NYT: ACA cuts reimbursement for illegal ED visits

[Emurgency]

How do you think this will affect us?

http://www.nytimes.com/2012/07/27/n...409C5DF73D5B9E2BC0A556B801&ref=general&src=me

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[EctopicFetus]

I think the article is clear. If you work at a place that cares for these types of patients you are gonna be screwed. If you dont then it wont affect you much if at all until the other hospital(s) shut their doors..

 

[The White Coat Investor]

I think the article is clear. If you work at a place that cares for these types of patients you are gonna be screwed. If you dont then it wont affect you much if at all until the other hospital(s) shut their doors..

I don't know it will affect us directly much. That money goes to the hospital, not the physicians. Separate business entity.

 

[EctopicFetus]

I don't know it will affect us directly much. That money goes to the hospital, not the physicians. Separate business entity.

If the hospital gets squeezed they will find a way to squeeze us.

 

[deleted65604]

All this legislation ultimately affects us by forcing us to become, in effect, agents of the state. Take Washington state for example, now all the ER groups in the state are bending over backwards, doing the will of the government so that their revenue streams aren't destroyed. They are for the first time, trying to extract less money from the state for medicaid patients so that the government gets off their back. It is a game of chicken where the government knows they can't lose. It is successful even when the legislation actual fails. Look at insurance companies and Obamacare. It is the same situation, they are so afraid of government putting them out of business, that they voluntarily become agents of the state to avoid that (for example- giving in to the mandate to ignore pre-existing conditions, which is insane from a business standpoint.)

 

[DrAwsome]

How do you think this will affect us?

http://www.nytimes.com/2012/07/27/n...409C5DF73D5B9E2BC0A556B801&ref=general&src=me

This is ridiculous. Why the heck are we allowing the gov to do this? We are getting attacked from all sides and just taking it. How about starting to ask for identification before treatment? If illegal, run a credit card before giving treatment. If not then some people who non emergent needs need to be turned away. What is this craziness? This can't be sustained long term.

 

[The White Coat Investor]

This is ridiculous. Why the heck are we allowing the gov to do this? We are getting attacked from all sides and just taking it. How about starting to ask for identification before treatment? If illegal, run a credit card before giving treatment. If not then some people who non emergent needs need to be turned away. What is this craziness? This can't be sustained long term.

Are you seriously advocating a wallet biopsy prior to ruling out serious medical conditions? Attitudes like this are what make EMTALA necessary.

Doesn't matter anyway. In my experience there are very few illegals in the ED with non-emergent concerns. The non-emergent cases are nearly always medicaid patients and the mentally ill.

 

[EctopicFetus]

Are you seriously advocating a wallet biopsy prior to ruling out serious medical conditions? Attitudes like this are what make EMTALA necessary.

Doesn't matter anyway. In my experience there are very few illegals in the ED with non-emergent concerns. The non-emergent cases are nearly always medicaid patients and the mentally ill.

Agreed.. Oh and the uninsured.. The ED is cheaper than Urgent Care.

 

[DrAwsome]

Are you seriously advocating a wallet biopsy prior to ruling out serious medical conditions? Attitudes like this are what make EMTALA necessary.

Doesn't matter anyway. In my experience there are very few illegals in the ED with non-emergent concerns. The non-emergent cases are nearly always medicaid patients and the mentally ill.

For non emergent conditions? Absolutely. That's what I said in my post above.
No one needs to cost the system a thousand dollars to get a refill or a physical as many people do, or to get tylenol and advil for a sore throat.

I'm not suggesting someone having a stroke or a heart attack to have a "wallet biopsy' but for people with stupid non emergent issues, absolutely.

 

[engineeredout]

I'm not suggesting someone having a stroke or a heart attack to have a "wallet biopsy' but for people with stupid non emergent issues, absolutely.

Until they pick up on this and suddenly its "I have CP, oh and my throat is sore as well"

 

[DrAwsome]

Until they pick up on this and suddenly its "I have CP, oh and my throat is sore as well"

I would hope that EM attendings would be smarter than that. I've been people come to the ED for super serious things to stupid things like getting a physical, STD test, for "fever" that started 20 minutes before coming, for 1 episode of resolved diarrhea, and my favorite-to get a Dermatology referral. I'm sure EM attendings can tell the different between these and the stroke patients who need help. When these situations were people simply are screwing around, the wallet biopsy should be entertained, and patients will instantly get better, unless they are seriously in need. I've seen this done a number of times for patients who simply did not want to leave the floors for example. Social work would talk to patients and tell them they were medically discharged, let the family know, make arrangements, etc. If they simply wanted to stay, or the family did not want to pick them up, they would be told that they'd be responsible for all bills from there on. Patients got well instantly and family would be there to pick up patients in no time.

