The future of medicine in Washington State

[Asysin2leads]

So Doc, if I have it straight, ERs will still be under obligation to afford treatment to those aforementioned maladies but the State will no longer be under any obligation to pay for those treatments? There hasn't been any changes to the EMTALA laws when I was asleep, right?

If that's the case, then if any good comes out of it will be to produce an incentive for healthcare providers to try and keep asthma, CHF, and heart dysrhythmias managed before they become and emergency.

Edited January 17, 2012 by Asysin2leads

[chbare]

EMTALA has not changed. Unfortunately, I'm not as optimistic. Even with great follow up and perfect compliance, people with chronic problems can acutely decompensate if you will. We've all seen what a run of the mill Billy Ray Viral infection can do to some diabetics.

[ERDoc]

Asys, EMTALA as not changed. All it says is that a person who presents to an ER be given a screening exam to see if there is a life threatening condition. It does not say anything about treating non-life threatening conditions. In theory, you can tell someone, "Your bronchitis is not life threatening therefore you do not need to be seen in the ER. Goodbye." The problem is, with lots of things, you don't know if it is life-threatening without a workup. Another issue is pt satisfaction. Do you think your satisfaction scores (which will soon be tied to your payment) will be very high if you turn everyone that doesn't need to be there away? It's a double edged sword. You also asked about incentive to control things such as asthma. The problem is that there is no incentive to do this. This bill in WA only affects ERs. We are not good at long term control of chronic conditions. That is what PCPs are for. So, we are being punished for the pt's lack of responsibility for not going to their PCP and for their PCPs failure to control their medical problems (which most times is out of the PCPs control due to pt compliance). We are the ones that have virtually no control over the situation and we are bearing all of the responsibility.

The PERC is used to stratify people who have already been determined to be in the low risk group. If they meet the 8 criteria they have less than a 2% chance of a PE. If they don't meet the 8 criteria but you still classify them as low risk (Wells, clinical gestalt, crystal ball) you can use a d-dimer to rule them out. If your d-dimer is negative you have ruled them out, positive, they need to be worked up. It is a good screening tool because it has such a high sensitivity but sucks for making a diagnosis because it has a low specificity. There are many other things that can increase the d-dimer. People in the moderate or high risk groups can have a negative d-dimer but because the possibility of having a PE is so high, they d-dimer does not adequately rule it out, so further testing in necessary. Not everyone who presents with chest pain will get a d-dimer. It is only used when PE is a concern.

[Asysin2leads]

ERDoc, so I have a better understanding of the situation, how much does Medicaid reimburse for ICU stays? I mean, I've seen ICU bills run up to $100,000 a day. How much of that does Medicaid actually pay for John Q. Crackhead who refused to take his high blood pressure medication and then had a stroke, necessitating the ICU stay?

I'm not trying to bait or anything like that. This topic just reminded me I wanted to find out what Medicaid reimbursement rates were for the ICU.

[chbare]

Medicare and other programmes often base reimbursement off of the diagnosis related group (DRG) type system. Basically, an issue or constellation of issues involves a certain set of services or products. Reimbursement for the so called product is based on what DRG the patient falls under. DRG classification is based largely on the ICD classification and a few other factors. Also, certain conditions that are considered hospital acquired and considered largely preventable suc as catheter related infections are typically not reimbursed.

[ERDoc]

Here is a blog from an ER doc in Washington.

http://allbleedingstops.blogspot.com/2012/01/washington-medicaid-vs-prudent.html

Asys, that is a very difficult question to answer. Each state is responsible for its medicaid program so reimbursement varies from state to state.

[systemet]

The PERC is used to stratify people who have already been determined to be in the low risk group. If they meet the 8 criteria they have less than a 2% chance of a PE. If they don't meet the 8 criteria but you still classify them as low risk (Wells, clinical gestalt, crystal ball) you can use a d-dimer to rule them out. If your d-dimer is negative you have ruled them out, positive, they need to be worked up. It is a good screening tool because it has such a high sensitivity but sucks for making a diagnosis because it has a low specificity. There are many other things that can increase the d-dimer. People in the moderate or high risk groups can have a negative d-dimer but because the possibility of having a PE is so high, they d-dimer does not adequately rule it out, so further testing in necessary. Not everyone who presents with chest pain will get a d-dimer. It is only used when PE is a concern.

Cool, thanks for the teaching point! I wonder how much further ahead EMS would be if more ER physicians engaged themselves in helping paramedics better understand medicine?

Thanks again.

[Kiwiology]

I agree mate; but Ambulance needs to take its own responsibility for learning and professional development and the global trend towards University over higher education is showing that some places are actively doing that.

