Crash Cart: ACEP vs TrumpCare, Joint Commission inspections, and malnutrition

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This week: ACEP speaks out against TrumpCare changes to AHCA. Plus, study shows that watchful eyes (the Joint Commission) equals less patients dying. Join in as our editors discuss the week’s headlines.


American College of Emergency Physicians found the proposed AHCA changes worth breaking its traditional silence on legislation

The Freedom Caucus of The Republican Party wants states to be able to decide minimums of coverage. However, while 51% of ER docs identify as Republican, the governing body says gutting ER services and nine other “essential health benefits” merits their opposition. Original Article by Slate.

Jyoti Mahapatra, MD: Sigh. I have very little positive to say about our current administration, but I will try to remain objective. IF I gave the politicians behind the AHCA the benefit of the doubt, I would hope that by limiting emergency services they are attempting to cut down on inappropriate use of the ED. I would also assume they have a plan to ensure that patients have timely access to an outpatient setting to get non-emergent complaints addressed. As well as increase health literacy since many people, regardless of insurance status, just don’t know that rash, cough or fever isn’t an emergency. But I highly doubt any of these assumptions are the motivation behind removing emergency care from AHCA mandates. That’s about as likely as my wish coming true that the AHCA supporters would have to be insured under their own plan for a year to truly understand their own policy.

Nicholas Genes, MD, PhD: I don’t understand this paean to neutrality and tradition. Somehow the dozens of medical organizations, like the AMA, American Hospital Association, American Academy of Pediatrics, all managed to point out that the bill was not in the best interest of patients or providers. Does that make them partisan? Of course not – it makes them level-headed and maybe a little brave.

Ryan McKennon, DO: I think it’s a tough position to be in for professional organizations to take an official stand on political issues. The risk is that you end up alienating a certain percentage of your members.  The closer the bill is to the mission of the relevant organization, the easier it is to take a stand. Certainly if EMTALA ever comes up for amending, ACEP can and should take a stand as it relates to emergency medicine. What about a bill for a single-payer system? This does effect emergency medicine but is much more of a political question than a medical one. It’s also important to remember that because one did not agree with the AHCA does not mean one necessarily thinks highly of the ACA.

E. Paul DeKoning, MD, MS: Ryan, great synopsis and agree completely. We should focus on the issues that affect our patients and our practice–in that order–and those that are in alignment with the organization’s mission. Let’s debate the issues and avoid “taking sides.”

Nicholas Genes, MD, PhD: As Jeremy Faust wrote in the Slate piece, emergency physicians touch all segments of society on a daily basis. The ED is already a theater for shortcomings in policy, and it’s likely the we’ll play a larger role, as federal support for immigrants and the poor come under fire. Already there are reports of ICE agents targeting immigrants patients in emergency departments – and calls for EDs and hospitals to serve as “safe harbors” for the sick. Is this a partisan issue, or an issue of human decency? I hope ACEP doesn’t sit out that debate.

William Sullivan, DO, JD: Any time that an organization advocates for issues germane to its own interests, many onlookers will scream “bias.” The view of ACEP’s stance on the AHCA is no exception – as can be seen in the comments to the article. People will always make a value judgment as to what services they choose to purchase. That’s the way it should be. It isn’t as if insurance plans were refusing to provide coverage for emergency medical care before the ACA. Just because a condition isn’t *mandated* doesn’t mean that it won’t be *covered*. If consumers think the plan is too thin on coverage, they won’t purchase the plan. I still believe that there should be choice in the insurance markets. If patients don’t want coverage for certain conditions, they should have the choice not to pay for that coverage – with the understanding that they may be stuck with a large hospital bill if they end up with non-covered conditions. I not wading into the argument about what services should and should not be considered “essential”, but at some point we need to consider the utility, social costs, and unintended consequences of forcing someone who lives in a desert to pay for flood insurance.

Seth Trueger, MD, MPH: Bill: the problem with leaving it up to consumers to not choose plans with too thin coverage is that people don’t always have a full range of options to choose from. See, in particular, the individual market for insurance before Obamacare. Without meaningful regulation (eg, essential health benefits) insurers have shown that they will do everything they can to avoid covering treatment for illness, such as excluding pre-existing conditions and underwriting. The market didn’t solve it before Obamacare — why should we think it will solve it under Ryancare or Trumpcare?

William Sullivan, DO, JD: The market *did* address it before the ACA. Coverage for pre existing conditions was limited to encourage people to purchase better coverage rather than to wait until illness occurs then purchase insurance to game the system. Even with ACA “safeguards”, insurers are still doing whatever they can to avoid paying for treatment – only now the premiums are unaffordable and the deductibles are obscene. This discussion is off topic WRT the article, but what exactly has the average consumer gained?

Seth Trueger, MD, MPH: “…but what exactly has the average consumer gained?” Essential health benefits, out of pocket limits, end to annual and lifetime benefit caps, limits on the medical loss ratio, no more pre-existing condition limits…

William Sullivan, DO, JD: Essential health benefits (that most people don’t want and won’t use), out of pocket limits (if they can afford deductibles more than 50% of their annual income), end to annual and lifetime benefit caps (which are utilized by few if any ACA recipients), limits on the medical loss ratio, no more pre-existing condition limits (so people can forego insurance until they become ill then jump into coverage, thereby increasing premiums for everyone who pays into the system each month – or driving insurers out of the market) … Yep. Great system.

