Washington State Medicaid will no longer pay for “unnecessary” ED visits

By now you must have heard the news that as of April 1, Medicaid in Washington State will no longer reimburse hospitals for care of what Medicaid deems unnecessary ED visits. [The Seattle Times report is here.] The problem, of course, is that many times the perceived lack of necessity can only be determined after the patient has been worked up. Even a patient brought in by ambulance will not be covered if it turns out that his illness is not a true emergency as defined by the rules. And hospitals will not be allowed to bill the patients. The unnecessary visits list includes illnesses like hypoglycemic coma and asthma attacks. Unstable vital signs do not matter if the visit is eventually found to be unnecessary.

Hospitals and ED docs in Washington have vociferously objected to this patently stupid plan but so far the state’s Medicaid boss [a doctor] is standing firm.

In addition to the obvious problem of not knowing whether a patient is sick or not before he is examined, what is an ED doc supposed to do if an ambulance brings in a Medicaid patient with a cold? Should the patient be refused entry into the ED?

That probably would not be wise because of a federal law known as EMTALA [Emergency Medical Treatment and Labor Act]. From the website EMTALA.com: “EMTALA requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.”

What happens if EMTALA is violated? “A hospital which negligently violates the statute may be subject to a civil money penalty (i.e., a fine, but without criminal implications) of up to $50,000 per violation. If the hospital has fewer than 100 beds, the maximum penalty is $25,000 per violation.”

Anyone who works in a hospital knows that EDs are being inundated with patients who don’t really have emergencies, but shifting the blame and cost to the hospitals and EDs is not the answer.

Like many issues today, personal responsibility is no longer expected or required. The Medicaid card is the “everything” card. Get one and you’re all set. I worked in a city hospital for several years. The Medicaid patients had absolutely no interest in controlling costs. They knew that if they went to an ED, they had to be examined and treated.

Assuming that there are enough primary care doctors, accountable care organizations or “medical homes” in the State of Washington to accommodate the no longer ED-bound Medicaid population [a factor that apparently no one has brought up], wouldn’t it make more sense to shift the responsibility of deciding whether they should go to an ED to the patients themselves?

But that would require some restrictions on the “everything” card. I doubt that any politician or bureaucrat would have the balls to even suggest, much less implement, such a policy.

Finally, an internist discovers some pitfalls of the ACGME work hours restrictions

In a blog post, noted patient safety expert and hospitalist movement founder Bob Wachter discussed some new realities in resident education as a result of the recent [July, 2011] ratcheting down of resident work hours by the Accreditation Council for Graduate Medical Education [ACGME]. While applauding the more humane conditions under which residents now labor, he noticed disturbing changes in the way residents are being trained. The issues he raised have been well-known to surgical educators since the institution of the 80-hour work week in 2003.

He unknowingly agreed with something I wrote recently about today’s residents lacking opportunities to function independently, which leads them to worry about their competence after graduation. Wachter wrote: “Learning from one’s mistakes is fundamentally unethical when you have a human life in your hands. But an environment in which the housestaff are trained to read the attending’s body language before making a tough call can’t be right either, particularly when our third-year residents morph from resident to attending on June 30th each year.”

Continuity of care is another issue. Wachter: “A second worry is the relative dearth of patients being followed by a single resident from admission to denouement. Our teams inherited nearly half their patients as handoffs from night admitters.”

He stated the problem very well. “So many emergency admissions traverse a trajectory in which an early assessment is followed by a period of data gathering (tests, consults), followed by an initial patient response, which is evaluated in context. In a system in which half the patients are cared for by two sets of doctors during these crucial stages, neither group fully sees this arc play out, and their education suffers.”

And regarding hand-offs. “While some trainees forced themselves to rethink their patients’ problems and actively ward off anchoring bias, others didn’t, accepting what they were told as gospel and never coming to know the handed-off patients as well as those they admitted themselves.” This happens a lot more often than most people think.

He wondered how this fragmentation of care could be ameliorated but did not offer any solutions. Fragmentation of care during resident training will at least prepare internal medicine residents to become hospitalists, since lack of continuity permeates most hospitalist services that I am aware of.

