Money (nearly) up front

[Doctor Bob]

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http://m.news9.com/story.aspx?story=25496818&catId=112032

At first I kept looking at the source, expecting it to say "The Onion".

I mean... I love the concept... but I'm not sure this idea would catch on.

If docs can still be liable for people they deem "non-emergent" and the patient is then dissuaded by the potential bill, goes home and has a bad outcome, how many people are going to do any less of a workup in the future prior to calling people non-emergent?

 

[Arcan57]

http://m.news9.com/story.aspx?story=25496818&catId=112032

At first I kept looking at the source, expecting it to say "The Onion".

I mean... I love the concept... but I'm not sure this idea would catch on.

If docs can still be liable for people they deem "non-emergent" and the patient is then dissuaded by the potential bill, goes home and has a bad outcome, how many people are going to do any less of a workup in the future prior to calling people non-emergent?

That is one of the most poorly written articles I've ever seen. I think the editor was drunk or English wasn't their first language.

In regards to the actual topic, Medical Screening Exams (MSEs) have been prevalent in Texas for a while and are gaining ground throughout the mid-South. The idea is one of those things that seems to make sense at first but completely falls apart on closer examination. The only scenario where screening out patients makes sense is if your shop uses a lot of ED resources on patients without emergencies. If you routinely order MRIs for chronic low back pain, keep patients in the ED for multiple rounds of IV narcotics for patients asking for refills of their chronic Norco scripts, or check CBCs, CXR, flu, and strep on viral URIs then your hospital will save some time and money with MSEs.

As Doctor Bob points out, none of the legislation regarding MSEs offers any sort of protection for the doctor so essentially the doctor is being asked to assume all the risk they normally do for little to none of the pay they would normally get. Without hospital subsidies no one gets screened out and with hospital subsidies I'm unclear how the hospital comes out ahead. Now if you said that a doctor had sovereign immunity or there was some greatly increased barrier to filing a malpractice suit in patients that were MSE'd that would be a gamechanger.

 

[MSmentor018]

I don't know about the rest of the states but it's been happening in the SE for years. I've even seen a major metro hospital went from near bankrupt to a surplus! at least that's what was told to us at the staff meeting in 2004.
but this was before obamacare, not sure how that plays a role now

that's a good question about liability esp most of MSE are done by PA/NP but I know there are strict guidelines on what is non-urgent- no pay -go home types. they're suppose to staff with you but you know how that goes. arcan is right, all the liability and no protection. i don't even know if sovereign immunity helps in this case.
if you do a work up before offering them treatment then that'll defeat the purpose. less of a work up and prob more intense H+P and use of "rules" like Ottawa, SF syncope.....etc. to back up the chart.

for the hospital it weeds out the no payers that urgent care centers won't see and gives a rep that they charge for non urgent services. hopefully less no payers showing up. on the other hand hospitals are now being ran like a hotel service so I wonder what would press ganey say

funny enough that whole "you are entitled to pain relief" crap and pain scale that is forced upon us doesn't apply here. no pay, no rx

 

[Hercules]

I'm in the SE too and MSEs have been around for a while. As a physician, I have almost no use for them whatsoever. If I take my time to go see them then I'm billing and documenting a visit period. Our hospital admin tried to get us to do MSEs a while back and we politely explained that the hospital was more than welcome to use their employed triage nurse for the MSE (as is done is several states and a few other hospitals in my state) and that there was no need to have the physician involved. Of course this requires the hospital to own what they are doing, put the rules in writing, and take on all of the liability as well. They decided the MSEs weren't that important any more.

 

[MSmentor018]

I'm in the SE too and MSEs have been around for a while. As a physician, I have almost no use for them whatsoever. If I take my time to go see them then I'm billing and documenting a visit period. Our hospital admin tried to get us to do MSEs a while back and we politely explained that the hospital was more than welcome to use their employed triage nurse for the MSE (as is done is several states and a few other hospitals in my state) and that there was no need to have the physician involved. Of course this requires the hospital to own what they are doing, put the rules in writing, and take on all of the liability as well. They decided the MSEs weren't that important any more.

strong work!

