No Ophtho Resident?

[tennik]

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There are a decent number of places that have an Emergency residency but no Ophthalmology program. Does this mean the attendings are covering in the middle of the night or that the EP just does more?

 

[USCDiver]

Think about all those emergency departments in the country that don't have residents! Are the attendings covering in the middle of the night?

At my program there is no Ophtho, Ortho, or ENT residency programs. We call the attending on call in the middle of the night if need be. Honestly there aren't that many ophtho or ENT emergencies that they need to come in for. Usually you are calling so that the patient can be seen in the office first thing in the morning and the doctor on call will be familiar with the case. Unless it's a ruptured globe or foreign body or something that needs immediate attention.

 

[docB]

And think about all the places where there is no ENT, Optho, URO etc. The EP stabilizes and transfers or treats and streets with as much follow up as possible.

 

[fedor]

And think about all the places where there is no ENT, Optho, URO etc. The EP stabilizes and transfers or treats and streets with as much follow up as possible.

Please allow me to ask for a clarification here. In cases where there is no ENT, optho, or uro, can a patient be transferred even if the patient is uninsured? I believe you mentioned in a previous post (the search function is disabled at the moment) that this could be arranged because it would be a vertical transfer -- the service is nonexistent at the originating ED. Is there some law which requires hospitals to accept vertical transfers?

 

[DropkickMurphy]

As long as you are transferring for a medically valid reason (a specific type or level of care not available at your facility for example), then it's not considered patient dumping regardless of insurance status. As for whether hospitals are legally obligated to accept such patients, I have no idea but if I had to guess I would say no.

 

[docB]

A transfer for a valid reason like needs higher level of care is valid. A hospital IS legally obligated to take the pt if they have the services and capacity to take it regargless of insurance status.

 

[fedor]

Is it safe to assume that the vast majority of ED's operate at a loss for hospitals?

If so, what is to prevent hospitals from closing their ED's entirely? (not to mention closing parts of them, such as their Burn Centers which are notorious for running at a loss)

 

[docB]

Is it safe to assume that the vast majority of ED's operate at a loss for hospitals?

If so, what is to prevent hospitals from closing their ED's entirely? (not to mention closing parts of them, such as their Burn Centers which are notorious for running at a loss)

No. We don't run at a loss. We'd close if we did. As the payer mix erodes we get closer and closer to running at a loss and when that happens we might close.

You also have to look byond the ED to see the true financial impact. If your hospital makes money on its inpatient side and most of those pts come through the ED then it's probably worth it.

 

[Apollyon]

Is it safe to assume that the vast majority of ED's operate at a loss for hospitals?

If so, what is to prevent hospitals from closing their ED's entirely? (not to mention closing parts of them, such as their Burn Centers which are notorious for running at a loss)

Since we went to an electronic chart, our billing has gone UP.

 

[fedor]

And think about all the places where there is no ENT, Optho, URO etc. The EP stabilizes and transfers or treats and streets with as much follow up as possible.

So let's say a patient presents to an ED with an MI or a GSW. The ED stabilizes the patient but the patient is uninsured. Thus they will want to transfer the patient. They can't street the patient yet but the patient is stabilized. Why would a hospital accept the transfer?

I can't imagine a private hospital to accept the transfer voluntarily. So does the originating hospital keep the patient longer even though the patient is stabilized and could theoretically be transferred? Or are there some hospitals out there which do accept transfers even if the patients can't pay. In Chicago, Cook County accepts transfers from the entire Chicagoland area. But in cities like Philadelphia, I don't think that there are any county hospitals. What happens in areas like those? Does the originating hospital keep the patient indefinitely?

 

[f_w]

> Is it safe to assume that the vast majority of ED's operate at a loss
> for hospitals?

Depends on the payor mix and the average disease severity. There are two extremes, and most hospitals are somewhere in between.

A suburban ED with a population that is either insured or has medicare but is on average not terribly sick is a goldmine for the hospital.

A inner-city ED with a largely uninsured population (which often has multiple health-problem not properly attended to on an outpatient basis) is a gigantic money pit.

There are other reasons to keep an ED, even if it runs at a loss. EDs create a lot of secondary revenue for the hospital (mostly lab and imaging services ). If there are enough paying patients who get such services, the income will easily offset the losses for charity care at the ED level.

Also, 'profit' and 'loss' in a hospital setting are numbers easily manipulated by the hospital administrators. If I wanted to run 'my' ED at a 'loss' (in order to keep these pesky ED docs in check), I would charge all kinds of bogus expenses to their budget but book the revenue created under different departments.

 

[f_w]

So let's say a patient presents to an ED with an MI or a GSW. The ED stabilizes the patient but the patient is uninsured. Thus they will want to transfer the patient. They can't street the patient yet but the patient is stabilized. Why would a hospital accept the transfer?

