Press Ganey, meet Wong-Baker

For those not actively engaged in the practice of medicine, this will mean nothing to you. For those of us in the trenches:

IMG_0847

I cannot wait for the day the government realizes this misguided effort is costing them Billions (and harming patients and providers).

 

IRS: Cheapest Obamacare Plan Will Be $20,000 Per Family | CNS News

“Affordable” Care act.

Under Obamacare, Americans will be required to buy health insurance or pay a penalty to the IRS.

The IRS’s assumption that the cheapest plan for a family will cost $20,000 per year is found in examples the IRS gives to help people understand how to calculate the penalty they will need to pay the government if they do not buy a mandated health plan.

The examples point to families of four and families of five, both of which the IRS expects in its assumptions to pay a minimum of $20,000 per year for a bronze plan.

“The annual national average bronze plan premium for a family of 5 (2 adults, 3 children) is $20,000,” the regulation says.

via IRS: Cheapest Obamacare Plan Will Be $20,000 Per Family | CNS News.

Unbelievable. Enjoy the Sticker Shock.

Feds get specific on ACA individual mandate rules  : ACEP NEWS

After years of legal wrangling and a showdown in front of the Supreme Court, the federal government has finally begun to implement the Affordable Care Act’s controversial individual insurance mandate.

Starting on Jan. 1, 2014, Americans will have a choice: Buy basic health insurance, qualify for an exemption, or pay a penalty when filing federal income taxes, according to proposed regulations issued Jan. 30 by the Treasury Department and the Health and Human Services Department.

via Feds get specific on ACA individual mandate rules  : ACEP NEWS.

Go and read all the exclusions. For an incredibly intrusive and expensive mandate there sure are a lot of people that still won’t have to be covered.

Health Insurance Brokers Prepare Clients For Obamacare Sticker Shock – Forbes

(emphasis added):

By Dr. Scott Gottlieb, M.D.

A California insurance broker, who sells health plans to individuals and small businesses, told me that she’s prepping her clients for a sticker shock. Her local carriers are hinting to her that premiums may triple this fall, when the plans unveil how they’ll billet the full brunt of Obamacare’s new regulations and mandates.

via Health Insurance Brokers Prepare Clients For Obamacare Sticker Shock – Forbes.

You. Don’t. Say.  Thanks, Obamacare!

Don’t open wide: Annual check-ups are pretty much useless

I suspect this underestimates the problem. I think a lot of ‘chasing incidentalomas’ in medicine start here:

Two doctors in Colorado scanned through 14 randomized, controlled studies involving 182,000 patients. The articles spanned from 1963 to 1999. The doctors looked at whether those who had regular check-ups had higher mortality rates than their counterparts who dodged such visits. They could not find a difference.“General health checks do not improve important outcomes and are unlikely to ever do so based on the pooled results of this meta-analysis spanning decades of experience,” write authors Allan Prochazka and Tanner Caverly. ”There remains a belief in the value of general health checks despite the accumulating evidence. This belief is buoyed by screening advocacy groups and insurance coverage, and they have ramifications for patient welfare and health care costs.”

via Don’t open wide: Annual check-ups are pretty much useless.

They point out that Canada actually stopped paying for ‘routine checkups’ in 1979.

(Please understand I’m not including chronic condition maintenance in this category, like CHF or diabetes visits, as once you’ve got a chronic condition that’s where office visits probably really do help).

26 States Decline ObamaCare Exchange; ‘Administrative Nightmare’ Seen – Investors.com

So, this is an inauspicious beginning…

The federal government will likely be involved in running the ObamaCare exchange in at least 30 states, 26 of which expressly declined to establish state exchanges. One health-policy expert refers to it as an “administrative nightmare” for the Department of Health and Human Services.

Friday was the deadline for a state to let HHS know if it planned to establish a state exchange. Thus far only 18 states and the District of Columbia are planning on doing so.

Enrolling them will likely prove a daunting challenge for the federal government.

