Wednesday, August 29, 2012

Reducing Health Care Costs

ACEP, the professional association for Emergency Physicians has established a "task force" with a goal to see where we ED physicians can reduce healthcare costs. The focus of the group seems to be on "clinical decision" rules that are used by ED physicians to guide our decisions about when to order more invasive or expensive tests.

I am all about treating DVT as an out-patient with the appropriate setting. I treat and street lots of things like chf, afib, copd if the pt improves and can see their doctor the next day. I also think its important to know the various managed-care derived Canadian C-spine rules, Ottawa knee and ankle rules, and straight leg raise/hip fracture and various other clinical decision tools (San Fransisco Syncope, CENTOR criteria, PORT Score, TIMI/Grace Risk, PERC, NIH Stroke, etc)

However, when it comes to lowering healthcare costs, there is nothing more expensive than missing a diagnosis as well as missing the expectation of the patient. In many cases, I may suggest my initial impression based on a clinical tool to the patient. However, because the patient is not paying, their anxiety about their symptoms may exceed their trust of the ED Physician and our clinical opinions. The Media and other phycians don't help ED Physician public perception. ED docs are the least trusted and respected physician.

If the person is anxious enough about their symptom and clinical decisions and therapeutic/diagnostic treatment is not helping the symptom or the patient anxiety, the patient is going to probably get the X-ray, or the GI referral for the EGD/HIDA scan or be admitted to the Obs unit for a cardiac stress test (unless age 24 and low TIMI risk).

Using clinical rules to save money is great but a failure by the physician to validate/address patient concerns and expectations will result in greater healthcare costs by the patient going to another ED saying "the other ED did nothing for me". Or the patient bringing legal action against the ED doctor for a missed diagnosis and bad outcome because "that ED doctor didn't do anything for me". The jury rewards the plaintiff for any bad outcome (regardless of clinical rules).

Ignoring patient anxieties and mistrust of doctors clinical decisions negatively affects patient satisfaction scores. "they didn't do anything for me" perception will earn a poor evaluation score regardless of the quality of the clinical decisions.

Furthermore, many clinical decision rules depend on history and clinical signs. Patients are routinely very unreliable in giving a history anpanicking good effort in the physical exam. Therefore, clinical rules have limited application in many patients. Sometimes you don't know who is giving an incomplete history or who is not giving good effort on exam.

Finally, patients that can be successfully treated conservatively and discharged from the ED without testing need to have an availible primary source of care. Again, many times patient anxiety and perceptions and discouragement and not having access to usual source of care (frustration at not getting am appointment with their PCP) is projected onto the ED doctor resulting in greater mistrust and worse patient satisfaction with the ED.

Radiological testing and invasive diagnostics can be excluded in Patients who are triaged to main ED in referral-center Hospital with high pre-test probability of disease where their anxiety about having to pay for the radiological study and their trust of the ED physician and the clinical decision rule outways their anxiety about their symptoms and a clinical rule rules out the need for the more invasive/expensive test. The patients have to be dependable, have an available primary source of care, and give a good history and good effort in exam.

Radiological testing and invasive diagnostics should not be excluded in Patients who are triaged to main ED in referral-center Hospital with high pre-test probability of disease where anxiety about their symptoms outway their trust of the ED physician, the clinical decision rule, and the financial burden of paying for the radiological or other expensive diagnostic procedure. Tests may be ordered if patients are not dependable, have no primary source of care, and fail to give a good history and good effort in exam.

The answer to saving healthcare costs does not rest with the ED. We are the safety net. Yet it seems too much responsibiliy for patient satisfaction vs clinical decision is being placed on our shoulders. Give ED docs a break. We only have a few clinical labs, a few X-rays and a CT scanner at our disposal anyways. In a majority of cases, considering the incidence and pre-test probability of patients in my ED who are triaged to be seem by the ED physician vs ExpressCare/minor tx, I don't consider any ED test to be causing more harm than benefit. Also, if the patient is triaged to the main ED, getting the labs and CT doesn't prolong their stay. What prolongs a stay is to not order the labs and studies initially and have to reorder later.

