSI recipients receive more or less than the federal benefit rate. For starters, the federal benefit rate for couples is of $1,100"
"The California Employment Development Department (EDD) determines your weekly benefit amount by dividing your earnings for the highest paid quarter of the base period by 26, up to a maximum of $450 per week. Benefits are available for up to 26 weeks."
"After a quick glance through the list of reimbursement rates by state, you might estimate that $20-$25 per day (or about $1 an hour) is an average amount per child."

married couple, both previously working, "disabled", 4 kids = approx 5300/mo.
5300 x 12 = 63,600/yr
rent, power, water, school lunch is fixed
why bother selling drugs?

 

[MSmentor018]

I've had a bunch of these
so ****ing annoying

Worse are those fibromyalgia people with multiple ed visits and they're like TREAT MY PAIN OPIATES DONT WORK and I'm like ma'am you've been to the ED like 5 times in the last month, what do you expect me to do that the other doctors didn't?

I tell them if it isn't working, don't take it. there is a small cluster of predominately affluent, insured, rich population at one of my sites that always comes in with what i call fibrostorm or end stage fibromyalgia. they must shop around (2 competing hospitals within 10 miles) b/c I am starting to see " i am allergic to haldol" but haven't seen an allergy to ketamine yet. try that, it works wonders on those "depressive, fibromyalgia, psych" receptors

 

[Psai]

I tell them if it isn't working, don't take it. there is a small cluster of predominately affluent, insured, rich population at one of my sites that always comes in with what i call fibrostorm or end stage fibromyalgia. they must shop around (2 competing hospitals within 10 miles) b/c I am starting to see " i am allergic to haldol" but haven't seen an allergy to ketamine yet. try that, it works wonders on those "depressive, fibromyalgia, psych" receptors

I'm thinking about starting to add ketamine for the psych patients and the fibromyalgias but I don't see any of the other residents using it or the attendings. I hear scott weingart talking about it all the time and looked at his dsi paper. It's interesting to me but I don't want to be the lone wolf deviating from practice patterns, especially as an intern.

As to your other post, the next time I see a medicaid patient have a worse phone than me will be the first.

 

[deleted77919]

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[deleted77919]

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[Mad Jack]

you have no idea. ever seen see'em with smart phones, tattoos, nice sneakers, or a family of 4 here for the flu eating mcdonalds during the exam? that stuff isn't free. you're obviously not going to get rich and unless you work under the table your monthly income is capped. that's the whole premise in the last 8 yrs, to elevate and level the playing field in for all socialeconomic status. ha! this quote is just from the SSI website, california unemployment. throw in a couple of kids (or foster a kid)

"While SSI is a federal program (administered by the Social Security Administration), and the federal government pays a standard base rate of $733 per month, most SSI recipients receive more or less than the federal benefit rate. For starters, the federal benefit rate for couples is of $1,100"
"The California Employment Development Department (EDD) determines your weekly benefit amount by dividing your earnings for the highest paid quarter of the base period by 26, up to a maximum of $450 per week. Benefits are available for up to 26 weeks."
"After a quick glance through the list of reimbursement rates by state, you might estimate that $20-$25 per day (or about $1 an hour) is an average amount per child."

married couple, both previously working, "disabled", 4 kids = approx 5300/mo.
5300 x 12 = 63,600/yr
rent, power, water, school lunch is fixed
why bother selling drugs?

Unemployment benefits are temporary, and SSI is very paltry.

https://www.ssa.gov/oact/cola/SSI.html

You could get about 17k if both people were independent and fully disabled. They can't be considered disabled and essential persons.

Could get an extra $964/mo for up to five years maximum in my state, after which TANF would expire. That could bring income to about 29k. Could get another $7,800 with SNAP. And

Section 8 can get $900/mo toward a 3 br place. That's $10,800.

That's $47,800 for a family of four to not work. 12k expires after 5 years, dropping income to $35,800, but I concede you're right, 50k is definitely possible if two people can pull the disabled card.

 

[hundreddaysoff]

I'm thinking about starting to add ketamine for the psych patients and the fibromyalgias but I don't see any of the other residents using it or the attendings. I hear scott weingart talking about it all the time and looked at his dsi paper. It's interesting to me but I don't want to be the lone wolf deviating from practice patterns, especially as an intern.

As to your other post, the next time I see a medicaid patient have a worse phone than me will be the first.

A few attendings like to push ketamine at my place. I've seen it work, but it does have some drawbacks in this application that wouldn't be relevant to Weingart. If an end-stage FM or chronic pancreatitis pt has an emergence reaction, they'll hate you even more and make their nurses' life hell and you'll likely be forced to admit them for pain control to appease them and then they'll sit in the ED for 12 hours and be jerks. And at my place nurses aren't allowed to push ketamine, and I never learned how to use the medication pump, so I need to push it over 10 minutes by hand or else risk even higher chance of emergence reaction. Not so fun.

("Learn to use the medication pump," you say. Yeah, I probably should.)

 

[deleted109597]

They shouldn't emerge, as you're giving subdissociative doses.

 

[Psai]

A few attendings like to push ketamine at my place. I've seen it work, but it does have some drawbacks in this application that wouldn't be relevant to Weingart. If an end-stage FM or chronic pancreatitis pt has an emergence reaction, they'll hate you even more and make their nurses' life hell and you'll likely be forced to admit them for pain control to appease them and then they'll sit in the ED for 12 hours and be jerks. And at my place nurses aren't allowed to push ketamine, and I never learned how to use the medication pump, so I need to push it over 10 minutes by hand or else risk even higher chance of emergence reaction. Not so fun.

("Learn to use the medication pump," you say. Yeah, I probably should.)

Low dose ketamine should calm them down without causing dissociation. I'm thinking maybe 0.1-0.3 mg/kg, not 1 mg/kg

 

[TooMuchResearch]

Low dose ketamine should calm them down without causing dissociation. I'm thinking maybe 0.1-0.3 mg/kg, not 1 mg/kg

Some of them will have bad experiences in the 0.3 mg/kg range. Tread lightly.

 

[MSmentor018]

Some of them will have bad experiences in the 0.3 mg/kg range. Tread lightly.

yeah they will. I've only had 1 bad exp, she went down anxious though which I believe was the cause. when she emerged she jumped out of the bed, grabbed my lab coat and literally said "I am dead, what the hell is going on, why am I dead". a little ativan cured that. I read this article in anesthesia journal by a pt that had this exact same experience. I discussed this case w our anesthesiologist, they confirmed that this happens and the feeling of death is a just trip down the "k hole"