ER doctors' fees targeted by governor

From the Sacramento Bee

Gov. Arnold Schwarzenegger on Tuesday acted to stop emergency-room doctors from charging patients for costs not covered by managed-care insurance plans.

In an executive order, the governor ordered the state agency that oversees managed health care to issue regulations barring the practice. He also directed the Department of Managed Health Care to set up a system for mediating payment disputes between insurers and doctors and determine fair prices for health services.

State officials said it was unclear whether the department would try to enact emergency regulations immediately or go through the normal regulatory process, which requires hearings and a public comment period.
"Gov. Schwarzenegger is firmly taking a position that no patient should be caught in the middle of a dispute between a doctor and an insurer," Cindy Ehnes, director of the DMHC, said Tuesday.

The practice, known as "balance billing," usually occurs when a patient enrolled in a managed-health care plan gets emergency care at a hospital that is not part of the health insurer's network. If the insurer pays less than the health-care provider is willing to accept, the provider charges the patient.

Emerging Med-Mal Strategy: 'I'm Sorry'

From Law.com

Doctors' apologies for medical mistakes may not be a cure-all for litigation, but explaining unforeseen outcomes and making early settlement offers have proven effective, say lawyers who have participated in the process in the last decade.

The concept is called "full disclosure/early offer," and it's spreading.

The U.S. Department of Veterans Affairs' Veterans Health Administration -- as well as a number of hospital systems and insurers across the nation -- are among the entities that have adopted variations of the policy.

Two states -- Illinois and Vermont -- have recently passed legislation providing for pilot programs to test the efficacy of full disclosure/early offer policies. Tennessee, Texas and New Jersey may soon follow.

The concept also is being promoted as a solution to the national debate over medical liability between tort reformers who would create an administrative system of "health courts" and the plaintiffs' bar and its supporters.

U.S. senators Hillary Rodham Clinton, D-N.Y., and Barack Obama, D-Ill., are currently sponsoring the National Medical Error Disclosure and Compensation (MEDiC) bill, a national version of the full disclosure/early offer policy.

Plaintiffs attorneys and defense attorneys agree that the program -- often referred to as Sorry Works! from The Sorry Works! Coalition, a Glen Carbon, Ill., advocacy group -- is a sound strategy miscast in the public perception as a touchy-feely ritual.

Site Encourages Blacklist of Med-Mal Plaintiffs

From the Daily Business Review

In the latest effort to enable doctors to shun patients who sue, an offshore company has launched an Internet site that lists the names of plaintiffs who have filed medical malpractice cases in Florida and their attorneys.

The site, LitiPages.com, encourages doctors to consider avoiding patients who are listed in the database, and it strongly encourages plaintiffs who have lost their cases at trial to turn around and sue their plaintiffs attorney.

"If your attorney proceeded with a lawsuit without warning you of the risks involved, you may be the victim of Legal Malpractice and may be entitled to compensation," the site states.

The new Web site is likely to trigger a fresh round of acrimony between doctors and plaintiffs lawyers in their long-running war over medical malpractice litigation. Plaintiffs lawyers and medical ethics experts say the LitiPages.com site is unethical.

Andrew Yaffa, a plaintiffs attorney at Grossman Roth Olin Meadow Cohen Yaffa Pennekamp & Cohen in Boca Raton, Fla., called the site "disgusting." Yaffa said "it's a devious attempt to intimidate people from pursuing their rights."

The registered operator of the Web site, Medico-Judicial Online Media, has begun gathering data on Florida medical malpractice cases filed after July 4, said company spokesman Vishal Castun. The operators plan to make the database available for free starting next July, and eventually hope to publish a database covering medical malpractice cases across the United States.

Medication errors injure more than 1.5 million yearly, study finds

From CNN.com

WASHINGTON (AP) -- Medication mistakes injure well over 1.5 million Americans every year, a toll too often unrecognized and unfought, says a sobering call to action.

