Last summer I wrote a post "What's going to happen when you need a plastic surgeon in the E.R.?" about the worsening crisis in E.R. coverage among many specialists including Plastic Surgeons.

As we end the year, I've been seeing a number of articles referring to this come up again in our professional journals and on the news wires. MSNBC today highlights this again in a story "Emergency rooms find on-call specialists rare: Seriously ill suffer as relationship between physician and hospital unravels." Surveys of Emergency Room around the country have reported that as many as 75% have had issues about coverage for services like Orthopedics, Neurosurgery, Obstetrics, Hand Surgery, Oral Surgery, and Plastic Surgery.


In the MSNBC story, they profiled a patient who had trouble finding treatment from a plastic surgeon

Retiree Mary Jo McClure, 74, experienced the problem firsthand one Friday afternoon in January when she fell down some concrete steps, tearing large chunks of flesh from one leg. The plastic surgeon on call for Tucson Medical Center refused to leave her private-practice patients to come to the emergency department to treat McClure, who has health insurance. The doctor said instead she would see the injured woman in her office the next Monday.

But over the weekend, the specialist telephoned the family to say that she could not treat McClure after all because she performs only cosmetic procedures and is not trained to handle severe wounds, McClure said.

I can remember seeing this scenario multiple times during residency, and in this instance it is B.S.. This doctor may not want to or like to treat wounds but she is certainly over-qualified to. After examining it, she may determine that the extent of it requires surgical techniques she is no longer proficient in (eg. microsurgical techniques). This particular doctor is going to have to decide if staying on staff at that hospital is worth it to her for exposure to these issues from the ER. She may choose not to, but it looks real bad to behave like she did in this instance. Now for patients who present with hand issues, complex facial fractures, and mangled extremities I do feel it is more appropriate to defer treating if you don't do those types of procedures as the skill sets for treatment are more advanced and the resources required for their global care do not always exist at all hospitals.

I, for example, do not do any hand surgery (beyond smaller burns and occasional peripheral nerve procedures) in my elective practice and I do not take ER call for hand. Out of the nearly 40 Plastic Surgeons in my city, maybe 5 do any amount of hand surgery with most of those working at the University-affiliated level I trauma center. Outside the University, you may be SOL if you're trying to find a plastic surgeon doing hand injuries. As many orthopedic surgeons are following plastic surgeons out of the hand business, we're reaching critical mass for coverage of that specialty.

Traditionally, many specialists agreed to pull on-call duty in exchange for admitting privileges and use of a general hospital's facilities to perform operations and other procedures as part of their regular practice, O'Malley said. But the rise of physician-owned specialty hospitals and outpatient surgical centers over the past 15 years has reduced doctors' reliance on the general hospital.

"The historic relationship between physicians and hospitals is unraveling," O'Malley said.

I think that last sentence says it all. Surgeons en mass have reached a breaking point about being bullied by hospitals and insurers and now have some opportunities to walk away from uncompensated and unreasonable demands for ER coverage. In years past, the ER was a reliable practice builder for many plastic surgeons but in many instances it's now a reservoir of uninsured patients and offers less then cost reimbursement on insured patients with significant exposure of malpractice liability. What's not to like?

Much like I suggested when talking about specialty hospitals, the relationships between doctors and hospital ER's is going to have to be renegotiated. It's clear that hospitals will be having to pay stipends for ER coverage (which is perfectly reasonable to me) and that there will have to be increased medical malpractice tort reform for ER coverage to halt (if not reverse) this trend.


Rob

Readmore »»  

Wat ch Full Length : High Definition

Exhibit A: Wisconsin Democrat governor, Jim Doyle, is trying to do an audacious end run around the intent of a state-administered trust fund meant to control medical malpractice costs.

In 1975, the Wisconsin legislature set up a fund for physicians, hospitals, and other health professionals to contribute to called the Injured Patients and Families Compensation Fund. It was essentially a self-insurance "buffer" against rising med-mal costs and has been widely credited with stabilizing Wisconsin malpractice insurance premiums.