“HHS expected to be running zero exchanges,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute. “They have been throwing money at states to bribe them to start exchanges. HHS maintains they’ll have these things up and running by October 2013. I don’t know anyone who is confident about that and I’m ready to predict that they will not.”

via 26 States Decline ObamaCare Exchange; ‘Administrative Nightmare’ Seen – Investors.com.

Why aren’t the States playing? They aren’t interested in being a conduit for plans they don’t run, the state gets all the blame for decisions they don’t make. (That, plus general opposition to the whole idea: it’s your plan, you run it…).

All this, by the way, projected to insure 25 million Americans through this plan in the next seven years. None of this controls costs, or spending.

CBS News: (some) ER Docs pressured to admit at a for-profit chain

For the record, nobody’s ever told me I need to admit more (or less).

Hospitals: The cost of admission

December 2, 2012 4:42 PM

Steve Kroft investigates allegations from doctors that the hospital chain they worked for pressured them to admit patients regardless of their medical needs.

 

First thoughts: this HMA company’s about to get an ugly look-at by the feds. I feel bad for the docs (and the admins) that blew the whistle.

Wonder if any of them filed a Qui tam action?

A physician takes his flu vaccine under protest

Good, well written rant-

A physician takes his flu vaccine under protest

by Doug McGuff, MD on November 27th, 2012in Physician

To hospital administration,

I am writing this letter to inform you that when I take my mandated influenza vaccine I will be doing so under protest and with the understanding that failure to do so could result in loss of my ability to earn income for myself and my family. Unfortunately, I do not qualify for any of the exemptions allowed by our facility. Since I am not religious, I have no religious objections, I am not allergic, and I have never had Guillane-Barre as a result of a flu vaccine. My objection to the vaccine is based on rational evidence and moral indignation.

via A physician takes his flu vaccine under protest.

UT-Austin Med School, and why they’re just getting one now

UT Austin is finally going to get a teaching hospital (built by Seton):

The medical school facility, which will include academic and medical research space, will be financed by UT-Austin.According to the university administration’s internal estimates, the cost of the entire endeavor is approximately $4.1 billion over 12 years. Central Health will cover about 10 percent, and Seton is expected to cover nearly half, including the clinical faculty and residency slots for graduate medical education.The rest will largely come from UT-Austin.

Good, I suppose. We’re going to be short doctors soon anyway, and more training slots are welcome. (Insert dichotomy between what society needs and what they’re willing to pay for and its distortion of the residency training market).

And now, Story Time with GruntDoc:

“I think people will look back and say, ‘How did this community work without having a major medical center here?’” Powers said.

via UT-Austin Med School Plans Proceed After Election — Higher education | The Texas Tribune.

A good question, now let me tell you they ‘why’ as it has been told to me*.

In the early ’70s, the Texas Legislature set aside the authorization and funding for a new medical school in Texas. All understood it would be a UT Austin school, right there in the backyard of the Texas Capitol.

For those unaware, the Texas Legislature is in session for 90 days every two years, and the last minute flurry of bill passage and amending is said to be quite remarkable. And, this is how a powerful legislator stuck a rider onto a somewhat unrelated bill that said ‘all the money from that other bill is for Lubbock’, and it was passed.

The UT Austin medical school was hijacked, and landed squarely in Lubbock. Reportedly powerful people were ticked but couldn’t do much about it, and Lubbock has supported the Med School well (I myself attended several generations past). Shenanigans in legislatures? Who’d have though.

Now, Austin will get a Medical School. Better late than never. Congrats!

 

*This was told to me as a tale when I was quite young, so I suspect the details aren’t spot-on, but it makes sense given how the Texas Lege works and how little Texas Tech would have been expected to get a Medical School over UT in the early ’70s. Let’s not use this for a Wikipedia entry, okay?

Oklahoma Doctors vs. Obamacare – YouTube

The title is theirs, and it’s unnecessarily inflammatory, really it should be “Price Transparency in Medicine vs the Traditional Model”.