 

[Daiphon]

Until they pick up on this and suddenly its "I have CP, oh and my throat is sore as well"

They already do this to (try and) jump the line... one of my pet peeves.

Sent from my DROID BIONIC using Tapatalk

 

[The White Coat Investor]

For non emergent conditions? Absolutely. That's what I said in my post above.
No one needs to cost the system a thousand dollars to get a refill or a physical as many people do, or to get tylenol and advil for a sore throat.

I'm not suggesting someone having a stroke or a heart attack to have a "wallet biopsy' but for people with stupid non emergent issues, absolutely.

What exactly do you think I do at work? I don't do physicals, refills, or prescribe tylenol or advil. I tell them they don't have an emergency and discharge them. Then they either pay me or they don't. But I still have to go in there, take a history, do a physical and sometimes, do some lab tests to ensure they don't have an emergency before looking at their ability to pay. That's probably a good thing compared to a wallet biopsy up front.

 

[DrAwsome]

What exactly do you think I do at work? I don't do physicals, refills, or prescribe tylenol or advil. I tell them they don't have an emergency and discharge them. Then they either pay me or they don't. But I still have to go in there, take a history, do a physical and sometimes, do some lab tests to ensure they don't have an emergency before looking at their ability to pay. That's probably a good thing compared to a wallet biopsy up front.

My point was that a normal EM attending would know the difference between someone who would have a serious problem and would be seen even if they can't pay vs. someone who is just there for a non emergent reason, and for those cases, they should be forced to pay. You can't simply go into a store and take merchandise without paying can you? You can't walk into a dentist's office and say hey treat me and I'll see if I can pay you. Medicine is the only field where people can decide whether they'll pay or not for services provided. It's completely out of line. If people had more responsibility and liability (ie-being charged like you would at any other normal establishment for getting care) then maybe our system would not be in the shambles taht it is

 

[The White Coat Investor]

My point was that a normal EM attending would know the difference between someone who would have a serious problem and would be seen even if they can't pay vs. someone who is just there for a non emergent reason, and for those cases, they should be forced to pay. You can't simply go into a store and take merchandise without paying can you? You can't walk into a dentist's office and say hey treat me and I'll see if I can pay you. Medicine is the only field where people can decide whether they'll pay or not for services provided. It's completely out of line. If people had more responsibility and liability (ie-being charged like you would at any other normal establishment for getting care) then maybe our system would not be in the shambles taht it is

Oh they're all charged, and they're all sent to bill collectors and have their credit ruined if they don't pay. Don't worry about that. For me it's 17-18% of my patients that don't pay.

But it's almost never as cut and dried as you suggest. Most patients who come to the ED do so with a complaint that could represent an emergent condition- an acute injury, abdominal pain, chest pain, dyspnea, altered mental status etc. Of course, after evaluation, sometimes including tests, most of them don't have an emergent condition. But how are they supposed to know that sitting at home if it took me 4 years of college, 4 years of medical school, 3 years of residency, $3000 in tests, and 2-4 hours to figure it out?

Yes, some are obvious when I walk in the room. Nope, your toe pain isn't an emergency. At my shop, those cases get billed if they have insurance and if they don't I offer them a "medical screen-out", which they all take, since it means they won't get a bill from me or the hospital.

But if I have to do labs and a chest x-ray, sorry, you're getting a bill. Don't pay it and you're going to have a tough time getting a mortgage.

ACEP says less than 10% of ED visits represent non-emergent complaints. That seems about right in my experience. But the truth is almost all of those are Medicaid and very few are true "self-payers" AKA no-payers.

The world is far more complex than it seems young paduan. Your suggestion that "a normal EM attending" would know what's emergent and what isn't the second he sees the triage note simply isn't true. And if he has to do more than that to determine if an emergency exists, well he's already done 90% of the work, so might as well finish up and bill the patient. There's always a chance they might pay anyway.