 

[Birdstrike]

Such a medical screening process was at work the last place I worked in the ED clinically, and I worked under that policy for a few years. I seems good in theory, but inevitably we had a few things blown off as non-emergencies by certain providers, that came back critical. Often times the patients leave, can't pay the fee, so you as the MD make nothing, yet increase your liability dramatically. Of course admin, showed some studies that claimed it didn't increase your liability, but it never passed the sniff test for me. Most doctors over-rode 99% of cases as "emergencies" and just treated them all as emergent, to avoid the inevitable "non-emergency" land mine from going home and exploding.

Bottom line: the hospital wants you to endorse booting out supposed "non-emergencies" while taking all of the EMTALA and med-mal liability on yourself, without any real compensation.

 

[Khaos]

I've sent a couple home based on the MSE. It was, "I want a pregnancy test." There was no associated symptoms, just didn't want to pay the 2 dollars to get a pregnancy test at the store. I'm pretty sure the liability there is close to nil since they had no other associated symptoms. That's it...everything else adds to your liability with no benefit to you.

 

[WilcoWorld]

A friend of mine worked for a hospital where the docs were expected to meet a quota of patients that they screened out after an MSE and would get a talking to if they weren't sending out the right %. I recall one case he told me about where he diagnosed acute renal failure after the Nurse Navigator had given him a very hard time about not "MSE-ing" the patient. Yes, that's anecdote, but when it comes to counterexamples, you only need one.

 

[emd123]

A friend of mine worked for a hospital where the docs were expected to meet a quota of patients that they screened out after an MSE and would get a talking to if they weren't sending out the right %. I recall one case he told me about where he diagnosed acute renal failure after the Nurse Navigator had given him a very hard time about not "MSE-ing" the patient. Yes, the second part is anecdote, but when it comes to counterexamples, you only need one.

Common.

 

[VA Hopeful Dr]

Someone a few years ago here mentioned the idea of doing the full history/exam and if non-urgent, not giving out the prescription until the patient pays. I liked that idea.

 

[The White Coat Investor]

We do medical screen outs at our hospital. We try to use it to our and our patient's benefit. If it is a patient who is uninsured, doesn't need any testing, and doesn't need any prescriptions, then I tell them "You know what I'm going to do for you? I'm going to give you an MSO. That means you just got my advice for free and neither I or the hospital is going to send you a bill!" Then I give them written discharge instructions with resources and sliding scale clinics where they can follow-up. I also often recommend some OTC treatments. Patient's happy. I'm happy. Hospital's happy. The only people who aren't happy are the coding/billing folks and the collections agency. I wouldn't have done anything differently anyway, so there's no increased liability. Of course they're not going to pay the $250 fee (which goes to the hospital anyway, not me.) But the hospital just wants to avoid the bad debt so it looks better to its investors; it's not so much about the $250 (although they'll take that too.)

But it's probably only 2% of our patients, which is about right in line with ACEP statistics. They suggest 10% of visits are non-emergent, and our population is about 20% uninsured. So 10% of 20% is 2%.

It works out well for us, since we only collect about 3% of what we bill to self-pay patients. We create some good will and that's useful since a good percentage of our uninsured are acutely uninsured, not chronically uninsured. So they'll come back to us when they have insurance. Plus, it's all in our control and I've found most doctors don't mind doing some charity work, they just want to be able to pick and choose who they do it for. If the guy is a prick, you just call him "emergent" and ruin his credit.

 

[Rendar5]

I would do such an exam of people coming with minor abrasions that don't even need a Band-Aid, minor hernias that don't need any repair and are completely nontender, people who come in requesting to go to a detox facility without any withdrawal symptoms. I also did the same thing yesterday with a patient who had cerebral palsy and called 911 so that we could get him transferred from his group home to a nursing home for very stupid reasons. And a nice lady who had planter fasciitis just been seen the month ago in the Ed, who had not been able to get any podiatry followup; she could not find somebody that her insurance covered. She was convinced by a friend to come to the ER again for very unclear reasons. If we don't provide treatment or prescriptions, and the person is between the ages of five and 65 we can do this examine them and distraction without charge. I still provide a community resource guide for follow up.