A good example is I was watching one of the underfed, horrendously overworked and dangerously fatigued House Surgeons' examine a patient's belly; she put one hand on top and one on bottom (the patient was lying down, so one anterior and one posterior) on the mid-lower right side and gave it a good push; I have no idea what she was palpating for, probably spleenamegly, spell, spelan, enlarged spleen or some shit ... damn underfed, dangerously fatigued and horrendously overworked House Surgeon's and their super sly super secret super fundamentals-of-medicine physical examinations not taught to dumbshit Ambo's!

Or if you nick around to a GP's urgent and the GP hands (or tells you) lab values or such like ... most ambo's don't understand what they are, they might know "the patient needs a blood tests for their heart attack" but do not know a normal CK_mb or trop-T is or the physiological significance

Mind you a lot of nurses here probably can't either' I do some tutoring of our nursing students and their lack of appreciation for the basis fundamental of clinical medicine which have been established over thousands of years is just appalling; be it that everything has some sort of physiological end-point (that you can trace sign or symptom or condition back to some physiology) or that you should make sure the patient's bedsheet is not all wrinkled and that a shivering patient should get a blanket ... it just boggles the mind

Some of those dangerously underfed, overworked and fatigued House Surgeons should be reminded of that too ... never hurts to rub the bell of your stethoscope between your hands to warm it up before you shove it down frail old Nana's hospital gown or not to walk away and put the bloods in the lab tray if the patient is talking to you; even if it is just two feet.

Mind you, I am just a Consultant Kiwiologist (if only in my mind ....) so what do I know?

Edited January 18, 2012 by kiwimedic

[ERDoc]

Kiwi, your house surgeon might be more overtired than you think if she was feel the right side of the abd for a spleen. As for the nurses, they are trained in nursing, not medicine. There is some medicine in the nursing course but it takes a good nurse to put the extra effort in to learn the extra stuff. Luckily, there are quite a few of them where I work and they are more than awesome.

As for healthcare reform, I think it should be required that all ERs have inhouse, conultant Kiwiologists. If not, I might need to hire my own personal one. Must look good in a bikini, even in Michigan during the winter.

[Kiwiology]

Kiwi, your house surgeon might be more overtired than you think if she was feel the right side of the abd for a spleen. As for the nurses, they are trained in nursing, not medicine. There is some medicine in the nursing course but it takes a good nurse to put the extra effort in to learn the extra stuff. Luckily, there are quite a few of them where I work and they are more than awesome.

True. What I was getting at was more most take little to no interest in the actual medical management of their patients, the reasoning behind what they do or generally fail to advocate for their patients which is where a little foundation knowledge comes in mighty handy. For example, this one bloke with horrendous nausea curled up in a ball in a half-upright position on the bed (ED trolley); the sheet under him had slipped halfway down the bed and he was clearly in much discomfort. Wanting an MSU out of him they loaded him up on oral fluid, which made his nausea and gastro much worse.

The RN told him "well we can't do anything if the ondansetron and cyclizine haven't worked we need a urine sample out of you if you don't drink we're going to catheter you" and just walked off; I noted one of the students then whipped in and fixed his bed up for him ... bloody hell

Now, being the educated type I hit up the House Surgeon to give the bloke some IV fluid and gravol ... not 200ml of NaCl later he was in the loo pissing like a race horse! See how easy that was ... and this bloke looked 2000% better, magic!

Normally I tend to put the ED physicians offside a bit (most notably the House Surgeons) for being very brisk, walk in, palpate this, mumble something and walk out never mind that the patient is shivering cold or covered in faeces or something ... they look at the medical needs of the patient and some are quite bad at ignoring everything else but then you get those that are great at actually look after the non-medical needs of their patient, even if they are underfed, overworked and dangerously fatigued!

As for healthcare reform, I think it should be required that all ERs have inhouse, conultant Kiwiologists. If not, I might need to hire my own personal one. Must look good in a bikini, even in Michigan during the winter.

Look mate you can't even speel Consultant bloody hell what are we going to do with you

Oh and I'll come to Michigan, just not Flint or Detroit man I don't want to get murdered or nothing, bravo 711 calls radio, we're jamming this thing into overdrive and legging it ... oh but first you have to tell me the answers to USMLE Step 1 ... is it ask the Registrar? Like it's ask the Registrar 322 times over right? or is one of them "ask the consultant on-call because the registrar died from fatigue and malnutrition?" ... right? thats it right?

I might have to go back to upstate New York but bloody hell all them blokes can't understand a word they say, for example

Me: Yeah this is Little Timmy, he went into the football tackle sort of slightly abnormally and heard a loud crack in his neck, he has no neurological signs but the first person to him, this fella over here, is a Consultant Physician, he said he felt a step at C6

Rural upstate New York volunteer EMT: I see, yo can we get some subtitles up in here?

Dramitisation may not have happened

Gosh look at me getting all off topic and such

Edited January 18, 2012 by kiwimedic