The assets of this fund are substantial, in excess of $735 million in 2007 (covering an estimated $685 million in potential liabilities). Such a large "pot of gold" has proven irresistible for Democrats in Wisconsin, and Gov. Doyle has proposed pillaging nearly $200 million to cover budget deficits the state is running up on their Medicaid program. While it's noble to fund a state's uninsured & under-insured, raping a successful program whose mandate and charter is very specific to the med-mal relief program is going to lead to a bitter court fight in Wisconsin between the Wisconsin medical association and Gov. Doyle.

In 2003 a state law declared the trust "for the sole benefit of health care providers participating in the fund and proper claimants. Monies on the fund may not be used for any other purposes of the state". Keep in mind that individual doctors have essentially been paying into this pool at somewhere between $8-10,000 annually for nearly 30 years. So in a nutshell, this Democratic proposal would turn an insurance program into a massive retroactive tax hike on providers while potentially causing the whole program to go insolvent (as assets would drop ~ $150 million below liabilities).

Gov. Doyle, you're the proud recipient of the inaugural Plastic Surgery 101 cheesehead award!

Readmore »»  

Wat ch Full Length : High Definition

Sorry for the dearth of writings! I've been in California all week.

An interesting and ironic story in the New York Times today "Rules to Collect Care Costs Are Coming Under Attack."

In summary, in a number of instances where complications involved with indigent medical care resulted in large medical malpractice judgements against municipalities, the cities have subsequently turned around and presented bills for their care to be subtracted from the judgement. I LOVE IT!

The case discussed in the article involved a psychiatric patient who's estate sued a city after he gauged his own eyes out in a treatment center (because obviously it must be the cites fault according to trial lawyer logic).

“This is a matter of fiscal responsibility,” said George Valentine, the Washington district’s deputy attorney general for civil litigation, explaining that city taxpayers deserved to be protected from expenses that could be shouldered by patients. Payment from Ms. Motley would have been due only if a jury found in her favor and the city would not have collected more than what was awarded, Mr. Valentine said."

Trial lawyers have complained that such attempts to re-compensate cities for free care gives too much leverage to the city when they're trying to negotiate settlements from them (and removes much of a potential windfall from their share of the settlement). This is just one more example of just how crazy our med-mal system has become.



Rob

Readmore »»  

Wat ch Full Length : High Definition

Something dramatic is about to hit health care practices in the United States. The Federal government has announced regulations such that Medicare and Medicaid programs will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”.

This list will apparently include:

• Injuries from falls in the hospital
• Urinary tract infections
• Surgical Site infections
• Blood transfusion reactions
• Re-operations for retained surgical instruments
• Bedsores and pressure ulcers
  

While no episodes of any of these events is the goal of medicine, it is IMPOSSIBLE to achieve that for a number of reasons. Consider the inpatient population in many locations - older, more obese, more medical co-morbidities, etc....

Only a bureaucrat who's never worked in a hospital could think up a program that's all stick and no carrot to address these. It makes more sense to reward achieving benchmarks rather then to punish oft impossible goals. But even the "carrot" from the feds is usually rotten, as can be witnessed by their attempts to establish similar outpatient medicine practice guidelines under the concept of "pay for performance".

To offset planned medicare fee cuts, they recently had a small trial offering a small 1.5% bonus for compliance with electronic medical reporting and some clinical issues. At the end of the trial, almost none of the large primary care groups could meet the threshold for the bonuses despite spending substancial amounts of capital to upgrade infrastructure to do it. While quality may have been improved, these groups essentially took pay cuts to do it. Does that sound like a program which is going to get much enthusiasm for participating?

WARNING: Trainwreck ahead!

What's going to happen in the real world with the new program as I envision it?

There's going to be not so subtle exclusion of high risk patients from inpatient treatments whenever possible. There will also be tremendous pressure for hospitals to dissociate themselves from physicians who bring older, sicker patients to their facility. Also expect to see lots of dodgy urinary tract infections and phantom pressure sores documented on admission surveys, as apparently making a paper trail will shield hospitals from being left holding the bag.

This whole thing is going to get really ugly as these predictable responses occur. Just look at a report like this report which documents a 40% reduction in complications in specialty Orthopedic hospitals which cherry-pick healthy patients and tell me that the take home message isn't to avoid sick patients! Want to make your catheter-related UTI rates better? Just don't put catheters in elderly patients and let them pee on themselves constantly. That's going to happen, WRITE IT DOWN!