Seth Trueger, MD, MPH: Please note that the whole point of insurance is to cover things most people won’t use.

William Sullivan, DO, JD: Which leads directly to the point that I made initially when I said I didn’t want to get into this argument – at some point we need to consider the utility, social costs, and unintended consequences of forcing everyone who lives in a desert to pay for flood insurance. [mic drop]


A recent JAMA study shows a significant dip in patient deaths when The Joint Commission is inspecting

The effects are modest, and reasons for it are unclearOriginal Article by The New York Times // Accompanying Study by JAMA

E. Paul DeKoning, MD, MS: More quotable quotes: “Although the reasons for the effect are unclear, the lead author, Dr. Anupam B. Jena, an associate professor at Harvard, suggested that “when docs are being monitored, the focus and attention placed on clinical care goes up. I’d say it was figuring out the diagnosis and matching the treatment correctly, because you’ve been a little more thoughtful.”” Yeah, not buying it. Unless it means that, in my attempt to avoid the site visitors, I’m hiding in patient rooms and spending more time at the bedside.

Jyoti Mahapatra, MD: Claiming that physicians are less thoughtful when not under inspection is a totally unfounded correlation, not to mention insulting.  I would venture to say that doctors already feel like they are being watched all the time, from tracking adherence to core measures, timely and accurate EHR documentation and physician order entry, and press ganey scores just to name a few.  These inspections certainly make me more ‘thoughtful’ but not in a way that improves patient care. The article also omits the role of all the other members of health care, such as nurses, pharmacists, administrators etc.  It seems that they are the ones under more scrutiny during a JHACO visit anyways, the physicians are just warned to put their drinks away.

Nicholas Genes, MD, PhD: I secretly welcome Joint Commission visits – those are the weeks when admitted patients magically move upstairs promptly, where staffing finally seems appropriate, and when a lot of meetings with administrators get canceled. The stuff they quiz us about in the ED – locations of fire extinguishers, nametag placement, etc – seems easy enough to manage. Maybe, as the authors hypothesize, there’s some effect on inpatient central line infection rates or sacral ulcer care. But I tend to believe TJC is more a drill for administrators than clinicians.

Ryan McKennon, DO: Hold on, let me get my jump-to-conclusions mat…okay all set. So lets see why a 0.18%change in 30-day death rate before and after site visits is related to doctors being watched. Did they account for any other hospital variables? What about staffing levels between the two time periods?  Holidays? How about this — since typically in the week(s) after the joint commission visit, hospitals adjust to follow the recommendations given.  This adjustment leads to an increase in mortality and, thus, the Joint Commission’s recommendations result in increased mortality. Obviously this is not the case. The only part of my practice that changes during a site visit is my diligence in making sure my coffee is not out where anyone can see it.

William Sullivan, DO, JD: Oooh. The study forgot to mention that more psych patients are associated with full moons and that surges in emergency department volume are associated with someone saying the “Q word.” Color me skeptical. There was a difference in the 30 DAY mortality for admissions during survey weeks. Let that sink in. Researchers didn’t just look at the mortality for the days/times when the surveyors were actually “in the HOOOOOUSE” (when the medical providers would presumably be “behaving” for fear of getting cited) but rather extrapolated data to include patient outcomes a month after the surveyors left (far after “bad” behavior would have resumed), assuming that there could be no other possible intervening factor causing the whole 0.001 change in mortality rates other than the effect of some bespectacled frump with a clipboard and a JCAHO badge looking over each medical provider’s shoulder at the exact moment that the provider is performing some mission critical life and death task. Did anyone notice that the indicators in which “surveyor observation” may have had a downstream effect weeks later (for example, C. difficile infections) had *no change in frequency* before, after, or during “Joint” inquisitions … er, um … visits? I have a better idea for a study. Tell me why it is a grievous threat to patient safety for medical providers to take a sip of coffee (with hazelnut creamer yet – be still my heart) in a “patient care area” but it’s perfectly fine for patients to be served trays heaped with food on tray tables that are pulled *directly over their beds* so that the patients can spill food and drinks on themselves several times a day. Why we up with this idiocy is beyond me.


A UNC study shows poor oral health and scarcity of food are culprits leading to malnutrition in adults

ERs need to link malnourished patients to national programs such as Meals on Wheels, author says. Original Article by Science Daily.

E. Paul DeKoning, MD, MS: Seems to fit with my practice. Not sure if poor oral care is the chicken, the egg, or the canary, but I see it in the young and old. Its effects are, as are many, magnified with age. It is really difficult to get my patients access to timely (or any) dental care, regardless of age. I routinely see patients in their 20s with horrible dentition (or what’s left of it) and many dentists require cash up front; these patients often just don’t have it. More nutritious food is more expensive, plain and simple. Cheaper food is full of all the crap that triggers those pleasure centers in our brains (sugar, bad fats, etc) and rots our teeth in the process. Add to that a dash of poor self-image/mental health disorders/other comorbidities, and a scoop of expensive (if even available) dental care and you’ve got a recipe for EM job security. And I don’t mean that as a good thing.

William Sullivan, DO, JD: Interesting that the study classified 12% of 250 subjects as being “malnourished.” Not sure why patients living in an assisted living facility would be at risk for malnourishment. Note that the study says that malnutrition and poor oral health were “associated” – don’t know if anyone will ever be able to determine which was the chicken and which was the egg in this scenario.


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