Ratios Wars

Hospitals Need 25% More Nurses | LAT | 10.26.04

Officials say the L.A. County facilities cannot fully comply with state ratios. Some employees refusing to take on more patients are suspended.

Los Angeles County’s five public hospitals are more than 25% short of the number of nurses they need to fully comply with state laws on nurse-patient ratios, and officials doubt they can substantially increase the nursing ranks anytime soon. …

County officials deny they are jeopardizing the health of patients but acknowledge they are not in full compliance with the ratios. The county says it needs 4,555 nurses to meet state rules but has only 3,361 nurses at the five hospitals.

Dr. Thomas Garthwaite, director of the county’s Department of Health Services, said he is unhappy with the situation but sees little alternative…”If it was unsafe today, we would take immediate action,” he said. …

Nurses at Harbor-UCLA Medical Center and County-USC have refused to take on more patients than allowed and called union representatives to back them up. Some arguments with supervisors grew so heated that police were called. …

Los Angeles County is not alone in its struggle to meet the state’s mandate, said Jan Emerson, a spokeswoman for the California Healthcare Assn.

About 85% of the hospitals throughout the state do not meet the nurse-to-patient ratios. On average they had 15% fewer nurses than needed to fully meet the ratio rules. …

“They’re always staffing to the bottom line, saying they didn’t anticipate emergencies or anticipate a nurse calling in sick.”

Anyone working in a high performance EMS system will recognize the tremendous conceptual gulf that nursing-ratios have created between what has been implemented and what is needed. In essence, ratios are the EMS-equivalent of the responsive time parameter. If an EMS system has a response time of 4 minutes for BLS at the 90^th percentile and 8 minutes for ALS at the 90^th percentile this translates into a time-of-day, day-of-week, and time-of-year staffing regime. A high performance EMS can [not] offer this degree of performance based on anything less than a peak-staffing model based on historical data. What the nurse-staffing ratios forced in January was average staffing driven in a reactionary fashion. Peak-staffing is expensive, but in the long term it may be the only way to meet compliance (which is not going away, on the horizons are significant litigations—not to mention what role ratios will play with malpractice) and decrease the tremendous costs of filling staffing deficiencies with “travelers.”

With regards to a nexus between ratios and malpractice, will ratio non-compliance ever be used to prove negligence, via negligence per se, in proving negligent liability?

“Not-Profit” Toss

Ala. uninsured suit dismissed in first such ruling | Modern Healthcare Alerts | 10.22.04

A judge dismissed one of 48 class-action lawsuits on file against hospitals nationwide on behalf of uninsured patients, ruling that the charges had previously been tried in state court and that a foundation of the suit — the Emergency Medical Treatment and Active Labor Act — did not apply. …

Plaintiffs had already lost in state court before the class-action suit was filed, and the federal court cannot rule again on the charges under the legal concept res judicata, the judge said. …

The plaintiffs, though, said the panel’s ruling indicates that the Alabama decision may not apply to other cases. “It would be inappropriate to speculate on whether (the judge’s interpretation of EMTALA) applies to other cases. The issues and facts are different,” said Robert Siegfried, a spokesman for the coalition of law firms. Meanwhile, Emerson Hopkins’ point about res judicata “was a technical decision,” Siegfried said.

Suit against Baptist hospitals dismissed | The Birmingham News | 10.23.04

A federal judge has dismissed the class-action lawsuit against Baptist Health System filed on behalf of uninsured patients who claimed they were overcharged and subjected to unfair collection tactics. …

“The dismissal doesn’t really change the egregious nature of the way these plaintiffs were treated,” Lamb said. “It has nothing to do with the merits of the case or whether what Baptist did is wrong or illegal.” …

See PointofLaw.com and Press Releases.

It’s nice to see class action litigators forget about res judicata. Solution? Just swap out the named claimants (subset of plaintiffs in the class) and the claim preclusion bar is removed.

Facial Foolishness Followup

Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit?
Annals Emerg Med | 10.22.04

See under “Articles in Press”

See here

Canadian Mythology

No time for Kerry’s Europhile delusions | Chicago Sun-Times | 10.24.04

Speaking of which, if there’s four words I never want to hear again, it’s “prescription drugs from Canada.” I’m Canadian, so I know a thing or two about prescription drugs from Canada. Specifically speaking, I know they’re American; the only thing Canadian about them is the label in French and English. How can politicians from both parties think that Americans can get cheaper drugs simply by outsourcing (as John Kerry would say) their distribution through a Canadian mailing address? U.S. pharmaceutical companies put up with Ottawa’s price controls because it’s a peripheral market. But, if you attempt to extend the price controls from the peripheral market of 30 million people to the primary market of 300 million people, all that’s going to happen is that after approximately a week and a half there aren’t going to be any drugs in Canada, cheap or otherwise — just as the Clinton administration’s intervention into the flu-shot market resulted in American companies getting out of the vaccine business entirely.