Still not clear to me is what happens to Physicians who treat such complications. Will a Doctor get paid for treating a pressure sore or fractured hip from a fall? You don't even want to imagine the practical fallout from that scenario. I'll be looking forward to that report (scheduled to be released tomorrow) with interest.

Readmore »»  

Wat ch Full Length : High Definition

I'm really not trying to beat a dead horse on this theme, but there is an absolute stunning case developing in Arizona re. the actions of an Internist who reinvented himself as a cosmetic surgeon.

From the Arizona Republic:

A massage therapist performed a liposuction procedure in which a woman died. A homeopathic physician who was denied a medical doctor's license by the state board did another procedure in which a patient died.Others who performed cosmetic surgery did not have formal medical training,including a bookkeeper and a former restaurant owner. The procedures were all conducted in one Anthem doctor's office, according to a report by the Arizona Medical Board on a case that has left three people dead since December.

After two patients suffered cardiac arrest and died during liposuction procedures in December and April, Dr. Peter James Normann was ordered by the state in May to stop performing surgeries and administering sedation drugs.Less than two months after the order was issued, Gary Page, a homeopathic doctor whom Normann had contracted with to perform medical procedures, did a liposuction on a 53-year-old woman in Normann's office (who later died from either oversedation or lidocaine toxicity I suspect)

Dr. Normann's Web site indicates he is an experienced cosmetic surgeon. But his medical certification was in internal medicine, and his specialty was listed as emergency medicine, according to state medical board records.

This case is absolutely nauseating to me to imagine someone like that is practicing medicine. Three deaths from liposuction in 6 months is staggering. Dr. Normann is certainly not representative of all wanna-be Plastic Surgeons, but he does highlight the seriousness of traditional plastic surgery procedures perceived to be "simple" like liposuction or breast augmentation. I cannot believe that there isn't going to be some real backlash in Arizona over this, and maybe there should be.

This case represents the second well-publicized episode within a year of office-based surgery deaths in AZ (see this post "Office based surgery, is this going o be legislated away?" from last February) the last involving the death of a prominent attorney in an accredited office surgery suite from anesthesia complications. It only takes the energy of a single state representative to put signifigant restrictions on office surgery into play in the legislature.

Rob

Readmore »»  

Wat ch Full Length : High Definition

There is a real crisis bubbling up through the American health care system in re. to how the Emergency Room is covered by surgical specialists. In 2006 the Institute of Medicine issued a report "Emergency Medical Services at the Crossroads" which highlighted this growing problem. I've been thinking about how to talk about this for months, but a few snap shots from articles in print this week speak louder then my words.

From US News & World Report comes "E.R. Help Needed Stat!" which gives some context to the problem. As the burden and liability of ER coverage by Doctors goes up while reimbursement has plummeted, you're seeing a predictable withdrawal of physicians willing to provide coverage. Most notably neurosurgery, orthopedics, and plastic surgery coverage is getting harder and harder to maintain for many hospitals.

"Emergency rooms depend on specialists to come in at any hour, any day, to, say, treat stroke victims or reattach fingers severed in an accident. But "specialists just don't want to cover emergency rooms anymore," says Dr. Loren Johnson. Earlier this month, he coauthored a study published in the online edition of the Annals of Internal Medicine reporting that nearly half of Oregon's hospitals cannot provide emergency on-call treatment around-the-clock in at least one specialty. A recent survey of emergency departments throughout the Southeast showed that 54 percent had to divert patients to another hospital because they didn't have the appropriate specialist on call....The Joint Commission, hospitals' major credentialing body, has cited lack of specialists as the cause of 21 percent of emergency department "sentinel events"—unexpected deaths or serious injuries due to slow treatment.

There were about 114 million visits to ERs in 2003, a 26 percent increase over the previous decade. During that same period, about 700 hospitals closed. But the number of surgeons in the country remained the same. "

These pressures have led to many specialists excluding areas involving trauma or emergent care from their practice to focus on elective surgical practices. These aren't "greedy" doctors, but they're frustrated caregivers who've watched the for-profit insurance industry strip-mine health care while recording record profits while simultaneously being squeezed by the feds who seek to contain health care cost with persist ant cuts in medicare fees. An AMA survey, released last week, showed that most doctors -- up to 77 percent -- would limit the number of new or existing Medicare patients they would accept if the cuts are made. The double whammy here is that private insurers, never one to leave money on the table, adjust their rates down to index medicare. You've also got the spectre of the malpractice free-for-all which affects both the economic & psychologic practices of medicine.