In reality, incidence of disease and pre-test probability is such that most people triaged to the main ED in some future time I predict all patients will be getting a level-1 diagnostic which would include a noninvasive full body scan and finger-prick capillary action lab panel on a chip. A doctor wouldnt need to order anything.

If you want to save healthcare costs, then focus on primary prevention. We need stronger families because it's mommy and daddy that do real primary prevention and not your doctor. If your talking to your doctor (except ob or peds) about prevention then it's probably too late.

Second, we need to stop poisoning and abusing ourselves with pornography, recreational sex, alcohol, cannibis, tobacco, illicit drugs, fluoride, etc.

Various rules have already been compiled by MedCalc 3000

There are no institutional barriers. This is how I currently practice. The barriers in the way of my current practice are "socialist/liberal progressives" who have have been fooled by the "Bohemian Grove/Fabian/Bilderberg/Davos/New-World-Order/Global Governance elite" into forming all these "sustainable task forces" which are designed to destroy the foundations of self- and local-government established by the US Constitution. It's these same "special interests" who wrote Obamacare and have established physician reimbursement which will now be based on some arbitrary quality factor. Instead of focusing on the wealthy elite who profiteer off of healthcare, they turn us against ourselves by having "sustainable task forces" impose burdensome regulations such as penalties for ordering too many CT scans.

Sometimes clinical decision rules are wrong. I routinely look for at risk factors in addition to history and physical exam when deciding to order a test. many times a vague complaint "I feel bad" can turn out to be a silent MI. Missing the MI because the patient didn't say they had chest pain or were short of breath is what adds to health care costs. ED Labs are a very small cost in comparison. All ED labs are done on automated machines. Again, high incidence of disease in main ED reduces harm by false positives.

Most importantly, the largest contributors to the rising cost of healthcare is the federal government via inflation and then a steady decrease in federal and state government reimbursement. As government reduces reimbursement, healthcare increases costs to keep pace. Since when can anyone walk into a Walmart and walk out with a $500 TV and tell them they will take $250 and like it. Secondly, the beuracracy between the patients and the doctor adds to the costs. Why can't communities get no-interest loans to build their own non-profit hospitals? Why do hospitals need a board of wealthy investment capitalists to profiteer off physician labor and disease? It's these same wealthy globalist investors who turn our attention away from their profit taking and fool us into turning against ourselves to penny pinch in the name of "sustainable growth"

The way to reducing cost in healthcare is the same way you reduce costs in industry. The secret is to reduce the number of people involved in the process. The more people involved, the more inefficient and expensive the process. Just consider how many extraneous people stand between the patient and the doctor. The key is using technology to reduce the number of people required in the process.

I have made the point that if we really wanted to reduce healthcare costs, after first reducing overall visits to the ED by providing patients with readily available sources of care, it is my opinion that every patient seen in a major referral ED could have some sort of non-invasive head-to-toe body scan and micro-capillary blood and urine panel. You may argue, that indiscriminately running a panel of tests on every main ED patient would cause harm due to false positives. I would remind you that false positives are only significant when there is a low prevalence of disease in the population. But when it comes to ED patients, the prevalence of disease is much higher than the general population.

If you don't believe me that the prevalence of disease in the ED population could justifies panel testing. This is exactly the reasoning the CDCis using to support HIV screening of all patients in the ED. If the CDC can justify screening ED patients for HIV, then any other ED diagnosis is justifiable. But until we have the technology to do it, well just have to decide what few ED tests to order on an individual patient basis.

Factors Required To Apply Clinical Decision Rule to exclude additional test.
1. Accurate, precise and valid clinical decision rule.
2. Patient trusts physician clinical judgement.
3. This is not 2nd visit where clinical decision rule has already been applied.
4. Patient can give good history
5. Patient gives good effort on physician exam.
6. Patient has low pretest probability for disease.
7. Patient has availible primary care follow up.
8. Patient anxiety about disease does not exceed anxiety about cost or invasiveness of procedure or test.

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