Hat Tip Brooks …

Finally someone posted the truth—the [only] reason that Canadian drugs are cheaper is because the cost is always subsidized from the primary to secondary (or peripheral) market(s). All that “outsourcing” of prescription drugs purchases to Canada is going to do is destroy the benefits (lower cost) enjoyed by those already purchasing from Canadian. Any increase demand will diminish the suppy to the secondary market with the only possible response being increased costs. This is a mega-DUH, that could only be sold as political Swill.

Healthy Mae

Momentum Builds for U.S. Role in Paying Highest Health Costs | NYT | 10.23.04

Senator John Kerry is pushing the concept, and so are some Senate Republicans. That is why lawmakers and lobbyists say that regardless of who wins the presidential election, Congress will soon take up the idea of fighting high health insurance costs by shielding employers from the most expensive medical cases.

In seeking to rein in the costs of the runaway insurance premiums paid by employers and their workers - nearly $520 billion this year and rising - politicians of both parties and some business groups are pushing an idea known as reinsurance. Such an approach might take its place alongside existing federal reinsurance programs, like the ones for floods and other natural disasters, or for the damages that might result from acts of terrorism.

Although Mr. Kerry’s proposal calls for a much larger government role than a plan recently floated by the Senate Republican leader, Bill Frist, the goals are similar: to reduce the financial burden on employers when their workers’ medical bills rise above a certain threshold. …

Dr. Frist has referred to it as a “national publicly chartered, privately run ‘Healthy Mae.’” …

“This would help insurers more broadly share risk, reduce administrative costs and create a vibrant secondary market for health insurance, just as we have done for home mortgages,” Dr. Frist said. …

Jeff Lemieux, an economist and health policy analyst for the insurance industry, said the Kerry and Frist proposals had similar goals. “In essence,” he said, “Frist’s Healthy Mae proposal is a public-private version of Senator Kerry’s direct-subsidy idea. But Healthy Mae would probably be less expensive than Kerry’s direct subsidy proposal, and it would be less likely to lead toward government regulation of health benefits.”

Megan E. Hauck, deputy policy director of Mr. Bush’s re-election campaign, said that if the government shared the cost of the most expensive cases, it would inevitably scrutinize and try to regulate the care it is paying for.

“If the federal government helps pay for costs above a certain threshold, it will look at every claim above that level,” Ms. Hauck said. She predicted that the government would then demand answers to many questions: “What counts toward the threshold? How did you meet the threshold? Why does your surgery cost more in one area of the country than in another?”

Some form of reinsurance makes very good sense, and because of the bipartisan support it will survive 11/2. A state version of a national “Healthy Mae,” see New York’s Healthy NY.

Facial Foolishness

Poor Health, Not Lack of Primary Care or Medical Insurance Found to Drive Emergency Visits
ACEP Press Release | 10.18.04

San Francisco — The first large-scale study of its kind finds the majority of individuals who use emergency departments have a usual source of care, medical insurance and are not poor. The biggest factor driving people to seek emergency care is poor physical and mental health, according to the study, which will be released today at the American College of Emergency Physicians’ annual meeting being held here. It is to be published Oct. 19 as an early online publication of Annals of Emergency Medicine (Does Lack of a Usual Source of Care or Health Insurance Increase the Likelihood of an Emergency Department Visit? Results of a National Population-Based Study).

“Contrary to popular perception, individuals who do not have a usual source of care are actually less likely to have visited an emergency department than those who have such care,” said the study’s lead author Ellen J. Weber, MD, Professor of Clinical Medicine in the division of emergency medicine at the University of California, San Francisco. “Many insurance programs, and particularly public and private HMOs, require beneficiaries to have a primary care physician, which may be expected to improve overall health and health care, but the continued rise in emergency visits implies that such programs have not had a substantial impact on overall emergency department use.”

Hat Tip CodeBlueBlog

It will be interesting to see the actual article—despite stating that it will be online 10/19 it isn’t available yet (I just checked). Very strange way to announce such a controversial article—at first blush this has no facial validity (not in my ER, or any ER I know). I’m sure it had nothing to do with the national ACEP meeting in San Francisco this week.

National ACEP may have just shot CAL/ACEP (California ACEP chapter) in the foot with their efforts to get Proposition 67 passed on 11/2. When the state chapter is making the Proposition argument that ERs in California are on the brink of financial extinction, it makes no sense for their parent national organization to issue a press release quoting an article, not published, that purports to shows that “85 percent reported having medical insurance, and 79 percent reported having incomes exceeding the poverty threshold” while the state chapter is asking for a 3% surcharge. Arguments: Bipartisan, Pro, Con.

Walk in My Shoes

Defensive medicine as the cost of an aggressive tort industry | RangelMD.com | 10.19.04

Another example is the high rate of cranial CAT-scans of children in the emergency department following head injuries. Every year thousands of children receive minor head injuries as a result of typical play and sports but every year thousands of these children receive CAT scans despite the fact that they have normal neurologic exams and normal mental status (i.e. no indication of serious intracranial injury).