Three years ago, Dr. Keith Smith, co-founder and managing partner of the Surgery Center of Oklahoma, took an initiative that would only be considered radical in the health care industry: He posted online a list of prices for 112 common surgical procedures.

via Oklahoma Doctors vs. Obamacare – YouTube.

More of this, please, much more.

ACEP 12 tweeting: Bukata and Hoffman

Those who don’t follow me on Twitter probably have calm, productive lives. Those who do wonder why I twitter at all. Because it keeps me busy and engaged, that’s why.

Here’s an edited compilation of two of the American College of Emergency Physicians Scientific Assembly 2012 lectures in tweets by me from Denver. These encompass about 3.5 hours of lecture by the same two legends, Jerry Hoffman and Rick Bukata reviewing the medical literature as it applies to EM.

I used Storify to put these together (it couldn’t have been easier). I left out a lot of comments from others, not as they weren’t interesting but as I’m trying to tell the story of this lecture.

At the end there’re some pictures of the Twitterers and Bloggers who get together after ACEP. Nice how we’re birds of a feather. For a bonus, at the end are Joe Lex’s 4 Rules of Emergency Medicine, which deserves its own compilation.

ACEP 2012 Tweets by me: Hoffman & Bukata

I went to the American College of Emergency Physicians Scientific Assembly held in Denver in October, 2012. I live tweeted some of the lectures I attended. Here they are.First, I’m going to combine the tweets from Hoffman and Bukata’s 2 lectures, as they’ll make more sense that way. Then pictures!

Storified by GruntDoc · Sat, Oct 13 2012 12:55:37

I’m going to start with my general Twitter disclaimer. I mean it.
Disclaimer: my tweets from #ACEP12 were paraphrasing, errors mine, don’t change practice based on reading tweets, do your homework.GruntDoc
And, off to the lectures:
HofKata: Trauma surgery is dooming their specialty going to the ER over and over for nothing surgical for them. #ACEP12GruntDoc
Referencing a European paper citing very very few went to the OR emergently from the ER to the OR, recommended calling TSS when the ER doc needs them, not a routine event.
(Will not catch on for a long time, Trauma needs their Activation Fee).
This following one had to do with ?whatever to do with those very tiny occult pneumothoraces we’re finding on trauma CT’s of the chest. Long, meandering discussion; sizes of the PTX weren’t defined, no criteria for getting a thoracostomy tube were made, just ‘did they get a chest tube or not’.
HofKata: discussion muddied as there is not a clear definition for want made the doc put in the tube to start with. #ACEP12GruntDoc
Not much was gotten from that article. Perhaps I missed the point.
HofKata: docs caught between doing what’s right for pt and right for doc; for doc getting test is right answer, not always for pt. #ACEP12GruntDoc
This next one tried to determine, in a ‘pan-scan’ for trauma ED, if there were some agreement on what trauma scans the ED attending and the Trauma Surgery attending could prospectively agree they didn’t need.

All the scans trauma wanted were gotten with a prospective form filled out by both about which scans they didn’t want. In the end the ED…

HofKata: wanted 30% fewer, and the TSS and EM in the end couldn’t decide about the value of the discovered incidentalomas. #ACEP12GruntDoc
They found a bunch of incidental things, and in the end couldn’t reconcile whether finding completely incidental things that didn’t affect management was worth the CT.
HofKata: factor VIIa is 10k for a 70kg pt in trauma and it didn’t help ( the non hemophiliac). Stop it. 97% uf use was off label. #ACEP12GruntDoc
HofKata: if you have 1 CT the likelihood is that you’ll have 5 in the next 5 years. Found a pt w 57 CTs. Wow. #ACEP12GruntDoc
The first CT is a gateway study to more, apparently.
HofKata: but when docs look at the same problem for themselves they typically choose less awful treatment, even if means pal care#ACEP12GruntDoc
Doctors will err on the side of survival in recommendations to patients, when they themselves often look at the data and decide they’d rather forgo some or all treatments and skip the unpleasant effects. Interesting.
HofKata: DC instructions. Pts have to understand, and they have to know when to come back. Ethical prob sending self limited prob #ACEP12GruntDoc
HofKata: to a referral, when its more cost for no benefit. #ACEP12GruntDoc
Bukata felt sending things like ankle sprains to PCP’s as a routine thing was ethically bad, as ‘it’s self limiting’ and costs the pt more for no benefit.
I disagree, many needs some Physical Therapy to have a more stable ankle that doesn’t recurrently sprain.