You're also missing the upside to EMTALA. We get to be the White Knights of medicine. I make a helluva lotta money yet still get to take care of people who can't afford to pay. Most docs can't afford to do nearly as much charity care or their practice would go out of business. Most docs don't see patients without insurance. Many docs don't even see Medicaid/Medicare patients. Yet I get to take care of people without ever having to even know what insurance they're on. I rarely even turn to the face sheet in the chart. I never have to tell someone "I'm sorry, I can't do anything for you because you can't afford to pay me this instant." That can be a beautiful thing.

If you're bitter now about not making more cash because some fraction of your patients doesn't pay you, think about how you'll be a decade from now.

 

[DrAwsome]

Oh they're all charged, and they're all sent to bill collectors and have their credit ruined if they don't pay. Don't worry about that. For me it's 17-18% of my patients that don't pay.

But it's almost never as cut and dried as you suggest. Most patients who come to the ED do so with a complaint that could represent an emergent condition- an acute injury, abdominal pain, chest pain, dyspnea, altered mental status etc. Of course, after evaluation, sometimes including tests, most of them don't have an emergent condition. But how are they supposed to know that sitting at home if it took me 4 years of college, 4 years of medical school, 3 years of residency, $3000 in tests, and 2-4 hours to figure it out?

Yes, some are obvious when I walk in the room. Nope, your toe pain isn't an emergency. At my shop, those cases get billed if they have insurance and if they don't I offer them a "medical screen-out", which they all take, since it means they won't get a bill from me or the hospital.

But if I have to do labs and a chest x-ray, sorry, you're getting a bill. Don't pay it and you're going to have a tough time getting a mortgage.

ACEP says less than 10% of ED visits represent non-emergent complaints. That seems about right in my experience. But the truth is almost all of those are Medicaid and very few are true "self-payers" AKA no-payers.

The world is far more complex than it seems young paduan. Your suggestion that "a normal EM attending" would know what's emergent and what isn't the second he sees the triage note simply isn't true. And if he has to do more than that to determine if an emergency exists, well he's already done 90% of the work, so might as well finish up and bill the patient. There's always a chance they might pay anyway.

You're also missing the upside to EMTALA. We get to be the White Knights of medicine. I make a helluva lotta money yet still get to take care of people who can't afford to pay. Most docs can't afford to do nearly as much charity care or their practice would go out of business. Most docs don't see patients without insurance. Many docs don't even see Medicaid/Medicare patients. Yet I get to take care of people without ever having to even know what insurance they're on. I rarely even turn to the face sheet in the chart. I never have to tell someone "I'm sorry, I can't do anything for you because you can't afford to pay me this instant." That can be a beautiful thing.

If you're bitter now about not making more cash because some fraction of your patients doesn't pay you, think about how you'll be a decade from now.

Based on some of the posts, it may make more sense to be an underworked, over paid nurse or tech than a doctor. On the forum apparently the new topic of discussion is techs making 80k wiht a 2 year degree. Why didn't I do that?! That goes to show you how little we are valued. Not sure what the point of our hard work, sacrifice and education is if everyone around us is making a ton of money with much less. Doesn't that ever bother you?

 

[la gringa]

...and this exactly is why some advocated for an attending-only forum...

it would take about 10 pages of posts for this dude to "get it" if at all. i'm not trying to be mean, but there are issues about medicine that change so much from the time you're a MS to resident to attending that you can't predict them all nor plan for them.

bottom line: if you're in medicine or EM or anything involving people for the money above all else, get out now.

i'm dead serious and i'm not trying to be cute. even the highest paid physician job will take a helluva a lot of patience dealing with people and society and their BS. reimbursement is only getting more difficult to figure out and changes based on the whims of elected official who know nothing about what you do and don't appreciate you. same for most pts. you gotta take your victories where you can and keep it movin'.

 

[8654Marine]

My point was that a normal EM attending would know the difference between someone who would have a serious problem and would be seen even if they can't pay vs. someone who is just there for a non emergent reason, and for those cases, they should be forced to pay. You can't simply go into a store and take merchandise without paying can you? You can't walk into a dentist's office and say hey treat me and I'll see if I can pay you. Medicine is the only field where people can decide whether they'll pay or not for services provided. It's completely out of line. If people had more responsibility and liability (ie-being charged like you would at any other normal establishment for getting care) then maybe our system would not be in the shambles taht it is

What some of the experienced folks are saying is that a cursory glance at someone can't predict the seriousness of their condition.

