Crash Cart: Gig-Style Staffing; Source of Surprise Bills; The Diagnosis of Human Trafficking

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This week: NomadHealth aims to reduce staffing shortages; One company behind many out-of-network charges; Why human trafficking needs an ICD code. Join in as our editors discuss the week’s headlines.


The Association of American Medical Colleges (AAMC) projects a shortage of 40,800-104,900 physicians relative to need by the year 2030

An offshoot of telemedicine, Nomad Health, describes itself as the “Airbnb” system of medical staffing, matching doctors—and soon to be nurses—with hospitals looking for freelancers. Original Article by Fortune.

E. Paul DeKoning, MD, MS: Sounds awful, even worse then locums. Don’t sign me up. Systems stuff is much of what we do on any shift and short-term assignments seem to be potential for systems-type medical errors. Doesn’t sound good to me.

Ryan McKennon, DO: I think this just increases the thought that we are all dispensable cogs that can be replaced by any warm body. Programs like this may help some areas staffing problems, but hurts others. The number of RNs (and physicians) is finite, programs like this do not increase the number of docs or nurses, just shift them around. It also is likely to increase errors. How do you acclimate to new systems with short periods of employment, this seems to be even shorter stints than locums work. Most importantly, what about the teamwork that develops when a group of people work together for a period of time. Systems like this encourage changing hospitals frequently and while this may be fun, new, and challenging, I don’t think in the long run it’s necessarily good for patient care.


In America, more than 1 in 5 visits to an in-network ER result in an out-of-network doctor bill, and nearly a quarter of all ED docs work for a national staffing firm

But new research shows the issue isn’t scattered at hospitals across the country; it comes from select doctors at certain hospitals run by a company called EmCare. California and a few other states have tried to cap how much out-of-network docs can charge and limit such “surprise bills,” but some doctors have fiercely lobbied against such actions, which may weaken their bargaining power. Original Article by The New York Times.

Ryan McKennon, DO: I don’t work for and have no affiliation with EmCare, but I think this piece was a bit unfair. The insurance company (who lists the hospital as in-network) refuses to negotiate with a staffing company who then bills patients directly and somehow no one is angry at the insurance company. Out-of-network bills will always be higher than in-network bills, this is not exclusive to EmCare. They compare with the previous ER group who was able to negotiate with the insurance company which is an unfair comparison. The level 5 charts increased from 6% to 28% when EmCare took over. This is likely because staffing companies like EmCare have a heavy focus on charting and billing appropriately so as not to lose revenue. Some of the older, smaller groups may not have that same focus (for good or bad). The implication here is that EmCare is billing inappropriate CPT codes. If they are, its fraud. And if the authors believe that is the case, they should say so in the article.


Is it time for human trafficking to be recognized as a medical diagnosis?

What do “struck by a duck,” “Sucked into a plane’s engine,” and “walking corpse syndrome,” have in common? They’re all codes in the International Classification of Disease (ICD) created by the World Health Organization (WHO). As the WHO approaches its 11th edition, two doctors that that research and treat human trafficking are advocating for its inclusion in the code, noting that an estimated 21 million individuals are victims of it. With reports of human trafficking in the U.S. on the rise, physicians can help identify victims by thinking about trafficking as part of their differentials. Original Article by STAT.

E. Paul DeKoning, MD, MS: The topic of Human Trafficking is an important one–I guarantee I/we are seeing these patients and missing opportunities to truly save lives. However, I’m not sure if this is the answer. I can also guarantee that I have never used the codes for “adult and child abuse,” “problems related to release from prison,” “disruption of family by separation or divorce”, or “victims of crime and terrorism.” I was taught to never state unequivocally that a patient was assaulted, but rather that there was “alleged assault”. This may be that. We simply don’t have all of the information at our disposal to make these types of definitive diagnoses and potentially give our patients a label that is just wrong, at least from the ED. It can be difficult to get wrong diagnoses or even erroneous allergies removed from a patient’s chart: “problem list drift” tends to end up carrying on thru a chart. Given the potential stigma associated with such a diagnosis, I would avoid ever using it—and I’m a proponent of giving voice to this hidden epidemic. A better option is to continue to give voice to the problem and get patients the care and protection they need; don’t worry about the ICD code.

Ryan McKennon, DO: I agree with the author that it is important for physicians to think about human trafficking, “Screening for trafficking, much like screening for intimate partner violence, involves recognizing a pattern of medical presentations from exposure to physical and emotional traumas as well as signs of being in an abusive relationship.” That being said, I’m not sure how an ICD-10 (or 11) code helps to do this at all.


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  1. Re: the NBER study on Surprise! Balance Billing The authors of this study indicate that the data from the millions of claims they reviewed suggest or imply that some EmCare providers: upcode their claims; charge excessively; overorder tests; arrange for unnecessary inpatient admissions; aggressively use surprise balance billing as part of their business model; and share the excess revenues generated with their hospitals through joint ventures. Granted, the claims data came from a single health plan source (and may have been manipulated first); the study is not peer reviewed; the authors seemed to have a bias; the source of funding for the study is unclear; the statistical methods are obtuse; and the conclusions and recomendations a bit one sided. But here is a question. What can or does the House of Emergency Medicine do if, despite this study’s flaws or shortcomings, some of these allegations are true?

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