Also not a fan of these 9 page DC instructions we’re printing out.

HofKata: IO lines are great, and stop doing central lines because you can’t find a vein, use CL if need to measure things #ACEP12GruntDoc
HofKata: no need to give hydrocortisone if you use etomidate for induction. (Silly study). #ACEP12GruntDoc
HofKata: Tylenol w Motrin, and either alone. Point of treating fever comfort, not medical. No support to use both at the same time #ACEP12GruntDoc
HofKata: AAP specifically advises against using Tylenol then Motrin and alternating, confusing. Also, tells mom it’s a big deal. #ACEP12GruntDoc
treating pedi fever is about patient comfort, not treating disease. making a big deal out of fever treatment tells mom it’s very important, when it’s for comfort only.
HofKata: UTIs in small kids: can have asymptotic bacteruria and have a viral illnesses w fever and get dxd w uti. Cults have false+ #ACEP12GruntDoc
HofKata: 2-5% of kids have UTIs before puberty. Not happy about treating a ton. #ACEP12GruntDoc
Many of which were incidental findings, and the treatments can cause their own problems.
HofKata: study of 1,228 acute scrotii showed +creamasteric reflex w dxd torsion! 7% had NL or increased flow on US!? #ACEP12GruntDoc
Several people disliked my plural of scrotums being scrotii. I believe scrotae is the correct plural.
HofKata: test torsion, cont: advocates getting a iron consult for those w real sx’s and a negative w/u. Then cites anecdote. #ACEP12GruntDoc
uro(logy) got autocorrected here to iron, No idea why.
HofKata: study of Canadian hosp quick response teams. No difference. Things that seem reasonable often don’t work. #ACEP12GruntDoc
HofKata: several papers, PCR tests didn’t change abx rxing, CRP in URI resulted in 6 hour ED stays and no change in abx Rx, etc #ACEP12GruntDoc
Things being tried to tailor or eliminate antibiotic prescribing don’t. At least not in these studies.
HofKata: docs are reluctant to abandon disproven practices "ESP when lucrative". Most standards of care have never been studied. #ACEP12GruntDoc
HofKata: BNP for dyspnea in the ED. "Routine testing is of no benefit". Targeted okay. #ACEP12GruntDoc
HofKata: high sens Troponins: markedly higher positives, but 90% were causes other than AMI. (I don’t know want this). #ACEP12GruntDoc
Joe Lex ( @JoeLex5 ) commented on this later, ‘you mean low specificity troponins?”, rather than the as-spun high sensitivity. He’s right.
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
HofKata: stable angina, med mgmt vs stenting: medical therapy on top for everything x persistent pain. #aGruntDoc
HofKata: the US spends 150mil A DAY on angiosperm and stents, most never had a trial of med therapy. #ACEP12GruntDoc
Okay. for some reason the iPad autocorrect thought Angio meant angiosperm, which is weird. I don’t type well, things are flying by, and so I didn’t proofread that one before I hit send. (there were several comments later which I didn’t get, so didn’t play along)(It was busy in there, with all the tweeting and misspelling).
HofKata: shocker: STEMI pts needing transfer for PCI didn’t get transferred within 30 minutes. Median time was 64 minutes. #ACEP12GruntDoc
Bukata said they fixed this at his joint by having the same EMS crew that brought them in take them out, which was very fast, and with the right conversation EMS was all over it.
HofKata: if you can get to the cath lab in less than 4 hours its better than TPa. The 60 min rule for TPa is based on no evidence. #ACEP12GruntDoc
HofKata: then says he’d rather have TPa than stenting. (Weird). #ACEP12GruntDoc
The weird was mine. I don’t get that.
HofKata: 124k STEMI pts w CABG capability did cath then CABG 3%, without very rare. CABG grps did worse. #ACEP12GruntDoc
Wow, confusing tweet.
Issue was, is it safe to do caths in places that cannot do ‘rescue CABG”? In a study of 124K pt’s in centers with and without ‘rescue CABG’ ability, answer was yes, and in places that could do CABG it was done a whole lot more than places where it wasn’t; occasional pt had to be transferred to CABG place, but not many.
HofKata: ABCD2 score for stroke after TIA isn’t reliable. Another data dredging tool fails in real life. #ACEP12GruntDoc
HofKata: redefinition of Tia w MRI findings of infarct to stroke makes both groups look better: makes studies over time hard #ACEP12GruntDoc
Way more ‘strokes’ are now very minimal (what we used to call TIA’s) so the ‘stroke category looks better, and the TIA category looks smaller. Will confound studies looking both directions.
