Washington HCA / Medicaid

[Pinner Doc]

Got this little gem in my inbox today....

http://hrsa.dshs.wa.gov/News/Fact/NonMedicallyNecessaryERVisitsFAQ.pdf

We all remember in October 2011 when the Washington HCA decided to limit Medicaid patients to three "non-emergent" visits. Starting in April 2012, "HCA plans to stop paying for hospital Emergency Department visits for Medicaid clients when it deems those visits “not medically necessary in the ER setting.”" Full stop.

If you're a Washington state EP or, worse yet, Washington state Medicaid patient, you should be upset. Especially because the HCA's former list of "non-emergent conditions" included abdominal pain, chest pain, and miscarriage with hemorrhage, to name a few.

Actually, if you're a WA state Medicaid patient, you have nothing to worry about, as you will *NOT BE BILLED.*

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Members don't see this ad.

 

[la gringa]

speechless.

 

[Birdstrike]

.

 

[la gringa]

Birdstrike, you said what i was thinking, but i found the whole thing to be so absurd that i didn't quite know what to say or where to start...

 

[Pinner Doc]

Thank you, Birdstrike! My thoughts exactly.

I don't even know where to start.... I'm 7 months out of residency and I feel like I'm - to use a crass term - taking it from both ends. I'd like to admit every Medicaid patient that walks through my door just to stick it to the state, but then I'm not cutting costs and risk losing the group's contract with the hospital.

What fresh hell is this?

And also, Birdstrike - it's not that they're not going to pay us after a certain number of business. When we sued (and won) for that f*ckery, they've turned it around and just said that they won't pay at all.

I was young(er) and more idealistic once. I do wish that every med student posting about residency interviews, etc, popped by this thread and saw the future.

 

[turkeyjerky]

I agree that this proposal is beyond ridiculous, but I just wanted to point out one in accuracy with birdstrike's post. Theymsaid that they would pay for the medical screening exam, they just won't pay for any "non-indicated care" or care that could also be provided at the pcp's office. One question I have, is does to mean you're supposed to send someone with an abscess to their family doc for drainage? (cause they could drain it) ditto for lac repair. I guess maybe they want you to send the dude with DKA to their family doc for a direct admit (especially if he's not compliant and it's his 12th episode of the year, thus defining him as a chronic abuser of the system) Bizarro...

 

[Pinner Doc]

I'm thinking about things like chest pain - which in their old list they considered non-emergent. You work it up. You do the CXR, EKG, enzymes (sometimes more than one set). You give the meds. Say it turns out to be benign and you send out with close outpatient follow-up. They are RETROSPECTIVELY looking at that ER visit and deciding it didn't need to be done. Meanwhile, we're supposed to hold the crystal ball on these patients? Eat the costs of these tests? I can't do a screening test on a chest pain patient and mystically say if it's cardiac or not.

 

[Birdstrike]

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[EM2BE]

http://hrsa.dshs.wa.gov/News/Fact/NonMedicallyNecessaryERVisitsFAQ.pdf

So....the government who required the ER physician by law to see such abusive patients, will stop paying the doctor after a certain number of abusive visits? In other words, punish the doctor for the patients abuse of the doctor and force, by law, the doctor to continue to be abused, but do nothing to prevent the person abusing to stop abusing, and still hold the ER physician liable so that patient can sue anytime, for any reason.....And they're going to require the ER doctor to screen the patient, for free, while exposing him/herself to all the liability of being sued and require you to deem the visit non-emergent so the ER doctor won't get paid?


YES.

Its pure MADNESS and the ultimate affront.



It's an un-effing believable abuse of the ERs, their doctors and nurses. The ultimate slap in the face to the only people propping up the system.

How does this not make you more angry?

How can this thread not be exploding?

How do you not stand up and fight?

Have we lost our minds?

Does our Hippocratic Oath require us to be sheep blindly walking to the slaughter?

God help us and God help this profession.

When will we all wake up and say,"Enough is enough! I'm done! We're not going to take it anymore!"?

When will we demand the end of EMTALA without payment and tort reform?! Demand payment at far market rates?!

Is this coming to every ER, city, state, specialty, and physician practice ushered in by those who dream of a socialist healthcare system? (yes). As long as we let it!

