Healthcare Update — 12-10-2010


Did I tell you how much Google sucks … BLAM! Droid phone explodes in man’s head while he is talking on phone.

Emergency department overcrowding takes another life. Short of breath 41 year old Ontario patient dies while sitting in emergency department waiting room for more than 90 minutes. Waits for patients with serious conditions can reach more than 12 hours. Some admitted patients waited more than 26 hours for a hospital bed to open up.

Downright scary emails from Alberta, Canada emergency physician to top Canadian political and health care leaders documenting lack of care in emergency departments. Direct link for .pdf download is here.
Waits of 5.5 hours for a potential stroke victim to get a bed. No tPA for you! Another potential stroke patient leaves after five hours without seeing a physician. A nine hour wait for a patient experiencing seizures. A man dies because he needed emergency brain surgery and couldn’t get it because of “overwhelming systemic overcrowding”. A suicidal patient leaves without seeing a doctor and then returns by ambulance after overdosing on prescription medications. Another patient boarded in the emergency department for an entire week. Patients in the waiting room threatening triage nurses and “screaming that we are letting people die.”
Did I mention that all those patients had national health “insurance”?

Oh just cut the damn payments already. Congress staves off physician Medicare payment cuts … again. Because we’re suddenly going to find hundreds of billions of dollars to make the system solvent in the next 12 months. Next time that we have to read about the same brinksmanship and watch Congress kick the can down the road a few more months: January 2012.

There’s the French Kiss, then there’s the … Sheboygan Chomp. Sheboygan, Wisconsin man ends up in emergency department after wife bites off half his tongue during kiss. The 79 year old victim noted that his 59 year old wife had been “acting strangely” for several days. No argument there.

911 … please hold.”

Louisiana appellate court throws out limit on malpractice awards, stating that the law is discriminatory because lesser-injured patients receive a full payout for damages, while more severely injured patients have their damage awards limited. In this case, a child was awarded $6.2 million, but her award was decreased to the statutory maximum of $500,000. If you were a physician, would this ruling have any effect on your willingness to practice medicine in Louisiana?

Georgia hospitals considers “program changes” to deal with unpaid medical care. Charity care at the Medical Center of Central Georgia increased by about $30 million in the latest year reported while uncompensated care statewide was estimated at $1.3 billion. I’ve got a better idea. Let’s just create more regulations.

Meanwhile, despite lower patient volumes in 70% of hospitals across the country, according to an American Hospital Association analysis, US community hospitals provided a total of $75 billion in unpaid care in 2009 – a significant increase from prior years. A different AHA survey released the same day showed that hospitals were able to earn a 5% profit margin in 2009.

“English only” or just “No Filipinos allowed”? California hospital establishes an “English only” policy for all of its workers, but then allegedly selectively enforces the policy against Filipinos while allowing Hispanic and Indian nurses to speak their native languages on the job. Now the EEOC has filed a lawsuit over the issue.

Nurses have more back injuries than truck drivers and more than half of nurses have experienced violence on the job. The article describes how nurses in California have been murdered by patients but how no one wants to “criminalize patients.” Give me a break. You touch a police officer or a judge and you’ll be at the Greybar Motel for the 25 year class reunion. You maim a nurse and you get a skate card because no one wants you to have a rap sheet? Must make perfect sense to JCAHO.
There are a lot of interesting statistics at the end of this article. Another tidbit: According to the U.S. Bureau of Labor Statistics, the healthcare industry constitutes 45 percent of the two million incidents of U.S. workplace violence between 1993 and 1999 — the highest of all work sectors.


    • I love all my devoted readers, but there’s nothing much to add here. WC’s right – single payer will result in more overcrowded EDs and longer wait times.

    • I think that these are all reasonable policies, and I think that – over time – they will have their intended effect of decreasing costs of medical care. Plus … they don’t include caps on judgments.
      Remember that it took decades to get to the point that we’re at and it is going to take a long time to establish a new point of equilibrium. We can’t reasonably expect a wholesale turnaround within a couple of years.
      For those who can’t/don’t want to access the .pdf file referenced, the text is below.

      Among the policies pursued, the following should be included: 1) Modifying the “collateral source” rule to allow outside sources of income collected as a result of an injury (for example workers’ compensation benefits or insurance benefits) to be considered in deciding awards; 2) Imposing a statute of limitations – perhaps one to three years – on medical malpractice lawsuits; 3) Replacing joint-and-several liability with a fair-share rule, under which a defendant in a lawsuit would be liable only for the percentage of the final award that was equal to his or her share of responsibility for the injury; 4) Creating specialized “health courts” for medical malpractice lawsuits; and 5) Allowing “safe haven” rules for providers who follow best practices of care.