At least a quarter of the errors are preventable, the Institute of Medicine said Thursday in urging major steps by the government, health providers and patients alike.

Topping the list: All prescriptions should be written electronically by 2010, a move one specialist called as crucial to safe care as X-ray machines.

Perhaps the report's most stunning finding was that, on average, a hospitalized patient is subject to at least one medication error per day.

ER waiting rooms defy stereotypes

From USA Today

Countering a popular belief, researchers say that communities with higher numbers of uninsured, Hispanics or non-citizens have a lower use of hospital emergency departments.
Instead, places with the highest levels of emergency department use are those with more elderly residents, communities where people have to wait a long time for appointments with their own doctors and places where a smaller percentage of the population is enrolled in HMOs vs. other kinds of insurance.

"Emergency room use is up across the population, including more middle-class folks with private insurance," says study author Peter Cunningham, a senior fellow at the Center for Studying Health System Change.

A Statewide, Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol

From the Journal of Trauma

A Statewide, Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol

Background: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization.

Methods: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes.

Results: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100).

Conclusions: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS- assessed trauma patients.

Growing Crisis in Patient Access to Emergency Surgical Care

The College of Surgeons has released a report entitled "The Growing Crisis in Patient Access to Emergency Surgical Care" which details the problems associated with the shortage of surgeons serving on ED call panels and the reasons for those shortages. The report advocates for some specific federal and state action to address the crisis. Some of the information contained in the report may be helpful in further supporting chapter efforts to educate policymakers and the public about the severity of the on-call specialist shortages and the need to address this problem. The report is available at http://www.facs.org/ahp/emergcarecrisis.pdf

Cervical Spine Examination

From the journal Trauma:

Delayed or Missed Diagnosis of Cervical Spine Injuries

Background: Correct diagnosis of cervical spine injuries is still a common problem in traumatology. The incidence of delayed diagnosis ranges from 5 to 20%. The aim of this study was to analyze the frequency and reasons for delayed or missed diagnosis at this Level I trauma unit and to provide recommendations for optimal examination of patients with suspected cervical spine injuries.

Conclusion: For optimal examination of patients with suspected cervical spine injuries, we recommend establishing specific diagnostic algorithms including complete sets of proper radiographs with functional flexion/extension views, secondary evaluation of the radiographs by experienced staff, and further radiologic examinations (computed tomography, magnetic resonance imaging) if evaluation of standard views is difficult.

Emergency Department Visits Remain at Record High Levels

From ACEP:

WASHINGTON, DC- Visits to the nation's emergency departments remain at record high levels with an average of more than 300,000 visits made to U.S. emergency departments every day in 2004, according to the latest statistics provided by the Centers for Disease Control and Prevention (CDC). Dr. Frederick Blum, President of the American College of Emergency Physicians (ACEP), said emergency rooms continue to be a safety net for the entire nation's health care system.

According to the CDC, visits decreased to 110.2 million annually, down from 113.9 million in 2003, although the drop was not considered statistically significant. Visits to emergency departments have increased 18 percent between 1994 and 2004, rising from 93.4 million to 110.2 million visits annually. In that same time period, the number of U.S. emergency departments decreased by 12.4 percent.

"Many factors are at work creating a gridlock situation in emergency departments around the country, including fewer emergency departments, a shortage of on-call specialists, many uninsured people who have nowhere else to go for medical care, and a shortage of hospital beds to transfer our patients to once they've been admitted through the emergency department," said Dr. Blum. "New reports from the Institute of Medicine conclude the emergency medical system itself is in crisis and time is running out to fix it."

The statistics show one-fifth of the U.S. adult population visited an emergency room at least once in the previous 12 months. Infants, under one year of age, accounted for 3.9 million of the nation's emergency rooms visits in 2004. The highest number of emergency room visits was reported by the CDC in 2003, with nearly 114 million visits recorded that year.