Have we all gone mad?

Am I the only sane person left?!

Am I the only sane person left?!

Couldn't have said it any better. I just read through the file. It's unbelievable. I hope things don't change to this in the future. I was thinking if Washington is doing this, I hope others won't follow. Massachusetts failed at their attempt. I'm hoping this fails even worse if they do it. I can say one thing, I can eliminate Washington off my list of places I will work in a few years. This is going to be very ugly.

 

[FunnyCurrent]

I wish I were born decades before and got to practice then (MS1 ). Jesus what the hell is going on?

 

[IDBasco]

Also, look at the list of what they consider "non-emergencies" . Some my fav's:

Chest Pain
Abdominal Pain
Asthma Exacerbation (acute)
Acute Cholecystitis
Hypoglycemic Coma
Pneumococcal Pneumonia
Pseudonomal Pneumonia
Calculus of Ureter (i.e. kidney stone)
Syncope and collapse
Salmonella Enteritis
Streptococcal Septicemia

You think it can't be so? Read the list

We're under assault.

Wow. Who do you suppose came up with this list?

Next new law- you must accept medicaid (regardless of specialty) in order to get your medical license. Watch and wait.

 

[zinjanthropus]

The PDF has two emails for Washington Health Care Authority staff.....Ready, Set, Go!

 

[EctopicFetus]

What they need to do is resubmit EVERY single denied bill. a 51 million dollar savings. Holy crap.I am sure they will find a way around this. I cant believe that this is legal CMS guidelines etc.

This is an affront to every EP. Washington is out to set a precedent that might come to EVERY state.

The golden days of medicine are long long gone.

 

[deleted109597]

So, what if the PCP decides to send the "chest pain" patient to the ED.
Now where is that catch-22 when you need it?

 

[EctopicFetus]

Lets be honest.. most primary docs wont just see someone same day or even the following day.

 

[deleted109597]

Lets be honest.. most primary docs wont just see someone same day or even the following day.

Or within 3 weeks at a resident clinic, much less some doc working on his/her own without droves of underpaid unsupervised labor.

 

[Hamhock]

First: I wonder (suspect) we must be missing something/there's more to this story. Anyone in WA with a bit of legal/political/activist inside info about this? ...or personal experience.

Second: what's ACEP or even WA ACEP doing about this? Any of you wide-eyed med students who believe in the AMA/ACEP know what's being done about this?

HH

 

[EctopicFetus]

First: I wonder (suspect) we must be missing something/there's more to this story. Anyone in WA with a bit of legal/political/activist inside info about this? ...or personal experience.

Second: what's ACEP or even WA ACEP doing about this? Any of you wide-eyed med students who believe in the AMA/ACEP know what's being done about this?

HH

The OP works in washingon state I believe.

 

[Birdstrike]

.

 

[Pinner Doc]

WA ACEP is suing:


http://www.acep.org/Content.aspx?id=82234


The policy has temporarily put on hold, but will be working its wake back through the courts, and will be arriving in an ED near you soon (unless we stand up and fight it):


http://www.acepnews.com/index.php?i...s]=897&cHash=09ba8923bcfd1ea7440d99be6b939068

No... unfortunately those two links are old news. I really like your energy, Birdstrike, but you're referring to a policy that went into effect in October. The new reality is much worse.

The three visit policy for Medicaid patients was proposed earlier this fall and went into effect on October 1st. We sued. The policy was put on hold.

The link I provided in yesterday's original post is a NEW policy. It was distributed to my department YESTERDAY. Now they are not paying for any non-emergent visits. And now, the Medicaid patient will not be billed; the hospital/physicians will eat the cost. There is nothing on ACEP or Washington ACEP's websites yet, to my knowledge. We have an MD/JD in my group who was involved with the original suit for the 3-visit non-emergent Medicaid, and he is looking into it, but obviously this is going to necessitate a lot of time, resources and support from Washington EPs as well as advocates across the country on our behalf.

 

[BADMD]

Anyone feel like moving to Washington State to set up shop? I feel a series of centers opening.

BADMD's No Insurance Accepted, Non-Emergency Clinic
"All the care you want to pay for up front."
No Haggle Pricing. 3% cash discount. No checks.