 

[Rendar5]

We do medical screen outs at our hospital. We try to use it to our and our patient's benefit. If it is a patient who is uninsured, doesn't need any testing, and doesn't need any prescriptions, then I tell them "You know what I'm going to do for you? I'm going to give you an MSO. That means you just got my advice for free and neither I or the hospital is going to send you a bill!" Then I give them written discharge instructions with resources and sliding scale clinics where they can follow-up. I also often recommend some OTC treatments. Patient's happy. I'm happy. Hospital's happy. The only people who aren't happy are the coding/billing folks and the collections agency. I wouldn't have done anything differently anyway, so there's no increased liability. Of course they're not going to pay the $250 fee (which goes to the hospital anyway, not me.) But the hospital just wants to avoid the bad debt so it looks better to its investors; it's not so much about the $250 (although they'll take that too.)

But it's probably only 2% of our patients, which is about right in line with ACEP statistics. They suggest 10% of visits are non-emergent, and our population is about 20% uninsured. So 10% of 20% is 2%.

It works out well for us, since we only collect about 3% of what we bill to self-pay patients. We create some good will and that's useful since a good percentage of our uninsured are acutely uninsured, not chronically uninsured. So they'll come back to us when they have insurance. Plus, it's all in our control and I've found most doctors don't mind doing some charity work, they just want to be able to pick and choose who they do it for. If the guy is a prick, you just call him "emergent" and ruin his credit.

Same as above

 

[goodoldalky]

We do medical screen outs at our hospital. We try to use it to our and our patient's benefit. If it is a patient who is uninsured, doesn't need any testing, and doesn't need any prescriptions, then I tell them "You know what I'm going to do for you? I'm going to give you an MSO. That means you just got my advice for free and neither I or the hospital is going to send you a bill!" Then I give them written discharge instructions with resources and sliding scale clinics where they can follow-up. I also often recommend some OTC treatments. Patient's happy. I'm happy. Hospital's happy. The only people who aren't happy are the coding/billing folks and the collections agency. I wouldn't have done anything differently anyway, so there's no increased liability.

If I am working in a salaried position then I can accept your case up to "there's no increased liability". First of all, there is always increased liability every time you see another patient and many times medmal suits are brought in cases you would have never thought in a million years would be involved in one or in one where you had no wrongdoing. These are low, but not zero liability cases.

Second if I am working in an RVU based position, I am taking my 5 to 10 minutes and participating in a non revenue generating activity. If I am paid based on what I have billed out I have an incentive to avoid doing this. I should take that 5 to 10 minutes 3 to 4 times a shift and go see other patients or work on maximizing my documentation for that time on billable encounters.

I am all in favor of the hospital designating an RN or other hospital based employee not being supervised under my time and medical license to do these diversions but I am incentivized to oppose this type of arrangement.

 

[Rendar5]

Honestly, level 1 and 2 visits, which these mostly are, charge so little that it's almost not worth my time to spend the extra 2 minutes making it billable and a more complete chart. Not only that but the speedy throughput (I discharge them myself with a handshake and a community guide and some free advice, and don't have to wait for the nurse to be free) and the patient satisfaction of doing it this way more than incentivizes me. That pads my job security.

 

[Doctor Bob]

I've sent a couple home based on the MSE. It was, "I want a pregnancy test." There was no associated symptoms, just didn't want to pay the 2 dollars to get a pregnancy test at the store. I'm pretty sure the liability there is close to nil since they had no other associated symptoms. That's it...everything else adds to your liability with no benefit to you.

Yea... this one I've done. "Any abdominal pain? Vaginal bleeding? Discharge? Fever? Urinary symptoms?... No? Well, you've received your screening exam. Have a nice day. There's a Walgreens on the corner which has pregnancy tests, or you can pick them up from the hospital outpatient pharmacy for a nominal fee."