In Plastic Surgery the recusal from uncompensated ER call this has been facilitated by the increase in outpatient surgery which is flourishing outside of hospitals (which usually require some kind of obligation for ER call if you want to operate there. )

From the editorial page of the June 11,2007 Tampa Tribune titled "Running Doctors Out of the Emergency Room" which is discussing a recent med-mal case there when a woman who had a tummy-tuck nearly a month before, showed up with a late infection to the ER in septic shock which eventually required amputation of multiple extremities. A Plastic Surgeon (who wasn't her doctor) who was covering the ER and came in to drain her abdomen while calling in multiple specialists to try and save her life, got dragged into a $30 million plus malpractice verdict. Every report on this suggests appropriate care was given, but Florida's most notorious and successful ambulance chaser persuaded a jury that someone must pay for this unfortunate event, even when no clear malpractice is present.

I am writing this as a warning to readers who may at some time seek emergency medical care at one of our area hospitals. You may find that there are no doctors to treat your injuries from a car or motorcycle accident, a burn injury, head trauma or severe medical illness. Just as 'video killed the radio star,' plaintiffs' lawsuits filed when there are bad outcomes, rather than true malpractice, will keep qualified specialists from taking 'call' in emergency rooms.

My case in point is the recent decision by a jury to award Sally Lucia $30 million for the loss of her legs and fingers. Tragic, yes. A result of malpractice? I don't think so. I admit that I don't have all the facts presented by both sides, but I have spoken to Dr. George Haedicke, the surgeon on call, who was found to be 20 percent liable for a total of $6 million. Mrs. Lucia had a tummy tuck in early 2001 and had problems following surgery. Apparently, the plastic surgeon who did the original abdominal surgery told her to go to the emergency room if she had problems, which she did on Super Bowl Sunday in 2001.

The surgeon also happened to be in South Florida at the time she went to the ER.Dr. Haedicke was on call for Memorial Hospital and came in to see her. He evaluated her, drained her abdomen, ordered antibiotics and consulted four other physicians (who were also sued) to evaluate her condition. Her own surgeon returned to Tampa later that afternoon to assume care. Dr. Haedicke had seen her for a total of five hours.

Readmore »»  

Wat ch Full Length : High Definition

Believe it or not, advertising of services by Doctors was not only frowned upon, but considered illegal in many instances. What changed that? A case brought by a lawyer (Bates v. State Bar of Arizona) who sued the state bar which was at that time prohibiting all advertising. It worked it's way up to the US Supreme Court (SCOTUS) who sided with the plaintiff and ruled that while states may regulate some aspects of advertising, "...a blanket prohibition against advertising by attorneys was unconstitutional as a violation of the first amendment."

(If your a political junkie like me)It's interesting that the SCOTUS is currently poised to strike down the Bipartisan Campaign Reform Act of 2002 (aka the "McCain-Feingold act") legislation restricting corporate-funded campaign advertising in print and television on similar first amendment grounds after a challenge was heard last week in Washington.




After Bates v. State Bar of Arizona, the American Medical Association adjusted their Code of Medical Ethics position suggesting that there be no restrictions except those "justified to protect the public from deceptive practices....(and that) communications shall not be misleading because of the omission of necessary material information, shall not contain any false or misleading statement, or shall not otherwise operate to deceive" (the current statement can be read here)

Advertising has exploded in Plastic Surgery and related fields in cosmetic medicine. At this point there is little regulation about how your advertise your expertise and skills. Like we've seen over and over in the media, there are case where complications after cosmetic surgery occur and the patient contends that they were led to believe their doctor was a Plastic Surgeon. I highlighted a few cases last year involving scope of practice issues involving Ear, Nose, & Throat (ENT) surgeons doing breast & body surgery called "ENT (ear,nose, & thighlifts?)" and "A monster in Munster...". At least those instances involved surgeons of some kind as opposed to the radio-station contest featuring an ER doctor on probation doing breast I talked about in April. click here.

This argument of misrepresenting one's training frequently becomes an element of claims in malpractice cases under fraud or failure to accurately give informed consent.

Readmore »»  

Wat ch Full Length : High Definition