 

[gutonc]

Anyone feel like moving to Washington State to set up shop? I feel a series of centers opening.

BADMD's No Insurance Accepted, Non-Emergency Clinic
"All the care you want to pay for up front."
No Haggle Pricing. 3% cash discount. No checks.

Like this? Across the river from WA though.

 

[BADMD]

Like this? Across the river from WA though.

Nah. They appear to take insurance.

 

[Birdstrike]

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[Apollyon]

Like this? Across the river from WA though.

Two things: first, 21 of 23 "providers" are women, including 2 of 3 docs.

And, "the Skype visit"? Either this is the cutting edge, or will flop. But it seems like direct to consumer telemedicine.

There is a Seattle office, though.

 

[EctopicFetus]

http://statdoctors.com/index.html

this is similar to the skype visit. DTC telemedicine may have a future.

 

[BADMD]

What is likely to happen is a shifting of diagnoses and very aggressive care during the first 3 visits. I also expect that they won't save nearly as much as they think they will.

Showing up for anything remotely like chest pain and the result will be a Cardiac Cath. That way at visit #4 for the year, you can feel comfortable tossing them out without significant work up. Anyone with asthma that needs admission will get Bipap and the diagnosis will be "Respiratory failure." Abdominal pain? Nope, it will be persistent nausea and vomiting with abdominal pain. Also expect a cadre of PAs/NPs paid to be triage walls. Expect some spectacular misses.

The real question is will the PCPs actually see their patients on an urgent basis? Unlikely. The patients will end up coming back in a few days when their condition becomes emergent, ultimately costing quite a bit.

 

[xaelia]

Bad policy begets bad care.

Yet again, amazing how we can be mandated to provide uncompensated care. And even more preposterous that we have to put our and our family's livelihood on the line for free with no additional malpractice protections.

I would imagine in the embryonic stages, we'll see EDs adjusting their discharge diagnoses to anything on the list - sort of how, with the new CMS guidelines for CT in atraumatic headache, you can add complicated headache, thunderclap headache, dizziness, etc. as secondary diagnoses to be excluded.

 

[Quirk11]

Birdstrike:

A future EM should refer to your "Bible"...Namely, to stay flexible and be able to move.

I would head for the door soon, I know the pain guys already were attacked there ..

I wonder if EM can do any concierge clinics, thats probably your best bet for the future..

Ok. So this is an even newer policy. My points are the same, I stand by them, and the newest update is even worse. It doesn't surprise me at all.

They absolutely want to kill us. It's scorched earth policy with no regard to what they destroy. Do they know what a mass exodus from Emergency Medicine and Medicine as a whole will bring?

Like I said in my last post, don't have a false sense of security if some judge temporarily puts such a policy on hold.

This fight will last for our lifetimes.

 

[Pinner Doc]

What is likely to happen is a shifting of diagnoses and very aggressive care during the first 3 visits. I also expect that they won't save nearly as much as they think they will.

Showing up for anything remotely like chest pain and the result will be a Cardiac Cath. That way at visit #4 for the year, you can feel comfortable tossing them out without significant work up. Anyone with asthma that needs admission will get Bipap and the diagnosis will be "Respiratory failure." Abdominal pain? Nope, it will be persistent nausea and vomiting with abdominal pain. Also expect a cadre of PAs/NPs paid to be triage walls. Expect some spectacular misses.

The real question is will the PCPs actually see their patients on an urgent basis? Unlikely. The patients will end up coming back in a few days when their condition becomes emergent, ultimately costing quite a bit.

The 3 visit rule was thrown out after a lawsuit this fall. Now they're not paying for any non-emergent visit (see original PDF).

 

[Birdstrike]

.

 

[BADMD]

The 3 visit rule was thrown out after a lawsuit this fall. Now they're not paying for any non-emergent visit (see original PDF).

I skimmed over it, but didn't glean that part. I thought they just tossed the list. Even better...

"That brain bleed could have been cared for as an outpatient. All you did was watch the patient for 24 hours and start them on Dilantin."

 

[goodoldalky]

The link I provided in yesterday's original post is a NEW policy. It was distributed to my department YESTERDAY. Now they are not paying for any non-emergent visits. And now, the Medicaid patient will not be billed; the hospital/physicians will eat the cost.