Wachter has also just noticed that formal educational conferences are another casualty of the time limitations. He said: “The other thing that worries me about the new schedules is the palpably limited time available for education. In the 16 days I spent as attending in January, I recall only two in which the entire team was available for our traditional hour-long teaching rounds.” Bob, this has been a significant problem since 2003. It didn’t start last July. There is no such thing as an afternoon educational conference any more.

It’s nice to know that someone else is at least concerned about this. Neither Wachter nor I have any answers. I will just echo what many doctors of my generation are saying. We hope we still can figure out who the good MDs are by the time we need care for ourselves.

Thanks to Susan Carr for tweeting a link to Dr. Wachter’s blog.

More on “Publish or Perish”

Bonus: What is a receiver operating characteristic (ROC) curve and how do you interpret it?

God knows I’ve written and managed to get published some downright awful research papers in my time. I was driven by the same forces that are at work today. “Publish or Perish” was very real for me as I needed to grind out papers to keep my general surgery residency from going on probation for inadequate “scholarly activity” as the Surgery Residency Review Committee (RRC) put it. [See previous blog]

A friend alerted me to a paper just published in Academic Emergency Medicine entitled “Diagnostic characteristics of S100A8/A9 in a multicenter study of patients with acute right lower quadrant abdominal pain.” This project took a lot of effort, and I respect the authors for that. And I am not opposed to the publishing of research that produces negative findings. But since no one at present is even considering using S100A8/A9 in the diagnosis of appendicitis and other biomarkers have not proven useful, I am not certain this needed to see the light of day.

Levels of a biomarker called S100A8/A9 [alias calprotectin] have been shown to rise in the presence of acute inflammation. The paper is a prospective, randomized, double-blinded multi-center trial investigating the utility of S100A8/A9 in the diagnosis of acute appendicitis, a disease that produces inflammation. Patients with right lower abdominal pain and suspected appendicitis had blood samples drawn. They were then sent to a central lab for measurement of S100A8/A9. The time it took to do this precluded the use of the results of the test for any decision-making. Presumably if the test was deemed useful, it would become part of every hospital’s on-site clinical lab.

The S100A8/A9 test was performed on blood from 848 eligible patients. When levels were elevated, it was found to be highly sensitive [It identified 96% of patients who had appendicitis] but poorly specific at 16% [That is, 16% of patients without appendicitis had normal S100A8/A9 levels; In other words, 84% of patients without appendicitis had elevated levels of S100A8/A9.] The area under the ROC curve was 0.66.

What does that mean? It means that the test’s accuracy approached 0.50, or 50%, the accuracy of flipping a coin. A very simple explanation of ROC curves can be found at the University of Nebraska Medical Center’s website. It points out that a diagnostic test with an area under the ROC curve of 0.66 would be considered poor.

The figure below is based on one from that site. The red line is the curve from the S100A8/A9 paper. The 50% line is illustrated in green. The S100A8/A9 blood test is not likely to replace CT scanning as the diagnostic test of choice in patients with right lower quadrant abdominal pain.

Despite these dismal results, the authors are undaunted and are planning more studies on this biomarker.

There’s a “Publish or Perish” situation in emergency medicine too. Here are three excerpts from the RRC for EM regulations:

1. There must be a minimum of one core physician faculty member for every three residents in the program.
2. The definition of a core physician faculty member is a member of the program faculty who provides clinical service and teaching, devotes the majority of his or her professional efforts to the program, and has sufficient time protected from direct service responsibilities to meet the educational requirements of the program. To this end, core faculty should not average more than 28 clinical hours per week. [Emphasis added. Unfortunately, this sweet deal is NOT found in the RRC for surgery regulations.]
3. The faculty must establish and maintain an environment of inquiry and scholarship with an active research component. [Translation: “Publish or Perish”]

So now you know why this research was done. It was published because there are so many journals that need to be fed. The Thomson Reuters SCIENCE CITATION INDEX lists 19 journals devoted to the topic of human emergency medicine. [See the last two paragraphs of a previous blog of mine about this.]

At least it provided an opportunity to say something about ROC curves.

Study: Robotic surgery financials explained

I thought I had seen the worst of robotic surgery research but the January 2012 issue of Surgery News, billed as “The Official Newspaper of the American College of Surgeons,” contains an article about a paper that surpasses all the rest. It can be found on page 17 here.