Because to some extent they have to due to EMTALA.

http://www.aaem.org/emtala/transfer.shtml

http://www.aaem.org/emtala/watch.shtml

 

[spyderdoc]

Since my hospital has a good payor mix, they frown upon us closing to saturation, since we are losing them A LOT of money on admissions, labs, studies, etc......

 

[DrQuinn]

Actually, I've heard that the hospital's three biggest money makers are:

The OR
The pharmacy
The ED

Q

 

[docB]

So let's say a patient presents to an ED with an MI or a GSW. The ED stabilizes the patient but the patient is uninsured. Thus they will want to transfer the patient. They can't street the patient yet but the patient is stabilized. Why would a hospital accept the transfer?

I can't imagine a private hospital to accept the transfer voluntarily. So does the originating hospital keep the patient longer even though the patient is stabilized and could theoretically be transferred? Or are there some hospitals out there which do accept transfers even if the patients can't pay. In Chicago, Cook County accepts transfers from the entire Chicagoland area. But in cities like Philadelphia, I don't think that there are any county hospitals. What happens in areas like those? Does the originating hospital keep the patient indefinitely?

They don't accept them voluntarily. They have to accept them by law (EMTALA).

 

[tennik]

Thanks for the EMTALA links fw - very helpful. I have to believe that neurosurgery is the number one money maker for hospitals.

Working at an academic hospital it seems like a lot fewer consults would be called if it meant an attending getting out of bed in the middle of the night (we call Ophtho consults multiple times nightly where I am). I guess it is different if the consult is in private practice and hears the cash register ring when she is called in!

 

[f_w]

Working at an academic hospital it seems like a lot fewer consults would be called if it meant an attending getting out of bed in the middle of the night (we call Ophtho consults multiple times nightly where I am).

In the real world (the 90% of medicine outside of academic teaching hospitals), the threshold to call a consult for bogus (sorry minor) stuff is indeed higher. Kidney stones go home, pink-eyes get treated and released, and most of the stuff you might call an ED consult for at an academic place will just be followed as an outpatient.

I guess it is different if the consult is in private practice and hears the cash register ring when she is called in!

Yep, they are really thrilled to come in at 2 am to stitch that lid laceration involving the margin on the town drunk. Really big bucks in the ED consult business. ED patients are known for their excellent insurance status and their dilligent payment habits.

 

[tennik]

I will get up at 2am for $500+ and a new patient in need of retinal detachment surgery. And I thought that people in the "real world" had insurance?

 

[f_w]

> I will get up at 2am for $500+ and a new patient in need of retinal
> detachment surgery.

That is if you'r retina. Most of the stuff seen in the ED is less glamorous. Lots of trauma, often related to alcohol, domestic violence or the combination thereof. The other favourite are 'flashing lights' and the sudden loss of vision in 25 year olds with a wandering uterus (which of course requires a $$$ workup to rule-out MS).

> And I thought that people in the "real world" had insurance?

People with insurance probably get eye problems as often as people without. Just that they call their PMD during the day and get themself seen at someones office. As a result, a lot of the things seen in the ED which are bad enough that you can't just put them off until the next morning end up as charity care.

 

[fedor]

So at large academic hospitals such as Hopkins or Penn, the attendings usually work Monday through Friday from approximately 8am to 5pm and after that the residents take over? Even the EM attendings? I figured a large academic hospital would always have EM attendings staffing 24/7.

 

[USCDiver]

So at large academic hospitals such as Hopkins or Penn, the attendings usually work Monday through Friday from approximately 8am to 5pm and after that the residents take over? Even the EM attendings?

Where did you get that from?

 

[fedor]

Where did you get that from?

No idea. Just throwing out some guesses looking for clarification. Pardon my ignorance.

From what I know (and please keep in mind I'm still a preclinical MS) at my academic institution in many specialties (rads, derm, neuro, etc.) the night and weekend call is done by residents and fellows. Attendings work regular hours. Meanwhile, in EM attendings work around the clock alongside residents.

 

[tennik]

Emergency attendings cover the ED 24 hours a day. Interestingly they are one of only THREE specialties that are in house (the other is trauma surgery and Anesthesia). I am curious if other hospitals have more in house specialties like general surgery and such.

 

[bartleby]

While you are indeed right that most specialties do not have in house attendings in academic hospitals, it is the rare clinician in medicine (outside of EM, of course : ]) who only works 8 hours a day.

So at large academic hospitals such as Hopkins or Penn, the attendings usually work Monday through Friday from approximately 8am to 5pm and after that the residents take over?

 

[Sessamoid]

Emergency attendings cover the ED 24 hours a day. Interestingly they are one of only THREE specialties that are in house (the other is trauma surgery and Anesthesia). I am curious if other hospitals have more in house specialties like general surgery and such.

And Ob for those hospitals that do Ob.