Healthcare Update Satellite – 10-21-2013


Setting the record straight about EMS myths. Well … really one myth … going to an emergency department by ambulance doesn’t mean you’ll go to the front of the line. The places that I work will frequently have patients who come by ambulance go directly to the waiting room. Other times when it isn’t as busy, the patients would have gone straight to a bed regardless of how they arrived. Calling an ambulance to try to game the system isn’t worth the expense.

One of the things people don’t think about when filing a lawsuit is called “subrogation.” If insurance has paid for care that is related to your lawsuit, they’re going to want to be reimbursed for the money they spent. If the government spent $250,000 on your care and you win a $500,000 malpractice suit, between the costs of suit, the attorney’s fees, and the government subrogation claim, you’re going to come away with very little money.
In this case, a patient is trying to block Oregon from taking $236,000 of her malpractice settlement – an amount that the state claims it paid for her care over 6 months. I’d like to see the itemized bill and receipts for that bill.
And if an insurance company is allowed to prevent a patient from receiving a “windfall” of a malpractice judgment, shouldn’t policyholders be able to prevent insurance companies from receiving a “windfall” of premium payments when the policyholders don’t use the insurance? You lawyers know of any “reverse subrogation” cases?

OK, these pictures are disconcerting. Now I’m going around looking at the size of senior citizens’ ears. How does a person’s appearance change with age? Ten photographic comparisons show that ears and noses get bigger, eyelids droop, and sun exposure kills a complexion. But the ear thing still weirds me out the most.

Dr. Ben Carson claims that Obamacare is “ the worst thing that has happened in this nation since slavery” and that it is “making all of us subservient to the government.”

The government that has the power to give everything to you also has the power to take everything away from you. Food stamp benefits set to be cut before the holidays. Maybe Dr. Carson was right.

Hospitals need to change their business models with the Unaffordable Insurance Act. Hospitals with better clinical outcomes and better patient satisfaction surveys will receive financial incentives under Obamacare.
For those of you who think that better outcomes and higher satisfaction are good measures of quality, be prepared to be transferred somewhere else when you’re a high-risk patient (hospitals won’t want to risk a bad outcome on your care) and remember the studies showing that highly satisfied patients are nearly twice as likely to die from their medical care.

United HealthCare fires “thousands” of doctors in Connecticut who are caring for Medicare Advantage patients. Slick move. United HealthCare took this action right before Medicare enrollment started, so that Medicare patients could enroll in the United HealthCare program and then find that there were a lot less physicians to take care of them. And when patients don’t have access to health care, they can’t utilize as many services … which means that United HealthCare doesn’t have to pay as much money for treatments and doctor’s visits.
United HealthCare stated that it was releasing physicians in order to build a “network of health care providers that we can collaborate with more closely ….”
But at least those seniors have medical insurance.

22 year old patient who was paralyzed after spinal surgery for scoliosis wins $4 million malpractice verdict … against law firm that represented her. According to the accompanying news article, a jury decided that the Virginia law firm of Paulson & Nace committed legal malpractice when they incorrectly filed the first complaint on behalf of their client, then
I find it odd that Paulson & Nace doesn’t have this $4 million malpractice verdict on their “Our Results” page. Must just be a web site programming glitch.
One thing that struck me about this article was the grace and determination with which this young patient is dealing with her disability. Very encouraging.

Why the Unaffordable Insurance Act won’t work.
“Many young people—who are two-thirds of the roughly 40 million uninsured—will prefer to pay the penalty ($96 in the first year) rather than buy coverage, especially since they can always [just purchase coverage]when they fall sick. That’s because Obamacare bans insurance companies from turning away patients with pre-existing condition or charging them rates much above what others pay—the so-called community rating mandate. Over time, this will unleash a downward spiral of adverse selection: Rising premiums will push more healthy people to drop out, leaving the insurance pool sicker, which, in turn, will cause premiums to rise further, which will require more subsidies from an already strained federal fisc—until the whole Rube Goldberg structure collapses.”
When you can jump into the insurance pool only when you’re sick, it kind of defeats the point of having insurance.

What’s wrong with the driver’s seats in Saudi cars? Leading Saudi cleric Sheikh Saleh Al-Loheidan warned that medical studies show that driving cars “automatically affect[s]a woman’s ovaries and … pushes the pelvis upward.” Even worse, children born to women who continuously drive cars “are born with varying degrees of clinical problems.”
Riding in cars apparently has no such detrimental effects, which leads me to believe that the Saudis don’t know how to properly design driver’s seats.
And I can only imagine what the constant driving must do to Saudi men’s woo hoos. The horror!

Oregon law capping civil damages in all cases doesn’t apply to medical malpractice cases, but cap doesn’t apply to prenatal injuries. Recent Oregon Supreme Court ruling states that injuries to a child occurring during delivery are not considered “prenatal” injuries and therefore are not covered by the cap.

When a patient files a medical malpractice case, plaintiff attorneys can talk to the treating physicians without a defense attorney being present. However, defense attorneys are not allowed to talk to the treating physicians without the plaintiff attorney being present. A Florida malpractice reform evened the playing field by allowing both sides to discuss the case with the patient’s physicians. Now a judge has ruled that the Florida malpractice law is invalid because it conflicts with Federal laws.

Study shows that emergency physicians spend 43% of their clinical time entering data in a computer and 28% of their clinical time in direct patient care.
Those numbers pretty closely correlate with the mini study I did about 18 months ago.