The paper was presented at the annual meeting of the American Association of Gynecologic Laparoscopists by a group from the Florida Hospital in Orlando.

The headline, “Robotic Hysterectomy Cuts Blood Loss in Obese,” is certainly catchy. Let’s look deeper. The study was a retrospective comparison of 111 patients who had robotic hysterectomy to 152 who had standard laparoscopic hysterectomy. All women had BMIs greater than 30. The robotic group had an average estimated blood loss of 85 cc versus 210 cc in the laparoscopic group. Sounds good, right? However, the difference in blood loss of only 125 cc [about 1/4 of a unit of blood] is hardly clinically significant. This was confirmed by the study’s own data. Average postop hemoglobin levels were 13.1 g/dL and 12.5 g/dL respectively.

There were also fewer conversions to open surgery in the robotic group. Duration of both types of operation was similar but does not take into account the lengthy set-up time, often as long as one hour, that robotic surgery entails.

The problem with any retrospective study is that confounding factors may not have been accounted for. It is likely that the women chosen for the robotic surgery were highly selected for suitability. We know nothing about either group’s co-morbidities, previous operations, uterine pathologies [e.g., cancer or not] or other possible factors influencing outcomes.

Here is the most interesting part of the report. The lead author said, “The robotic hysterectomy does … offer lower rates of conversion to laparotomy but does cause higher facility and total charges, as well as higher reimbursement rates.” The mean total hospital charge for robotic hysterectomy was $44,700 versus $25,557, a statistically significant difference. The average charge for the robotic instruments was $8,322 compared to $3,762 for standard laparoscopy equipment, also a significant difference. In response to a question about why there was such a disparity, the lead author said: “The charges are likely to recoup the cost of the robot purchase. We have multiple robots … four at our main institution and several others at other sites.”

The reimbursement actually received for robotic hysterectomy was $19,000 and for standard laparoscopic, a mere $$8,000.

I congratulate the authors for their candor [though no doubt inadvertent] in sharing the financial data and the reasons why robotic surgery is more costly. I am gobsmacked* at the differential in charges and reimbursement for the two types of hysterectomy and that the secret would be so openly shared.

I guess someone has to help the hospital “recoup the cost of the robot purchase.” But I wonder why third party payers are shelling out almost two-and-a half times more money for a procedure that has not been proven more effective than standard laparoscopic surgery?

And you wonder why health care costs are skyrocketing?

*gobsmacked-UK slang for astonished

Why robotic cholecystectomy may not become the standard way to remove a gallbladder

I have written in the past about robotic surgery pointing out that there is no proof that it is better than regular laparoscopic surgery.[Here and here]

Some think I am a Luddite. Other asked if I remembered all the naysayers 20 years ago who said that laparoscopic surgery was unnecessary. The answer is “Yes, but this is different.”

Here is why robotic cholecystectomy may not be the standard of care in the future.

Yesterday, a former resident of mine asked me if I thought he would be excluded from performing gallbladder surgery if he did not take a course in robotic surgery. I said I didn’t think so but since this thing is being marketed so heavily, it may become consumer-driven. He then told me that the hospital where he works has only one robot.

The lights came on.

There are about 700,000 cholecystectomies done in the US every year. How many robots would have to be purchased at $1.5M apiece to accommodate the volume? General surgeons would also be competing for use of the robot with gynecologists, urologists and colorectal surgeons, to name a few.

Will it be practical for busy hospitals to buy three or four robots? Are there more important things to spend health care dollars on? I think so.

Cheating, written board exams and “recall” questions

CNN "Exclusive: Doctors cheated on exams"

A recent dust-up about radiology residents accessing and memorizing questions from previous board examinations generated 1361 comments on CNN alone from physicians and others. Many more people took to Twitter and vented. Some said it wasn’t really cheating because the test-takers had to memorize the answers. Some said the radiology boards didn’t really sort out who was going to be a good radiologist anyway. Some said the questions were on non-clinical topics like physics. Some were highly indignant that such a thing could happen. I saw many comments suggesting the board simply write a new test every year.

The stockpiling of "recall" questions by residents and programs goes on in all specialties. I know it does in surgery.