Frankly, this policy, as well as decreasing medicare reimbursement, will come back to hurt the poor and impoverished.

What will happen is that the hospitals in urban areas, who see medicare and medicaid patients, will become far less profitable/sustainable. This policy will not decrease medicare and medicaid spending in a good way, because it will not decrease utilization by medicare/medicaid patients. Instead, it will decrease reimbursement coming out of the hospital/providers pocket as they eat that cost that medicaid is supposedly saving. MD's will exodus (so will hospitals in general) due to the new financial black hole. These hospitals in urban areas with a less affluent payor base will become largely midlevel staffed, if they stay open at all. Those that stay open will be dependent on subsidies and tax dollars to offset the black hole payor base. Most residency training programs will need some sort of subsidy to even stay afloat in these locations. Ridiculous reform ideas such as cutting CMS reimbursement for residency programs would further compound the problem, as residency programs provide most of the care for this increasingly expensive patient base.

Resources will shift even more heavily toward affluent areas where sustainability does not depend as heavily on medicare/medicaid, and MD's will essentially stay in these areas as affluent and wealthy patients will largely expect MD care and be able to afford it. It will become an advertising punchline, "Shiny New Hospital, Highland Park, see an MD, guaranteed!" You will have a two tier system: affluent, private hospitals in wealthy areas staffed by MD's, less dependent on medicare/medicaid, and dilapidated, county, medicare-medicaid hospitals, staffed by midlevels, where hospitals even still exist. Those that do will be ridiculously overcrowded and unable to shoulder the care for the massive urban patient base because of the exodus of other hospital systems and resources. The outpatient dichotomy will be even more obvious, with it being impossible to access even a primary care physician in the inner city with medicare/medicaid as similar cuts continue to affect healthcare providers in all fields.

The fact is that since we have EMTALA, and hospitals are required to take these medicare/medicaid patients, once policies such as medicare reimbursement and medicaid ED visit reimbursement limits take effect, hospitals will come to the breaking point where they either close doors or move to a location where they are able to minimize their dependence on medicare/aid. Ultimately, I think we will see a two-tier medical system, from the ED, to the clinic, to procedural and hospital-based practice. We will have the tax-funded subsidy dependent medicare/medicaid system with serious access problems (universal insurance plus or minus, but ultimately irrelevant), few MD's/DO's, reliant on midlevels, and lack of sustainability. Then we will have the private funded/concierge medicine located in areas where medicare/aid patients are most easily avoided which will tailor more easily to patient demand for MDs with their extra resources etc.. In the end, the poor will get poorer. But at least Washington State's medicaid will stay afloat.

 

[GeneralVeers]

Frankly, this policy, as well as decreasing medicare reimbursement, will come back to hurt the poor and impoverished.

What will happen is that the hospitals in urban areas, who see medicare and medicaid patients, will become far less profitable/sustainable. This policy will not decrease medicare and medicaid spending in a good way, because it will not decrease utilization by medicare/medicaid patients. Instead, it will decrease reimbursement coming out of the hospital/providers pocket as they eat that cost that medicaid is supposedly saving. MD's will exodus (so will hospitals in general) due to the new financial black hole. These hospitals in urban areas with a less affluent payor base will become largely midlevel staffed, if they stay open at all. Those that stay open will be dependent on subsidies and tax dollars to offset the black hole payor base. Most residency training programs will need some sort of subsidy to even stay afloat in these locations. Ridiculous reform ideas such as cutting CMS reimbursement for residency programs would further compound the problem, as residency programs provide most of the care for this increasingly expensive patient base.

Resources will shift even more heavily toward affluent areas where sustainability does not depend as heavily on medicare/medicaid, and MD's will essentially stay in these areas as affluent and wealthy patients will largely expect MD care and be able to afford it. It will become an advertising punchline, "Shiny New Hospital, Highland Park, see an MD, guaranteed!" You will have a two tier system: affluent, private hospitals in wealthy areas staffed by MD's, less dependent on medicare/medicaid, and dilapidated, county, medicare-medicaid hospitals, staffed by midlevels, where hospitals even still exist. Those that do will be ridiculously overcrowded and unable to shoulder the care for the massive urban patient base because of the exodus of other hospital systems and resources. The outpatient dichotomy will be even more obvious, with it being impossible to access even a primary care physician in the inner city with medicare/medicaid as similar cuts continue to affect healthcare providers in all fields.