The “Ottawa SAH Rule” published in JAMA has 100% sensitivity in determining when patients have a subarachnoid hemorrhage. Wonderful. Every one of patients with age > 40, neck pain, loss of consciousness, onset of pain during exertion, thunderclap headache, and meningeal signs has a subarachnoid hemorrhage. Are we not supposed to scan and LP patients who have fewer than six of those symptoms?
The real issue is that the rule doesn’t do a very good job in saying when people don’t have a subarachnoid hemorrhage … which is the question we need to answer in order to affect our clinical care. Caveats to applying the rule are contained in an editorial to the article by David Newman and Jonathan Edlow.

Georgia lawmakers attempting to overhaul the state medical malpractice system. Proposed system is a “no fault” system similar to worker’s compensation claims. If a medical injury occurs, a patient is compensated. No determination of “medical malpractice” is made. The bill’s proponents believe that under such a system, defensive medicine and subsequent litigation would decrease. If doctors’ names are reported to the National Practitioner Databank, the new law will increase defensive medicine and will increase litigation as doctors do whatever they can to keep claims from being reported.
When both the medical association and the bar association are against the proposed legislation, someone should get the hint that there may be a problem.


  1. The slide show was interesting.


    I’d like to know how they earned their lines. What is their story. Some looked so sad – worn out. Some agitated. Were they pricks/prickettes in life or did life turn on them?

    And some had a light about them. They aged …but seemed softer in appearance. I hope to be that fortunate – to age gracefully and with a light still shining outward.

    WC – Maybe it is a good thing that ears grow. Because …it might look a bit weird if everything else on a person’s face and neck drooped downward and yet …they still have these 2 little perky ears! Hmmm ..which causes me to wonder about people who get a lot of facelifts. Does that mean then that while their face is taught there ears will eventually hanger LOWER than their face? I wonder.

  2. I often picture what people I know looked like when they were kids. I just did it the other day when thinking about a neighbor and his personality. I smiled at the thoughts. But I could also be in conversation, face to face. 🙂

    I do that with anyone I didn’t know in their younger years. Friends, family I didn’t know, coworkers, talking heads on TV, my doctors, mechanic, pastor ..pretty much anyone I’ve seen more than once. I don’t know why. They’re cute images tho. 🙂

    Sometimes I see elderly (really elderly people), as what they looked like as babies – but with a lot of lines now.

  3. It sounds like you are arguing that the ACA should be modified to require every person to pay the full price of health insurance.

    The fundamental problem with health care in the US is that people receive something they do not pay for. There are basically only two solutions:

    1) Require everyone to pay “insurance” for the catastrophic care they could potentially receive.


    2) Be willing to refuse any medical care for those unable to pay at the point of catastrophic care or who decided not to purchase insurance. “Well, you are bleeding to death, but you decided to spend that $300 on a new phone. Too bad.” It is not as if we haven’t done something similar in the past. (See Dr. Charles Drew)


    It would be interesting to see if Paulson & Nace have previously argued that the medical damages cap was unconstitutional.

    • “Well, you are bleeding to death, but you decided to spend that $300 on a new phone. Too bad.” It is not as if we haven’t done something similar in the past. (See Dr. Charles Drew)

      The Charles Drew myth is a myth.

      It never was true, and it still isn’t.

  4. LawDragon, your friendly NW attorney and WhiteCoat afficianado, offering thoughts on the subrogation issue. I don’t see anything particularly unusual in the subrogation claim. Its routinely claimed and sometimes negotiated, typically in clams where the policy limits is obtained but fails to fully compensate for the injuries. Usually seen in auto accidents – really bad injuries, state minimum insurance, often PIP subrogation will be waived. In fact, when you have a client with whom Medicare has paid the meds, there is a paper process to work through which calculates the amount to be repaid. Admittedly, I haven’t seen the “we excluded past medicals from the settlement” argument before, but it seems to me there is something missing from that story. I would guess that perhaps the amount received was too low to compensate for the lifelong care the patient will apparently need. As for the claim that the State should pay its share of the recovery costs, that’s routine in some places. In my state of Washington we have the Mahler rule that requires insurers to contribute the contingent fee percentage amount of their subrogation amount back to the client so that they are sharing in the attorney fees and costs that gained the award. I believe Medicare does something similar as well. From my point of view this is a very fair rule.


    • I understand the principle behind subrogation, but my issue is that it seems one-sided.
      Patients are required to repay insurance companies if the patients get compensation for their injuries from another party, but insurance companies aren’t required to repay premiums if patients don’t make a claim. In other words, patients can’t have a “windfall,” but insurers can (and do).
      I like the idea of forcing the insurers to pay contingent fees back to the client. Doesn’t seem to hold true with government payors in all states, though, which puts patients on Medicaid/Medicare at a disadvantage. If patient’s injuries are severe, any judgments will be larger, but demands from feds/insurers for subrogation will be more.
      Does Washington state have to pay a portion of attorneys fees in a subrogation case as well?

      • I believe the key point that you are missing is that the repayment to the insurance company is for the cost of the medical treatment that is included in the settlement. Otherwise, the injured party gets a “windfall” due to the double recovery – once from insurance and again from the wrongdoer.

  5. “The “Ottawa SAH Rule” published in JAMA has 100% sensitivity in determining when patients have a subarachnoid hemorrhage.”

    This means that you can rule out SAH if a patient does not meet any of the criteria (100% sensitive). A high sensitivity indicates that if the test is negative, you can rule out whatever you’re testing for. Specificity will help you rule in a condition if the test is positive. This particular test had only 15.3% specificity, meaning that those symptoms ruled in SAH only 15.3% of the time.

    The high sensitivity does seem like a good way to avoid CT scans an LPs if all those criteria are negative…

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