      • “1) Modifying the “collateral source” rule to allow outside sources of income collected as a result of an injury (for example workers’ compensation benefits or insurance benefits) to be considered in deciding awards;”

        This is something physicians probably don’t want when you think about it. Right now, many providers, if they know there is a potential claim, will not submit to insurance unless forced to do so. Why? Because they’re more likely to get full value for their services.

        “2) Imposing a statute of limitations – perhaps one to three years – on medical malpractice lawsuits; ”

        Every state already has one. Most are two years.

        “3) Replacing joint-and-several liability with a fair-share rule, under which a defendant in a lawsuit would be liable only for the percentage of the final award that was equal to his or her share of responsibility for the injury; ”

        Why should a wrongdoer benefit from another wrongdoer’s insolvency at the expense of the harmed party? Although not really a factor in med mal.

        “4) Creating specialized “health courts” for medical malpractice lawsuits; ”

        Never going to happen without caps, and never going to happen without single payer anyway.

        “5) Allowing “safe haven” rules for providers who follow best practices of care.”

        Don’t even need to wait on that. Physicians can promulgate standards of care today. Nothing stopping them.

        All of those things put together don’t amount to a hill of beans in healthcare savings. 17 billion in 10 years? Healthcare costs are $2.3 trillion annually.

      • Matt, physicians already establish and follow best practices. They spend more than ten years learning what those practices are. It’s called “med school”.

        The point is “safe haven”, not “best practices”. The idea being that if you follow the approved practice and the patient dies anyway, then it wasn’t malpractice.

  1. Since there is lots of Canadian stories today I’ll comment.
    I work as a doc in a Canadian ER at a mid-sized community hospital. 14 monitored beds, 3 bed resus bay, 10 bay fast track area, a great ER built 3 years ago, nice equipment, great physical set up…’s the problem:

    2 years ago the admin moved hospital beds into our treatment area and re-branded it the ’emergency room overflow’. You can be an admitted patient and stay in this area indefinitely, it has never since been available to see fast track patients. On overage we have 22 admitted patients in our department. That’s 22 patients who have been seen assessed and admitted to hospital, and they stay in the emergency room. That means 22 of our 24 places to see new patients are on average filled up at all times. Often we have more admitted patients than beds. We keep ICU patients in our emerg often for days. When we have more admitted patients than physical beds we get creative and use our cast room, the area beside our desk, and the ambulance bay.

    (No Ms. this is not a closet we are putting you into it is a cast room…..what’s that? Oh no you don’t need a cast, we just don’t have space for you, now scream if you need anything there is no call bell in here.)

    If you come to my hospital with anything minor I will see you in a chair in the hallway or in the waiting room. Even if you wait indefinitely there will never likely be an appropriate private place to see you so I may as well see you quickly and in public. If you are sick at all you are going to the resus bay. Yes it is scary in there and no I don’t like treating your allergic reaction while we run a code in plain site of you but I can’t wait for a regular bed to open up, because it won’t ever happen.

    Although it is clear that keeping ED boarded patients is dangerous to both those patients and to incoming patients, there is real inertia to make changes, even though there is a robust literature on how to fix this problem. So if you are in Canada, stop on by my emerg. We are good docs and nurses and we will work hard for you. We don’t have customer surveys like they do in the states though, because they way we deliver your care is insane. Mostly you will not complain about us docs and nurses anyways, you will see we are running as fast as we can and worn out because we are pulling a double again because one of our colleagues just left (again) to work in a nice office…..

    Sounds great eh?
    Dr. J

    • Please understand that by posting these stories, I am not in any way putting down the docs and nurses that work in Canadian hospitals. To the contrary, I believe that you deserve admiration for the work that you do given the resources provided to you. I couldn’t imagine being in your collective positions – especially with what you have described.

      My intent in posting these articles is to show how governmental policies can have a devastating effect on the ability of citizens to obtain medical care and on the ability of providers to provide care.

      Right now in the US, so many people think that “insurance for all” provided by our new health reform is the answer to all our problems.

      I believe that it is jumping from the frying pan into the fire.

    • Dr. J
      I’m curious… do you have budget related inpatient bed closures? What percentage of your inpatient beds are closed? What percentage of your inpatient beds are waiting nursing home placement?
      What do you see as the major bottlenecks to patient flow? How much of a direct impact does government policy have on your situation in the ED? I think that your experience is a glimpse into our future.