The fact is that since we have EMTALA, and hospitals are required to take these medicare/medicaid patients, once policies such as medicare reimbursement and medicaid ED visit reimbursement limits take effect, hospitals will come to the breaking point where they either close doors or move to a location where they are able to minimize their dependence on medicare/aid. Ultimately, I think we will see a two-tier medical system, from the ED, to the clinic, to procedural and hospital-based practice. We will have the tax-funded subsidy dependent medicare/medicaid system with serious access problems (universal insurance plus or minus, but ultimately irrelevant), few MD's/DO's, reliant on midlevels, and lack of sustainability. Then we will have the private funded/concierge medicine located in areas where medicare/aid patients are most easily avoided which will tailor more easily to patient demand for MDs with their extra resources etc.. In the end, the poor will get poorer. But at least Washington State's medicaid will stay afloat.

You are correct, assuming that private health insurance stays legal. Under ObamaCare, the Secretary of HHS could easily regulate all non-government insurance into oblivion, essentially pushing everyone onto a form of Medicare/Medicaid. This has been the goal of Progressives all along - a single payer system that is government run. ObamaCare had nothing to do with "expanding coverage" or "reducing costs".

 

[la gringa]

goodoldalky -

what you describe is already what happens in areas w/ a public hospital - my experience was in Chicago. while i am grateful for the training i received, i wouldn't want anyone i cared about to have to come in as a non-connected patient to the County.

go to other areas of the country, and things are spread around more... though as you say, this may shift some. there are hospitals out there who attract enough paying patients to offset their % of MC (meaning care and caid), but if the balance shifted due to decr MC reimbursements, that will be a harder dance to do.

 

[docB]

Traditionally when hospitals are faced with a new restriction on payments from CMS they react by turning it into a physician issue. Core Measures, HCAHPs, DRG related bed days, etc. all get pushed back at us with a mandate to "do it right" so the hospital can get reimbursed. With this I would expect the hospitals to require EPs to look at old records before the patient is even fully registered into the ED. After recognizing the patients who have already expended their CMS visits the EPs would be strongly encouraged to limit care or defer care. Hospitals are also notorious for throwing the EPs under the bus with plaintiffs and regulators when these programs have bad outcomes.

 

[Birdstrike]

.

 

[deleted65604]

So, if I read this right, the state of Washington changed their previous stance:

1. There were three non-emergent ER visits allowed previously. Now no non-emergent visit will be reimbursed.

2. Non-emergent is defined as a diagnosis made with a retrospectoscope, so that abdominal pain without obvious cause (50% of cases) and chest-pain without obvious cause (about 70% of visits) will not be covered. Stroke-like symptoms that end up being anxiety, neuropathy, or complicated migraine will not be covered, and the list goes on.

3. There were previously exceptions to the rule such as MVA, patients that came by ambulance, patients with abnormal vitals, psych patients including depression, etc. Now there are no exceptions.

4. Washington medicaid will now refuse to pay for the patients who they've given medical coverage to. In order for this to be acceptable to the voting populace We are still prohibited by medicaid to balance-bill the patient. The federal government mandates we see a patient and the state prohibits us from getting paid for our time.

5. We are still open to getting sued if by chance we do miss a medical emergency. If the patient deteriorates to the point that they do have a medical emergency by not treating a tnon-emergent or urgent condition, we are on the hook.

Somebody point out how our freedom as American citizens is not being violated here?

"First they came for the Doctors, and I didn't care because I wasn't a doctor. Then they came for the nurses, but I didn't care because I wasn't a nurse. Then they came for the paramedics, but I didn't care because I wasn't a paramedic...." You get the picture.

Wake up people, this is a slippery slope.

 

[NinerNiner999]

No... unfortunately those two links are old news. I really like your energy, Birdstrike, but you're referring to a policy that went into effect in October. The new reality is much worse.

The three visit policy for Medicaid patients was proposed earlier this fall and went into effect on October 1st. We sued. The policy was put on hold.

