(new hospitalist) When do you refuse admissions from ER? Need help avoiding getting dumped on

[TulaneUnderdog]

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This is really the tragedy of Emergency Medicine, as a specialty. It was created to put doctors in the ER, who could and would dispo appropriately, in effort to avoid what you just described in your post.

That EM is now riddled with mid-levels (and EM physicians) who only practice CYA medicine is proof that EM is not a serious or well-defined medical specialty.

Might as well have internists, general surgeons, and pediatricians work the ER; if they're admitting anyway, they can do the whole intake.

I had at one point in the night my name as primary on the entire ED board of all dozen patients. Because they pan-Admitted them all and many of them dont even have basic orders, potassiums not repleted, and pain not addressed; yes we can do their job. And its safer for the patient as they still havent been stabilized; even shock has been mistreated (Ive seen some give lasix for “cardiogenic shock” that they documented!). It makes sense that they are being encroached; there is no thought process. just algorithm.

 

[DrMetal]

I had at one point in the night my name as primary on the entire ED board of all dozen patients. Because they pan-Admitted them all and many of them dont even have basic orders, potassiums not repleted, and pain not addressed; yes we can do their job. And its safer for the patient as they still havent been stabilized; even shock has been mistreated (Ive seen some give lasix for “cardiogenic shock” that they documented!). It makes sense that they are being encroached; there is no thought process. just algorithm.

My ER is the same. I admitted 47 patients (over 3 nights). None were worked up properly by a doctor before I touched them.

We (as a community of physicians) have egg on our face, b/c we advocated for the creation of EM, that it would be so important, so vital. Now we look foolish.

This is why when anyone suggests the creation of a new specialty ('primary care', 'rural medicine', 'obesity medicine' . . . pick your favorite silliness) . . I quickly admonish them.

We don't need new specialties (or sub-specialties) in medicine: we need more and better quality physicians doing the current specialties!

 

[helpfulApu]

Wow 30 on census is crazy for a hospitalist. With them pan-consulting, how hard was the job?

ive had 30+ more times than i can count , and even though you pan consult, its still a mess

first of all the panconsulting may not be helpful depending on the consultants

second, it's still 30+ Meemaws who are fighters, 30+ daughters from california, 30+ discussions about obscure cbc values in patients with chronic multi organ insufficiency since 2000, 30+ recurrent falls admissions due to being on 7 psychotropic agents at home not willing to stop and pcp gets mad if you bring it up , etc etc

 

[helpfulApu]

oh and i forgot , 30+ advanced cancer patients on 6th line chemo and onc apparently never heard of GOC, or simply chooses not to have GOC because patients just fire/report them and shop around to a more optimistic onc.

 

[dgdg]

My wife interviewed for a hospitalist job 10 years ago at a large regional hospital. The doctors there routinely had 30 patients on their census. This was accomplished by pan consulting for every problem the patient had. Sure they were all clearing 400k back in 2014 but that approach both sucks and is bad medicine.

How do you bill for that? If you bill for the same dx code as the specialist, the insurance will only accept billing provider. They don't want to pay for the same service twice. It's a race to see who bills first.

 

[VA Hopeful Dr]

How do you bill for that? If you bill for the same dx code as the specialist, the insurance will only accept billing provider. They don't want to pay for the same service twice. It's a race to see who bills first.

I have no idea, I've never been a hospitalist. How do things normally get billed if you admit someone and then (appropriately) consult another service?

 

[chessknt]

CMS will not pay the same code from providers of the same specialty (ie taxonomy) in the same group. If two specialists from the same taxonomy but different groups consult on the same day it is unlikely they both get paid however all other scenarios will (different specialties + same day, same specialty + different day).

 

[TulaneUnderdog]

I swear family who cried the loudest and longest for me in my entire year on shift was the one; who revoked his hospice, his DNR status, was told every day x2 weeks by us and Neurologist that he will forever remain GCS of 4 based on MRI, still not tolerating feeds, failing to thrive, too weak to even elicit a cough, and is aspirating with evolving right lower lobe PNA ; is the one who is shocked when he coded overnight and died and demands “all the paperwork and documentation”

 

[helpfulApu]

ive realized its not that complicated. its just cashgrabs.