Patient attacks two paramedics, takes over ambulance in Ohio

From JEMS:

A psychiatric patient overpowered two paramedics and hijacked their ambulance Tuesday morning while en route to a Geauga County hospital for medication, sheriff's officials said.

The woman — described in a frantic 9-1-1 call by one of the paramedics as violent and out of control — then spent roughly a half-hour driving the rescue vehicle along U.S. 322, where the attack took place in Claridon Township.

State Highway Patrol troopers eventually stopped Victoria Madge's getaway by flattening three of the ambulance's tires at the highway's intersection with Ohio 46 in Ashtabula County. She traveled more than 17 miles and crossed five townships while on the lam.

Medicaid Amends Emergency Coverage Rule

Iowa Medicaid provides emergency medical coverage for undocumented immigrants, so long as the patient meets the other eligibility requirements for Medicaid, such as Iowa residency. Applicable law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the patient’s health, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Labor and delivery is also considered an emergency medical condition.

In the July 5 Iowa Administrative Bulletin, the Department of Human Services published a final rule (ARC 5215B) changing the verification process for emergency Medicaid. Previously, the Iowa Medicaid Manual and corresponding administrative rules provided a list of diagnosis codes that qualified as emergency services, but the list of codes was often out of date, resulting in erroneous denials. The new rule eliminates the list of covered codes and allows the medical provider to verify that the condition was an emergency.

Effective July 1, to verify the presence of an emergency medical condition, the medical provider who treated the emergency medical condition or the provider’s designee must submit verification of the existence of the emergency medical condition on either Form 470-4299, Verification of Emergency Health Care Services, or a signed statement that contains the same information as requested by the form. IHA supports this change because it will substantially reduce the amount of denials and appeals for emergency Medicaid reimbursement.

The Iowa Medicaid program limits payment for emergency Medicaid services to the day treatment is initiated for the emergency medical condition and the following two days. The date the patient first sought treatment is considered as the first day of the emergency, regardless of length of treatment or the condition. Emergency Medicaid will be allowed more than once in a calendar month, but only for an emergency that is unrelated to the previous emergency

CDC Report on ED Care

The CDC released their annual report on emergency department (ED) care in the US. This report is based on 2004 visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the following ED statistics were notable.

Visit frequency
- Over 110 million visits were made in 2004, an increase of 18% over 10 years
- There were 38.2 visits per 100 persons, including one-fifth of all US adults in the past 12 months
- The total number of EDs in the US decreased by 12.4% over 10 years

Acuity measures
- Abdominal pain, chest pain and fever, all high-risk, were the most frequent chief complaints
- Medications were prescribed in three-quarters and procedures were performed in half of patients
- 15% arrived by ambulance
- 13% were admitted
- Of those classified, 15% of visits were emergent, 44% were urgent, 26% were semi-urgent and 15% were non-urgent

Overcrowding indices
- The mean time to see a physician was 47 minutes
- The mean time from arrival to admission or discharge was 3.3 hours
- About 2% left before being seen by a healthcare provider

To see a full copy of the report, go to http://www.cdc.gov/nchs/data/ad/ad372.pdf. For more information about the ED utilization from the National Center for Health Statistics (NCHS) Ambulatory Health Care, go to http://www.cdc.gov/nchs/nhamcs.htm.

Top Ten Conditions for Admissions to the Hospital Through the ED

From "Vital Signs" in ACEP News, based on estimates for 2003 from a nationwide database of inpatient stays, Agency for Healthcare Reseach and Quality:

Pneumonia, 935,000 admissions
Heart Failure, 807,000 admissions
Chest Pain, 702,400 admissions
Coronary Atherosclerosis, 521,000 admissions
Acute MI, 485,900 admissions
COPD, 445,200 admissions
Stroke, 436,100 admissions
Cardiac Dysrhythmia, 425,800 admissions
Complications of procedures, devices, implants or grafts, 412,700 admissions
Depression / Biploar Disorder, 387,500 admissions