The link I provided in yesterday's original post is a NEW policy. It was distributed to my department YESTERDAY. Now they are not paying for any non-emergent visits. And now, the Medicaid patient will not be billed; the hospital/physicians will eat the cost. There is nothing on ACEP or Washington ACEP's websites yet, to my knowledge. We have an MD/JD in my group who was involved with the original suit for the 3-visit non-emergent Medicaid, and he is looking into it, but obviously this is going to necessitate a lot of time, resources and support from Washington EPs as well as advocates across the country on our behalf.

Just curious - since this will effect both the physician and the hospital equally in regards to non-payment, has your group addressed assigning a hospital employee to be a designated medical screener to comply with EMTALA? Doing this might be a way to divert liability towards the hospital and away from the physician, if the hospital policy is constructed correctly.

Either way, there will be no way to predict the volume drop from such "screening exams" who never make it back to the main ED.

This is flat out wrong, and clearly a poor indicator for our future...

 

[GeneralVeers]

Just curious - since this will effect both the physician and the hospital equally in regards to non-payment, has your group addressed assigning a hospital employee to be a designated medical screener to comply with EMTALA? Doing this might be a way to divert liability towards the hospital and away from the physician, if the hospital policy is constructed correctly.

Either way, there will be no way to predict the volume drop from such "screening exams" who never make it back to the main ED.

This is flat out wrong, and clearly a poor indicator for our future...

Unfortunately this kind of thing is the only trick which politicians possess in order to reduce healthcare spending. Medicare and Medicaid are eating up an increasing portion of Federal budgets. Rather than cut people off, or require more financial participation, they keep increasing the amount of people covered while simultaneously squeezing physicians and hospitals. It's politically expedient, messy, and will ultimately force the system to collapse, which is what I suspect they want the long-run.

Can anyone explain to me a practical, non-political reason why Medicaid was extended for children of families making up to $105,000?

 

[EM2BE]

Unfortunately this kind of thing is the only trick which politicians possess in order to reduce healthcare spending. Medicare and Medicaid are eating up an increasing portion of Federal budgets. Rather than cut people off, or require more financial participation, they keep increasing the amount of people covered while simultaneously squeezing physicians and hospitals. It's politically expedient, messy, and will ultimately force the system to collapse, which is what I suspect they want the long-run.

Can anyone explain to me a practical, non-political reason why Medicaid was extended for children of families making up to $105,000?

Wow! Missed that memo. I thought it was much lower than that. That part should be adjusted. Maybe adjust for income with adjustment for number of children for income (I'm sure an equation exists for taxes already). I would think with that amount of income, you can afford health insurance. I was able to afford paying for it while in med school with no income (and minimal loan allowances limited by the school). Unbelievable. Just unbelievable. This is just making me more irate, and wouldn't even know exactly where to begin to fix the problems.

 

[GeneralVeers]

Wow! Missed that memo. I thought it was much lower than that. That part should be adjusted. Maybe adjust for income with adjustment for number of children for income (I'm sure an equation exists for taxes already). I would think with that amount of income, you can afford health insurance. I was able to afford paying for it while in med school with no income (and minimal loan allowances limited by the school). Unbelievable. Just unbelievable. This is just making me more irate, and wouldn't even know exactly where to begin to fix the problems.

It's the SCHIP program and many states do not have an upper limit at all, while a few of them have variable limits:

http://blog.cleveland.com/wideopen/2007/10/schip_income_eligibility_100k.html

In 2009 Obama eliminated Federal income requirements for SCHIP stating that differences in cost of living between states made income caps unenforceable:

http://www.health-insurance-carriers.com/blog/obama-child-health-insurance-schip/

 

[la gringa]

at least the expansion in SCHIP is supposedly funded by taxes on tobacco.... a better relationship between where the money comes from and where it goes than most taxes...

 

[GeneralVeers]

at least the expansion in SCHIP is supposedly funded by taxes on tobacco.... a better relationship between where the money comes from and where it goes than most taxes...

You've got to be kidding. All the tax revenue goes into the "general fund" which gets paid out for everything. There is no special account to pay for this.

It has done serious damage to the field of pediatrics as pediatricians have seen their reimbursement plummet as more and more patients drop private insurance and opt for SCHIP.

