Crash Cart: EM in space, costly teaching hospitals, and overcharging patients

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This week: Dammit Jim, medicine in space ain’t easy!; Learning the benefits and costs of teaching hospitals; Hopkins finds ER patients routinely overcharged. Join in as our editors discuss the week’s headlines.


Astronauts on long-term missions, like a crew going to Mars, face special medical risks that require ingenuity

Weakened bones, radiation poisoning, and decompression sickness are a few likely issues. CPR would need to be rethought. Approaches to such problems include basic medical training for all crew, matching crew by blood type, Telemedicne, 3D printing, and non-intervention in some cases. Original Article by Seeker.

E. Paul DeKoning, MD, MS: Makes me think of that old episode of ER where George Clooney’s character criched a kid with a Bic pen in a culvert that was rapidly filling with water. While I’d rather not be criched in space (or anywhere, for that matter), I’d readily put my life in the hands of a fellow EMP in an austere setting–it’s just what we do. Every day. For the record, I would NOT put my life in the hands of George Clooney.

Ryan McKennon, DO: I never thought about having to do CPR in space. Due to lack of gravity, strapping someone to the thumper would probably be your best bet. Although honestly, if a young healthy astronaut on his or her way to Mars is requiring CPR, there is probably no reversible cause. Seems like they could be focusing on other, more common and treatable, interventions.


For insurers and policy-makers, there are only two kinds of hospitals: teaching (26% of all American hospitals) and non-teaching

With Medicare paying more to teaching hospitals, the question is whether the added cost is worth the statistical benefit in positive outcomes. The debate is unlikely to end soon. Original Article by The New York Times.

E. Paul DeKoning, MD, MS: I’d like to think we save people’s lives. Every patient in my ED gets seen by at least two MDs, sometimes 3 and maybe a medical student somewhere in the mix as well. I’ve got to think that, despite the inherent challenges of providing training while simultaneously providing care, that that counts for something. Plus, training programs continually strive to stay ahead of the standard of care.

Ryan McKennon, DO: So there is an observed 1% mortality difference at 30 days for hospitalized patients who are discharged from a teaching v non-teaching hospital. That’s a correlation. The author of the article then concludes teaching hospitals save lives. When are we going to learn the difference between correlation and causation. Here is another equally plausible conclusion: teaching hospitals admit patients unnecessarily. The study was based only on patients hospitalized, not those who presented to the hospital or the ED. In my experience (I don’t have a study to prove this), teaching hospitals admit more patients who probably don’t need to be admitted than non-teaching hospitals. The 30-day mortality for those patients is near 0. If I just admitted everyone who come to my ER, my denominator of patients with a low 30-day mortality would be huge and thus my 30-day mortality for all hospitalized patients would drop significantly. Does that explain the 1% difference. I don’t know. Maybe teaching hospitals are, in fact, safer and provide better care. If so, we should look into why and try and emulate that at non-teaching hospitals. But until we know the answer as to WHY there is a difference, lets just put away our jump-to-conclusions mats.


A Hopkins School of Medicine study finds people are charged on average 340 percent than what Medicare pays for treatment and services

This illustrates the need for transparency of pricing according to the study published in JAMA. Massive disparities in costs aren’t the worse of it—the study EDs price gouging the most were more likely to be located in for-profit hospitals in the southeastern and Midwestern U.S. and serve populations of uninsured African-American and Hispanic patients. Original Article by Hub.

E. Paul DeKoning, MD, MS: Who is doing the billing? The EMPs themselves or coders? Systematic bias on the part of either is a problem.

Ryan McKennon, DO: See above on jumping to conclusions. This study looks like a narrative in search of data. On average, ER physicians charge higher rates above Medicare than the internal medicine docs do at the same hospital. So as the lead author states (a 4th year medical student) “[t]his is a health care systems problem that requires state and federal legislation to protect patients.” Or maybe we should look into the why first.  Insurers negotiate lower rates then those non-insured. The largest discrepancies were noted in out-of-network patients. As we have recently seen, insurers can make a hospital in-network but not allow the ED group at the same hospital to be to be in-network. Patients are much less likely to be admitted to an out-of-network hospital as the patients usually request transfer from the out-of-network ED.  Could that be the reason for the price “gouging?” This also only addresses charges, not collection. What about the hospital that, according to the study, charged 14 times the medicare allowable rate for all internal medicine services (higher than any hospital ER markups)? First, we need to find the reasons so the root of the issue can be addressed. Then the legislation if need be, not the other way around.


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