This next one it a review of IST-3, the never-ceasing desire to give TPa to every stroke no matter the time elapsed.
HofKata: IST-3 showed in a no blinded study using untrained family members as evaluators showed a tiny trend to improvement. #ACEP12GruntDoc
HofKata: IST-3 the first 300 pts evaluated by neurologists showed the tpa out to 6 hrs is much worse. #ACEP12 scathing editorials yesterdayGruntDoc
Family members, who knew whether or not their loved one got the TPa were asked by postal mail to evaluate their loved ones’ recovery, trended better for those who got TPa. Bizarre study bias built it. To say they were unimpressed would be an understatement.
HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12GruntDoc
“@gruntdoc: HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12” surprise surpriseJennie
HofKata: Geriatric and dizzy with a normal neuro exam will not have ICH. Based on a paper from 1998 w 4 pts found to have cblr bld. #ACEP12GruntDoc
There’s a practice that’ll be hard to change.
HofKata: no decent studies on ischemic stroke leaving BP up or the older lowering. Unless going to give TPa. #ACEP12GruntDoc
HofKata: kids w brain rumors typically represent w recurrent headaches, etc. authors rec scanning in kids w recurrent ha. #ACEP12GruntDoc
Means, don’t scan a kid on first HA or first week of HA.
HofKata:Canadian SAH CT study w 3rd gen scanner didn’t LP 50% of the pts in study. Gold std was pos CT. 30% lost to f/u. LP for SAH #ACEP12GruntDoc
HofKata: says Dr Newman who presented this paper yesterday as not needing LP is incorrect. #ACEP12GruntDoc
This could be ACEP’s first Pay Per View smackdown, Hoffman vs. Newman on this Canadian CT for SAH study.
HofKata: accumulating evidence quinolones can cause neuro sx’s. still safe drug as denominator is vast, but be aware. #ACEP12GruntDoc
HofKata: giving reglan over 15 vs 2 mins decreased the akathasia. 7% vs 26%. #ACEP12GruntDoc
Turkish study, makes sense.
HofKata: CO poisoning. Hyperbaric didn’t help, showed no benefit over high flow o2. Small study. #ACEP12GruntDoc
HofKata: studied on neurosurgeon, 1/2 sit vs stand on first postop visit. Again, pts like the seated visit. #ACEP12GruntDoc
Shocker here was that this was timed, it was these NS pt’s first post-surgical visit, and they lasted about a minute and 10 seconds. Wow.
HofKata: 8% of German studies eligibility criteria weren’t included in the paper,13 published modified info. Can’t extrapolate1/2 .#ACEP12GruntDoc
HofKata: 2/2 those findings to groups that were excluded. Theme is that funded studies seem to play fast and loose w reporting. #ACEP12GruntDoc
Throws a lot of what’s published into doubt, and when they don’t report excluded groups we assume their results are applicable for the general population, which isn’t correct.
What about the deep dive into the study information that’s given to the FDA from drug companies, that’s easily digestible, right?
HofKata: Cochrane authors report that it would take 2 FTEs 14 months to analyze, and found things never addressed in the papers. #ACEP12GruntDoc
The papers mean the studies that get publishe in journals. Not getting the whole story.
HofKata: Cochrane cont: the US FDA wouldn’t give the data, had to get from AUS. puts a lot of the publications in doubt. #ACEP12GruntDoc
Interesting.
This was about the new ‘high sensitivity’ troponins that are about to come out, for what reasons none of us in EM can discern, as it absolutely isn’t helpful…
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
Thanks, but I just tweet it. The glory goes to the lecturers, some were phenomenal. “@fayazg99: @gruntdoc fantastic stuff!” #ACEP12GruntDoc
Great coverage! RT @gruntdoc: That ends the lectures for me for today. Hope you enjoyed my coverage.Doc Gurley
@docgurley Awww, shucks ma’am. *tips hat*.GruntDoc
Meeting the social media twitter and blog greats at #ACEP12 @emcrit @gruntdoc @drrwinters @movinmeat @EMDocBrett http://pic.twitter.com/D6dLKId3Alexei Wagner
@JoeLex5 s 3 rules of emergency medicine:1) the nurse can hurt you way more than you can hurt themGruntDoc
@JoeLex5 s 3 rules of emergency medicine:2) you will never waken someone with narcan that you will like more awake than asleepGruntDoc
@JoeLex5 s 3 rules of emergency medicine:3) the LP target is always 1cm deeper than you think.GruntDoc
@JoeLex5 s 3 rules of emergency medicine:4) bonus: if you really don’t want someone to elope, hide their shoes.GruntDoc
“@gruntdoc: All the twitterers from #ACEP12 in one place. The rest of you are safe. For now. http://pic.twitter.com/j8i2uwb0” Wish I was there….realEDdoc