 

[la gringa]

the article you posted said:
"Critics of Obama's plans to expand SCHIP are mindful of the fact that funds for the scheme are coming from the tobacco industry in the form of a new consumer tax"

that's all i know. i know several people who COULD drop private insurance and be on SCHIP, but they NEVER would b/c they couldn't go to their dr, or have their choice of specialists... i suspect those using the expanded range are people who wouldn't buy regular insurance even if available. when i was in residency, we had kids in the trauma unit ALL THE TIME who qualified for medicaid and/or the state program, but their parents just couldn't be bothered w/ filling out the paperwork. pathetic.

in that same city (Chicago), the care for children on Medicaid was absolutely horrendous. children w/ severe persistent asthma had these nonexistent pediatricians who worked tuesday from 10-1 and thurs from 2-4 and crap like that. those kids LIVED in the ED, their parents had no clue how to manage their kid's asthma.... U of C's hospital had a limited # of beds for non-private insurance kids, so they stayed in the ED for inordinate amounts of time. followup for any subspecialty was at County, not there, even if the parents had to take 3 buses to get there.

care for the poor in our nation in general is so piss-poor that we are inordinately burdened. imho THAT is the BIGGEST problem... local govt's want to cut spending for mental health, and home services, and shift that burden onto us. i have a friend who worked for $12/hr making sure mentally ill pts in NC got their meds, got to their appts, had groceries, etc. he was laid off last yr due to budget cuts. what do you think happens to those pts??? they don't go get their depot haldol or their clozapine rx, and we all know where they end up.

ugh, i could go on all day....

 

[deleted65604]

the article you posted said:
"Critics of Obama's plans to expand SCHIP are mindful of the fact that funds for the scheme are coming from the tobacco industry in the form of a new consumer tax"

that's all i know. i know several people who COULD drop private insurance and be on SCHIP, but they NEVER would b/c they couldn't go to their dr, or have their choice of specialists... i suspect those using the expanded range are people who wouldn't buy regular insurance even if available. when i was in residency, we had kids in the trauma unit ALL THE TIME who qualified for medicaid and/or the state program, but their parents just couldn't be bothered w/ filling out the paperwork. pathetic.

in that same city (Chicago), the care for children on Medicaid was absolutely horrendous. children w/ severe persistent asthma had these nonexistent pediatricians who worked tuesday from 10-1 and thurs from 2-4 and crap like that. those kids LIVED in the ED, their parents had no clue how to manage their kid's asthma.... U of C's hospital had a limited # of beds for non-private insurance kids, so they stayed in the ED for inordinate amounts of time. followup for any subspecialty was at County, not there, even if the parents had to take 3 buses to get there.

care for the poor in our nation in general is so @#!*% -poor that we are inordinately burdened. imho THAT is the BIGGEST problem... local govt's want to cut spending for mental health, and home services, and shift that burden onto us. i have a friend who worked for $12/hr making sure mentally ill pts in NC got their meds, got to their appts, had groceries, etc. he was laid off last yr due to budget cuts. what do you think happens to those pts??? they don't go get their depot haldol or their clozapine rx, and we all know where they end up.

ugh, i could go on all day....

So what is your solution?

 

[Birdstrike]

.

 

[Apollyon]

Dude, Birdstrike, I don't know how many of your posts I want to print out and send to Congress (although my Member of Congress is just as good as any of them, so so much for that). Seriously.

 

[EM2BE]

This constantly came up in 2008 around election time, and then again when Obamascare was being debated in Congress. The thought by many of my ER colleagues that were in favor of Obama and his proposed plan was that if the government provided insurance for the uninsured "poor" in our country that currently have no insurance, that that would be a simple net gain for Emergency departments who had been unfairly burdened with taking care of the uninsured, all along. On the surface, it makes sense, with all other things being equal.

I and many others were very, very skeptical that the government would simply just give ERs more money for doing what what we were already doing. I simply put it in the category of "too good to be true". It's really a non-brainer. My feeling was and still is that there would be a big price to pay that would come in many forms:

1. Cutting payments from other sources (happening; see SGR, Medicare cuts, toxic/punitive Washington State Medicaid cuts)
2. Raising income taxes on the providers of care, NOT those receiving the benefits (proposed by Obama, blocked by Congress, certain to happen eventually)
3. Rationing care (has to happen; too many new insured, no increase in resources).