It would be difficult to create a completely new written exam every year. For several reasons, that is not a practical solution.

My understanding of the way the American Board of Surgery handles questions is this. Questions are recycled because they must be validated by analyzing them after they are used. In surgery, questions may appear on the residents' in-training exam one year, the re-certifying exam the next year and Part I of the boards the following year. Where appropriate, questions are also recycled through the subspecialty exams such as critical care, colorectal and others. As it happens, each test contains some reused questions and some brand new questions.

The board assesses certain things about each question such as do junior residents do as well or better on a question than chief residents? An ideal question would be one in which the percentage of correct responses increased as the training level of resident increased. They also look at whether the questions are framed correctly. For example, a question which generates two or more answers that are chosen by similar numbers of test takers may be ambiguously worded. Questions that have unusual patterns of response or ambiguous answers would be reformatted or discarded, and they would not be counted for the test that resulted in the unusual answer patterns.

A completely new test would contain quite a few questions that would have to be discarded if they were not validated by prior use.

Another problem is that writing good questions is very difficult. Most educators feel that a five-answer multiple choice question should have one correct answer, one plausibly correct but not exactly correct answer, two wrong answers and one really, really wrong answer. The correct answers need to be found in commonly used textbooks. And there are just so many questions that can be asked. Try writing a few questions. You’ll see how hard it can be.

I am conflicted about whether possession and use of copyrighted material from the boards constitutes cheating. Strictly speaking, I suppose it does. But where do you draw the line? When I was a residency program director, my trainees would often ask me what I thought the correct answers to some of the questions were. If I told them, would that be cheating? If they remembered a few of the questions and discussed them among themselves, is that cheating? What if a resident remembered a question and looked up the answer herself? Is that cheating? Or is it learning?

Here’s the good news. I’m not a residency program director any more.

What do you think?

Research on fatigue and work hours annoys me

A paper from the University of Pittsburgh just published in the journal Academic Emergency Medicine claims that emergency medicine docs have problems with short-term memory and sleep after working what seem to be modest shift durations of only 6 to 8 hours.

The study involved 13 ED MDs who were tested before and after both day and night shifts. As is typical of studies in this genre, the tests had nothing to do with what an MD actually does while working but rather were quizzes with names such as the Paced Auditory Serial Addition Test (PASAT), the University of Southern California Repeatable Episodic Memory Test (REMT), the Trail Making Test (TMT), and the Stroop Color-Word Test. Just reading about how these tests are done made me sleep. Never mind having to be subjected to them.

Quality of sleep was assessed by something called the Pittsburgh Sleep Quality Index (PSQI).

Facts that the authors probably did not anticipate would draw a reader’s interest include the following:

The ED docs worked an average of fewer than 10 shifts per month.
7/13 were overweight or obese.
4/13 had at least 4 alcoholic drinks per week.

Like most papers, the abstract does not really reflect all the goodies inside. Table 2 is an elegant massaging of the statistics with 32 different sets of 95% confidence intervals for the memory tests.

The paper notes “Sleep quality was worse in EPs (emergency physicians) compared to the normal population, with 31% of subjects reporting poor sleep quality.” Just in case you forgot, 31% of 13 is 4 people. In the discussion, the authors blamed poor quality sleep on fatigue, which was also quantified. They then made the startling revelation that “sleep disruption continues routinely beyond training years and may be a widespread issue among health care providers.” No kidding?

I have another theory. My experience (based on an “n” of one) is that I often have trouble sleeping when I’m working. I worry about the patients, the decisions I’ve made, whether I checked that lab result, will that clip fall off and lead to bleeding and so on. I think many doctors and nurses have similar thoughts.

But I saved the best for last. Performance on the memory tests was worse for all the ED docs AFTER WORKING BOTH DAY AND NIGHT SHIFTS.

The authors suggested “symptom improvements” might ameliorate these problems. My suggestion, which I blogged about in detail in October of 2010, is to do what the US Navy has successfully done for centuries. That is, have all doctors stand watches of no more than 4 hours at a time. It’s a little inconvenient, but it would reduce fatigue and stress markedly. [Click here to read how it would work.]

I want to thank Andy Neill who blogs at Emergency Medicine Ireland for bringing this paper to my attention.