    • WhiteCoat: I am quite glad you are sharing these stories and do not see it as being against the docs and nurses in Canada at all. I tell the patients why I am caring for them in the hallways every day. I make sure that the patients know I want to take care of them and would rather be doing it in a proper stretcher, but that working in the hall is the reality. I’m not going to participate in pretending that things in Canadian hospitals are okay, so I much appreciate you putting this information out there.
      IglooDoc: We have lost about 20% of our inpatient capacity in the last 2 years. We have also faced ‘regionalization’ of basic services like ortho, so though we have in house ortho some days I have patients with hip fractures waiting 24+ hours in my department for transfer to another site to have their operation. Transfer ambulances are also cut back so even when the stars align for transfer sometimes it doesn’t come off.
      Welcome to the future…

    • I am guessing a bit but I’d think Emerg doc $275K, general surgeon $400K, and any form of critical care nursing $100K.
      Salaries are quite good for hospital based work in Canada, but people will leave for less well paid office based work that is better managed (they are leaving the hospitals in fact)…

    • I meant that those were approximate salaries for each of those 3 separate specialties (emerg docs, surgeons, and critical care nurses). There is no overlap between the 3 fields really, each needs their own particular training.

      Emergency training in Canada is somewhat different than in the US (which may be what you are referring to), and is structured in such a way as to create doctors who can work in very rural environments so there is significant overlap between family medicine/general practice and emergency medicine. I, like many of my colleagues, am certified in both family medicine and emergency medicine, though I stopped doing family medicine years ago. The current salaries for family doctors are about the same as for emergency doctors, so with the high level of cross certification there has been some amount of exodus back to office based practice.

      • If those are the salaries, how much of a drop for you US docs is that? It doesn’t sound like single payer would pop you as hard as I thought it would.

      • Matt, in emerg I don’t think there is a huge difference between US and Canadian salaries. Canadian docs who are paid on a per patient basis make less per patient but collect on almost all their patients. In most of our emergs the ER doc sees a higher number of patients per hour than a US ED but the documentation expectations are also much less.
        Probably of interest to you, my malpractice premiums are about $3600 a year which can be a substantial savings versus the US.
        Although the salaries here are good the work conditions leave much to be desired and as a result there is certainly some difficulty with recruitment and retention for all positions associated with the ED.

      • Thanks for the info Dr. J. I wouldn’t have expected your malpractice premiums to be as high, since with universal healthcare much of the need for a malpractice claim is eliminated, and the jury presumably wouldn’t be making awards for past and future care, which make up the bulk of the awards here.

        I realize you say work conditions stink, but I guess it’s hard for us laymen to tell how bad they are v. here for physicians, since the physicians here do a lot of complaining about their work conditions.

      • Matt: Malpractice premiums are set on a region by region basis in Canada based on actuarial tables. I have never personally been sued, but that rate is for emerg docs in my part of the country. The highest rate in Canada is in Ontario and is about $6500 per year. My understanding is that the majority of awards are for lost income and cost of care for non-insured services like homecare and physiotherapy and assistive devices which are not covered by our health insurance in Canada.
        The work conditions question presents a strange conundrum, my day to day practice life is very pleasant, my patients are mostly nice and thankful for the care they are getting. I know that the care they are getting is non-ideal though and that bothers me. Overall I would say the work conditions are less of a problem than the patient conditions.

  2. Does anyone know where I can find a humorous article about the use of copy and paste in EMRs? I don’t remember the authors name and my google fu is failing me.

  3. Give me a break. You touch a police
    officer or a judge and you’ll be at
    the Greybar Motel for the 25 year
    class reunion. You maim a nurse and
    you get a skate card because no one
    wants you to have a rap sheet?

    WhiteCoat, you’ve been away from
    Chicago too long. Go have a look at
    Second City Cop and read about the plight of
    Bill Cozzi, the antics of J-Fled, and
    the “ghetto lottery”. Chicago has
    always been the ‘town of the big
    shoulders’, but now it’s more like.
    the ‘town of the better armed”.

  4. Ah yes the horrible evil national health care. No one ever dies in the ER in the US.

    Oh wait, yes they do.

    By the way, I have private health insurance. On my third endo this year.

    The last one required a referral from the PCP. Not my insurance, the doctor.

    10 months later I’m finally getting the bloodwork I should’ve had last Spring.

    I have known exactly what bloodwork I needed since March. I have a documented history to support my request and here I am at 9 months out, waiting for the test next month. Although they’ve screwed up the scheduling three times now, so who knows! Maybe they’ll just let me die first.

    Go private health care go!

    Seriously, if you are going to dog on national health care, find a better argument.


  5. Doesn’t take long to find articles on long wait times in US emergency rooms resulting in deaths either.

    Nice cherry picking on universal health care issues when the US has similar issues. Jackass.

    • OK, then, my eloquent, insightful, and captivatingly expressful reader … please do provide us with some links to hospital deaths in the US related to emergency department visits in the past few years that I haven’t mentioned in my blog.
      Until then, stifle yourself.

  6. If you think violence on the medical professionals is high now, wait until you get this young ones in a few years! As an educator, I have seen students hit, bite, kick and stab teachers, and NO punishment is handed down to the young one. In urban areas, I see 50-75% unemployment in 10 years.

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