The feeling about Medicaid was always along the lines of, "Oh well, if we can collect 25 cents of the dollar it's better than nothing". On patients with no insurance you can bill them and maybe collect 25 cents on the dollar and get something for the care you provided.

What Washington state Medicaid has done is essentially completely take away these peoples insurance (for "urgent" care matters) and essentially rendered them uncovered and uninsured, but because they still retain the label of "insured" makes it illegal from you to bill them for the balance. They've rendered them worse than uninsured.

We always knew Medicaid was much worse than private insurance, but they've successfully done what even I thought was impossible:

They've made Medicaid worse than no insurance.


Truly amazing.



I really think this is only the beginning. I believe that governments will become increasingly more toxic to providers to a level that is unfathomable. It will not reverse itself until doctors have snapped to the point that a crisis occurs. I personally witnessed people dying of head bleeds because neurosurgeons said, "F--- it, I've had enough". Did it make sense that governments let the malpractice situation get so toxic to doctors that entire specialties left entire states?

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No.






But they did it anyways.

My point? Just like to neurosurgeons and OBs decided that enough was enough, and got the ball rolling with tort reforms in many states, it will take a crisis to reverse course on the toxic treatment of physicians in relation to abusive policies such as:

-Arbitrary cuts in payment to all physician specialties

-Crushing lower paid primary care specialties with increased overhead (Electronic Medical records and "meaningful use") who are overburdened with irrational medical school tuition debt and shrinking payments.

-Satisfaction surveys that were designed for a fast-food restaurant concept as opposed to a medical environment where the "best practice" isn't always the most "satisfying" to people without a medical background.

-EMTALA (forced service without required payment)

-Predatory liability environment (where frivolous suits take years and hundred of thousands of hours and hours and hours spent doing depositions and testifying to beat, with no disincentive to file)

-Joint Commission (irrational mandates such as blood cultures on all pneumonia, requirements to lock up antibiotic ointment in Med cart)

-Stark laws (that prevent doctors from owning hospitals, which results in people running and owning hospitals who have less medical experience than doctors, nurses, PAs, medical assistants, paramedics or even hospital volunteers)

-Physician anti-trust laws (which deprive us of something that all other Americans consider a "right", the ability to form unions, bargain collectively or strike as a means to protect ourselves from the listed toxic, dangerous and overly burdensome regulations )

-Uncompensated "medical screening exams" which expose doctors to toxic liability, and hurts patients by encourages doctors to quickly screen out non-emergent patients (who invariably in some cases will have underlying severe illness) to save money primarily, for the hospital or in the case of Washington and other states, government insurance programs.

-Focusing on 15 minutes "door to greet" times for non-emergency care as a quality measure as opposed to encouraging high quality care within peer defined standards of care and quality measures.


If anyone else has a solution of how to resolve the above problems without letting it get to the breaking point of a mass physician strike, or mass exodus from certain states, specialties or the profession as a whole, please post it here. I have no desire to rant on SDN for the sake of ranting. I don't think the Government of the AMA are going to offer any help for any of these issues. I think we're going to have to figure out how to fix things on our own. Lets brainstorm here.

Wow this breaks down the reality of what everything has become. Very well written. I wonder how many politicians have to deal with these kinds of standards (even just one of them you listed). Sadly, I think it will take massive failure at this point to achieve a better solution. I am one that believes you should work for what you earn, not expect everything to be handed to you. Many people shouldn't survive like they have, and wouldn't be alive with the exception of the skills we use to save them from the brink of death (and many people on multiple occasions).

Maybe we could start rationing with stupidity. If you get shot / stabbed more than once while SOCMOBing, no care will be given. Actually, maybe GSW/stab wound could be added to Washington's medicaid plans as a non-emergent visit. Might as well for all the other conditions they excluded.

In all seriousness though, excellent post. And I should be drinking...although feeling drunk after call anyway. Ready for permanent shift work!

 

[xaelia]

Just a question - is it still disallowed "balance billing" if you bill someone for whom no reimbursement has been given? Obviously, you won't necessarily be able to collect much from (and might feel badly about billing) a Medicaid patient - but if their "insurance" declines to pay anything, is it still "balance billing"?