Movin’ Meat: Are low acuity patients congesting the ER?

Big big Kudos to MovinMeat for bringing data to an argument that seemed doomed to opinion-lock.


I have pointed out in the past that my BS-meter starts pinging when people start claiming that the ER is only caring for emergent patients and that non-emergency cases are rare. So this set me off, of course. My perception — and that of many of us in the trenches — is that we are absolutely beset by non-emergencies and that the ER is viewed by many as the "convenience clinic," if not the "vicodin clinic." But is this true? How can we quantify this?

via Movin' Meat: Are low acuity patients congesting the ER?.

It’s a terrific post. It’s worth your time.

Health Officials: No Need To Call 911 For Mosquito Bites « CBS Dallas / Fort Worth

Unbelievable.

FORT WORTH CBSDFW.COM – With hundreds of human cases of the West Nile Virus being reported across Texas and more than a dozen related deaths in North Texas it seems some people are overreacting and calling 911 when they’re bitten by a mosquito.In short, health officials say a mosquito is not a health emergency.“We understand peoples concerns regarding the West Nile Virus, but in the absence of any symptoms of West Nile then a simple mosquito bite is really not a reason for someone to call 911,” said Matt Zavadsky, public affairs director for MedStar Emergency Medical Services.One woman called Fort Worth 911 requesting assistance because her young nephew had a bump on his arm.

via Health Officials: No Need To Call 911 For Mosquito Bites « CBS Dallas / Fort Worth.

We’re seeing some of this in the ED, people with bug bites coming straight in ‘to get checked out’.

Sad.

More ABA Silliness – ProfessorBainbridge.com

Where have we experienced this before?

Christine Hurt reports on an American Bar Association effort to promote breed neutral vicious dog laws.

My question: WTF? Why is this the business of the ABA?

via More ABA Silliness – ProfessorBainbridge.com.

Oh, yeah. The AMA. Same political, and therefore membership trajectory.

Colorado Mass Shooting Tested an E.R. Staff – NYTimes.com

Wow. Amazing.

AURORA, Colo. — More than three weeks have passed, but Daryl Johnson still begins his emergency room shift at the University of Colorado Hospital here with a sense of foreboding.

via Colorado Mass Shooting Tested an E.R. Staff – NYTimes.com.

And horribly frightening. I pray I spend my entire career and not have a night like that.