Innocuous things can look serious, i.e. hyperventilation mimicing a PE.

Serious things look benign, i.e. aneurysm before the rupture.

I share your frustrations about the whole EMTALA issue, but before declaring what a normal EM doc should do or suggesting EM physicians aren't smart if they can't cursorily distinguish between "sick" and "not sick" only shows your lack of many things.

We all could learn more things.

 

[DrAwsome]

What some of the experienced folks are saying is that a cursory glance at someone can't predict the seriousness of their condition.

Innocuous things can look serious, i.e. hyperventilation mimicing a PE.

Serious things look benign, i.e. aneurysm before the rupture.

I share your frustrations about the whole EMTALA issue, but before declaring what a normal EM doc should do or suggesting EM physicians aren't smart if they can't cursorily distinguish between "sick" and "not sick" only shows your lack of many things.

We all could learn more things.

I was not suggesting EM attendings are not smart in the least. I'm sorry if that's how it came across. I'm saying that I think most EM attendings know better. In no way am I suggesting that EM attendings are stupid or anything like that.

 

[StevieStud]

I'm not suggesting someone having a stroke or a heart attack to have a "wallet biopsy' but for people with stupid non emergent issues, absolutely.

And who is going to make the determination about all those potential patients?

A triage clerk (oops, I mean certified hospital credit card processing technician) with 6 weeks of experience in the trenches and 18 weeks of technical training consisting of courses such as "remedial math for nurses" and 4 weeks of physiology from a text book that was out of date 20 years ago?

What if she is unable to diagnose the differences between migranes and strokes during the wallet biopsy and the credit card gets declined?

Are you going to eat that one?



Sorry dude, somebody has to be in charge. It better not be the clerk checking the health of the patient's credit cards.

 

[The White Coat Investor]

Based on some of the posts, it may make more sense to be an underworked, over paid nurse or tech than a doctor. On the forum apparently the new topic of discussion is techs making 80k wiht a 2 year degree. Why didn't I do that?! That goes to show you how little we are valued. Not sure what the point of our hard work, sacrifice and education is if everyone around us is making a ton of money with much less. Doesn't that ever bother you?

I don't know how it is in your shop, but partners in mine working the same number of hours as our techs can expect 10 times the income. Let me think....get paid 1/10th as much and spend all day hounding people for urine, doing EKGs, drawing labs, and occasionally putting on a splint. No thanks.

The average emergency doc is making somewhere between $230K and $330K (depends on what survey you believe.) Show me a tech or nurse making anywhere near that amount working in an ED.

 

[EctopicFetus]

I saw the recent Daniel Stern Survey and top 10% in EM is over 500k. It was printed in the ACEP magazine thing. Not ACEP news.

Like Actveduty said.. comparing a doc to a tech is stupid.. both in function and finance.

 

[DrAwsome]

I don't know how it is in your shop, but partners in mine working the same number of hours as our techs can expect 10 times the income. Let me think....get paid 1/10th as much and spend all day hounding people for urine, doing EKGs, drawing labs, and occasionally putting on a splint. No thanks.

The average emergency doc is making somewhere between $230K and $330K (depends on what survey you believe.) Show me a tech or nurse making anywhere near that amount working in an ED.

So you said partners of yours are making 10 times the income of the techs? Bc the techs are making around 80k. So your partners are making 800k? If they are, my bad and apologies are in order on my part. But I don't believe any ethical doctor, partner or not, is making 800k.

The figures you quote, 230-330k are very much believable, but that's after 11 years or more of education, vs. the 2-4 that techs have. Many nurses are making over 100k. Nurse in correctional facility in CA was making 270k with overtime.

 

[DrAwsome]

I saw the recent Daniel Stern Survey and top 10% in EM is over 500k. It was printed in the ACEP magazine thing. Not ACEP news.

Like Actveduty said.. comparing a doc to a tech is stupid.. both in function and finance.