As a result, thousands of children are exposed to very high levels of radiation despite the fact that there is no data that aggressive scanning changes head injury outcomes and very few of these scans show any intracranial pathology. One of the reasons many of these physicians give for ordering one of these scans is because of “pressure from worried parents”. The real reason for these excess scans is that ER physicians don’t want to sit in a court room and try to explain why they didn’t order a CAT scan for a child who is now dead or severely disabled. A single CAT scan can cost over a thousand dollars. This certainly adds to the costs of medical care.

Great article (as always)—but then I got to these paragraphs (supra) and I just had to comment. In my practice of Emergency Medicine (now into my 15^th year post-residency), my threshold for getting a head CT with isolated pediatric head trauma has gotten lower. I trained in a Level I trauma center and certainly saw the entire spectrum of head trauma (both isolated and in association with multi-system trauma) in adult and pediatric populations. Most of my practice has become more conservative—is it defensive, sure to a point. But it is also the natural course of training tempered by experience. It is also practice and experience tempered by practice realities. One of the most significant drivers for the need for head CT (along the lines of parent expectations) is the scripted responses from the advice nurse, which many health plans offer—planting the seed of need for a head CT. Or the call to the primary care provider (PCP)—who says go to ED immediately, the child needs a head CT… I’m placed in a no win situation, my hands are tied, and I order the test. Defensive? Yes, but not of my own doing. I’m sure many of my fellow emergency physicians can echo how our hands are tied by the seeds of expectation that are planted by those calls or those “front-desk” office visits with their PCPs (”you’re too sick to be seen here, go to the ER;” “we don’t take that insurance anymore go to the ER because you need a CT;” “you don’t have insurance, the ER can see you and do the tests,” or the barely legible scrawl on a presciption pad that says “patient is sick, please evaluate”). A reasonable history and physical would have disspelled any notion of a need for any testing.

With regards to the “cost” of the head CT, that is an artificial argument—because it really isn’t a cost argument, it is a “charge” argument—what is this particular patient going to be charged based upon their particular health plan. The marginal cost of that singular scan is quite small.

With regards to the “radiation” exposure, well that seems to be a much more significant argument, and certainly must be placed in the balance.

Finally, I practice on the tip of the emergent healthcare spear, some aspects of my practice are defensive in terms of thwarting future litigations; but also defensive because of the need to block the offenses of my fellow healthcare colleagues. My clinical agenda is many times set by the defensive agenda of my clinical colleague, and many times completely beyond any backfield maneuverings.

Preemptive VoIP

F.C.C. to Seek Net Telephone Oversight | NYT | 10.19.04

BOSTON (AP) — FCC Chairman Michael Powell said Tuesday that he would seek broad regulatory authority for the federal government over Internet-based telephone services to avoid stifling the emerging market.

Powell told a receptive audience at an industry conference that letting states regulate Voice over Internet Protocol,or VoIP, services would lead to a patchwork of conflicting rules like those which have ensnarled the traditional phone business for decades.

To do so, Powell said, “is to dumb down the Internet back to the limited vision of government officials. That would be a tragedy.” …

“We cannot avoid this question any longer,” he said. “It is very likely that treatment of VOIP will have some of the farthest reaching consequences of anything this commission has done or will do.” …

“There is no need to organize a regulatory regime around permits and prices and costs as we have done for nearly a century with common carriers,” Powell added.

Good news! VoIP, Preemption, Supremacy Clause, Commerce Clause

GruntFellow

Congratulations! Welcome to the club.

Quality and the Uncertainty Principle

4 Hospitals Get Surprise Inspections | LAT | 10.19.04
A national accrediting agency scrutinizes L.A. County facilities to see if they have the same problems as King/Drew

Reviewers from a national accrediting agency arrived Monday for unannounced inspections of four hospitals run by Los Angeles County to see if they are experiencing the same problems as the embattled Martin Luther King Jr./Drew Medical Center.

The teams are examining patient charts and other aspects of care at County-USC Medical Center in Boyle Heights, Harbor-UCLA Medical Center near Torrance, Olive View-UCLA Medical Center in Sylmar and Rancho Los Amigos National Rehabilitation Center in Downey.

The inspections come just days after the president of the Joint Commission on Accreditation of Healthcare Organizations sent a scathing letter to the county Board of Supervisors, unequivocally blaming it for serious lapses in patient care at King/Drew. …

“I wish to be clear that the responsibility for these failures — whose effect has been to place a uniquely vulnerable patient population in harm’s way — by definition lies with the County of Los Angeles Board of Supervisors,” wrote Dr. Dennis S. O’Leary, president of the joint commission, in an Oct. 14 letter faxed to each supervisor.

Shouldn’t this be how JCAHO normally operates? You know when JCAHO is coming…just look at all the nurse manager vehicles in the parking lot and see how many coffee pots are sitting in the front seat. You want to assess quality as it is on a daily basis—not as a variation of the Hawthorne Effect. There ought to be an Uncertainty Principle for healthcare: the certainty of quality can not be known when the time certainty of observation is known.

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