We do medical screen outs at our hospital. We try to use it to our and our patient's benefit. If it is a patient who is uninsured, doesn't need any testing, and doesn't need any prescriptions, then I tell them "You know what I'm going to do for you? I'm going to give you an MSO. That means you just got my advice for free and neither I or the hospital is going to send you a bill!" Then I give them written discharge instructions with resources and sliding scale clinics where they can follow-up. I also often recommend some OTC treatments. Patient's happy. I'm happy. Hospital's happy.

Hmm... I can see this being useful in only a small percentage of the population... but for that small percent I think I'm going to start using this.

Second if I am working in an RVU based position, I am taking my 5 to 10 minutes and participating in a non revenue generating activity. If I am paid based on what I have billed out I have an incentive to avoid doing this. I should take that 5 to 10 minutes 3 to 4 times a shift and go see other patients or work on maximizing my documentation for that time on billable encounters.

At the RVU-based place I work, the percent I get is based on the amount received from billing, rather than the amount billed. So if it's a patient that isn't going to pay anyways then there'd be no incentive for me to do the extra documentation to make it a billable chart.

A legally defensible chart though... well there's always incentive to make the chart rise to that level.

 

[Venko]

I agree with the other commenter that the English on the part of the physicians is very poor if they were quoted accurately.

Also, did anyone else think that if you have a broken bone you should come to the ER? I would hate to see those with significant orthopedic injuries mishandled in an urgent care.

Maybe it's just me...

 

[Arcan57]

It's URIs and chronic MSK pain w/o recent injury that comprise the majority of screen outs. Think of it like this: "If the CVS Urgent Care Clinic treats it then it's not an emergency".

 

[GeneralVeers]

In an ideal world, EMTALA would provide us clear, and concise guidelines on what constitutes a "Medical Screening Examination", who has to perform it, and how it should be documented. We should have a system whereby if an MSE has been done per guidelines, then any hospital/provider is exempt from suits arising from any bad outcome. This would vastly reduce the nonsense visits to the ED. Unfortunately since trial lawyers rule the world, such a sensible rule would never be adopted.

 

[The White Coat Investor]

If I am working in a salaried position then I can accept your case up to "there's no increased liability". First of all, there is always increased liability every time you see another patient and many times medmal suits are brought in cases you would have never thought in a million years would be involved in one or in one where you had no wrongdoing. These are low, but not zero liability cases.

Second if I am working in an RVU based position, I am taking my 5 to 10 minutes and participating in a non revenue generating activity. If I am paid based on what I have billed out I have an incentive to avoid doing this. I should take that 5 to 10 minutes 3 to 4 times a shift and go see other patients or work on maximizing my documentation for that time on billable encounters.

I am all in favor of the hospital designating an RN or other hospital based employee not being supervised under my time and medical license to do these diversions but I am incentivized to oppose this type of arrangement.

Okay, it's not zero liability, but it's pretty darn close for these cases. Certainly there is no increased liability versus if I sent them a bill, since I'm doing the exact same thing. In fact, it's probably less because they're happier that they didn't get a bill.

I understand you're incentivized to bill everything, but doing these also keeps admin happy, which makes our contract more secure. Since the contract is all important, it's worth losing a few bucks here or there to keep it. We've done much worse to keep the contract.

 

[Birdstrike]

Okay, it's not zero liability, but it's pretty darn close for these cases. Certainly there is no increased liability versus if I sent them a bill, since I'm doing the exact same thing. In fact, it's probably less because they're happier that they didn't get a bill.

I understand you're incentivized to bill everything, but doing these also keeps admin happy, which makes our contract more secure. Since the contract is all important, it's worth losing a few bucks here or there to keep it. We've done much worse to keep the contract.

This reminds me: I have a really good case, from one of these "low risk" screening exams, that ended very, I'll say.....unexpectedly. I'm going to write it up real good for DrWhiteCoat.com, and then I'll post it here first. I think it will add color to this conversation. I have more than one, actually.