Ectopic, maybe EM salaries have gone up quite a bit recently-and good for you guys, it's certainly not a job I could do and I've seen some awsome EM docs. But for many other docs out there, such as FM/IM/peds/path, they are making supposedly a lot closer to the 150-180k or so. If a tech/nurse/NP/PA is making 80-100k, it's not the best financial investment to be a doc in those specialties. No one ever compared the function of knowledge base of the two. Hands down agree with you that there is no comparison.

 

[Bojack Horseman]

Nurse in correctional facility in CA was making 270k with overtime.

no wonder the state is going bankrupt...

 

[DrAwsome]

no wonder the state is going bankrupt...

Yes. Bus drivers also make about 80k, correctional officers with high school education make 100k, etc. Everyone is overpaid. Techs make 80k+, etc. You get the idea. So when the gov says hey you greedy doc, let's cut your rates! I have a problem with that.

I'm kind of tired that everyone is so passive in medicine. ER docs have to treat all patients, patients abuse the system yet as BLADE in the anesthesia forum was saying patients that paid 0 dollars can still sue you. You can't order too many imaging studies, but if you hve to, radiologists will only get paid for 1 that is full priced. What the heck is going on>

While nurses have 6 figures with overtime, and techs make 80k. These are real figures people. Why isn't anyone cutting these people's salaries first> Why aren't nurses salaried? It's absurd.

 

[Druggernaut]

So you said partners of yours are making 10 times the income of the techs? Bc the techs are making around 80k. So your partners are making 800k? If they are, my bad and apologies are in order on my part. But I don't believe any ethical doctor, partner or not, is making 800k.

The figures you quote, 230-330k are very much believable, but that's after 11 years or more of education, vs. the 2-4 that techs have. Many nurses are making over 100k. Nurse in correctional facility in CA was making 270k with overtime.

Where are there techs making 80K? Pulling fairly regular overtime, with maxing out all the raises for learning additional skills, and with a shift differential, I didn't get much above 30K when I was doing it (and techs only required 3-4 credits to do the job, not 2-4 years). The physicians were making more than 10 times that before bonuses. Are you talking about ED Techs, or something higher on the totem pole?

Full time nurses were starting at around 40K. I know that's on the lower end, and I've heard the stories about the government nurses making 200K+ (though I think they also had something like 80-90 hours a week for the entire year, with more than time and a half when they entered into those extreme hours), but either you're in a very, very broken system, or you're looking at the extreme outliers too much.

 

[WilcoWorld]

I think that Druggernaut is right that we're talking about a lot of outliers who do a lot of overtime. If overtime is worth time & a half, and someone puts in 80+ hours/week, that person will break six figures with a baseline salary of 40k.

I don't think nurses are overpaid. I envy the workload protections that they've won themselves, but I think physicians should learn from that rather than get mad about their salaries. It's not like we have an overabundance of nurses these days.

 

[Arcan57]

I think that Druggernaut is right that we're talking about a lot of outliers who do a lot of overtime. If overtime is worth time & a half, and someone puts in 80+ hours/week, that person will break six figures with a baseline salary of 40k.

I don't think nurses are overpaid. I envy the workload protections that they've won themselves, but I think physicians should learn from that rather than get mad about their salaries. It's not like we have an overabundance of nurses these days.

I wonder if DrAwsome was thinking about scrub techs? I've never been in a shop where the ED techs made more than $15/hr, which at 80 hrs/wk would be $1500/wk which would be $75k/yr. With ED shifts tech shifts almost always maxing at 12 hrs, that's working 7 days a week for 50 weeks a year.

 

[fiznat]

You're also missing the upside to EMTALA. We get to be the White Knights of medicine. I make a helluva lotta money yet still get to take care of people who can't afford to pay. Most docs can't afford to do nearly as much charity care or their practice would go out of business. Most docs don't see patients without insurance. Many docs don't even see Medicaid/Medicare patients. Yet I get to take care of people without ever having to even know what insurance they're on. I rarely even turn to the face sheet in the chart. I never have to tell someone "I'm sorry, I can't do anything for you because you can't afford to pay me this instant." That can be a beautiful thing.

If you're bitter now about not making more cash because some fraction of your patients doesn't pay you, think about how you'll be a decade from now.

Just wanted to say thanks for this. It isn't often that I hear this perspective, and if I may be so bold, I think it does us all a margin of good to hear it. That certainly goes for me, at least.

...and this exactly is why some advocated for an attending-only forum...