Pennsylvania Injury Law Report : Accident Attorney Philadelphia: Personal Injury Attorney Philadelphia (PA), Injury Lawyer Philadelphia - Kreithen Baron & Carpey

On Tuesday, November 27, 2012, Dr. Youn wrote an article in CNN.com discussing the statistical worst time for a patient to undergo surgery, and what can go wrong if you have it at the “wrong” time. Dr. Youn is an assistant professor of surgery at the Oakland University/William Beaumont School of Medicine in Michigan and is the author of "In Stitches". According to Dr. Youn, the time of day you have surgery can affect your outcome, and it’s surgery team fatigue that leaves patients most at risk.

A study in 2006 at Duke University showed that operations taking place between 3 and 4 p.m. had a higher rate of nausea, vomiting and postoperative pain.

Why is this? According to Dr. Youn, there are two major factors:

Factor #1:

Our bodies follow natural circadian rhythms, which regulate our sleep/wake cycle, brain wave activity and certain bodily functions. These circadian rhythms dip between 3 and 5 p.m. each day, causing many of us to feel sleepy. The Spaniards apparently discovered this long ago when they instituted the afternoon siesta.

Surgeons, anesthesiologists, and nurses can’t nap in the operating room! This means sleepy healthcare providers and a higher rate of adverse events post-surgery.

Factor #2: (And arguably the more important factor). Most members of the surgical team start their work day around 6:30 or 7 a.m. This means that the end of their 8 hour work day falls right in the middle of the afternoon, around 3 p.m.

What happens next may surprise you.

As soon as their shift ends, a new team comes in and takes over, sometimes right in the middle of an operation. This means that the surgeons and nurses who comforted you and told you they would take good care of you will not be the faces you see when you wake up. Instead, you’ll open your eyes and see a team of faces you’ve never seen before.

Many times, team members who are being replaced do a poor job of providing information about the patient to the oncoming team. This could mean that the replacement anesthesiologist might not be aware that you don’t respond well to a certain nausea medication.

The moral of the story? Mid-afternoon surgeries put the patient at risk (although not usually life threatening) of incurring problems after the operation. We are all human, no one can work endless hours, and we are all susceptible to an occasional mistake. But when you put your well-being in the hands of a professional caregiver, there is a certain level of expectation that goes along with that. It is their job to ensure that the surgery and recovery goes smoothly, and surgeon team fatigue is an unacceptable excuse for it going any other way.

Should you ever need surgery, make sure you choose the 7 a.m. one, and not the 3 p.m.
 

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Have you ever tried to price out the cost of a colonoscopy? It can’t be done. Having just turned 50, my PCP (that’s code in the health insurance business for “primary care physician” a/k/a your family doctor) said I should get one done. For anyone who has had a colonoscopy, you, fellow soul mates, know that the actual “procedure” is one that you have no memory of, thank goodness, because of the mixture of anesthesia used which includes some sort of amnesia drug. However, I will spare you, dear readers, any further description of the “prep.” Look it up on Google. It’s no fun. Suffice it to say, be very close to a bathroom at all times.

But I digress. Back to the costs of medical procedures, Google, and health insurance reform. One of the great mysteries of our time, as far as I am concerned, is we as consumers can obtain the price for just about any product or service before we make the decision to purchase. There may be some negotiation in price, for instance in buying a car, but you go in at the very least knowing what the asking price is from the dealership.

When I asked the gastroenterologist's office who was going to do my colonoscopy what the cost of the procedure was, they couldn’t tell me. They provided vague answers dependent on the type of insurance I had. That’s curious to me, because, I, as the consumer of products and services, could not obtain an actual price before I purchased. All I was told was that I had a deductible to pay. What if there ended up being a dispute between my health insurance carrier and my doctor’s office, or the anesthesiologist’s office, or the surgicenter where I was having the procedure done? If I were eventually on the hook for the bill, I sure would have liked to know the costs beforehand. Assume I had no health insurance. Pricing would be much more important.

Come to think of it, whenever I’ve had an X- ray, MRI, or that ACL reconstruction on my right knee, no one ever gave me price information for the test or procedure. Of course, we all know that when we go into a medical provider’s office we sign an assignment of benefits. That allows your doctor to bill and obtain payment from your insurance carrier. But it also says that if payment is not made, your doctor bills you.

Now, of course we don’t choose our medical provider based on the fees they are charging. Usually a host of other factors are involved, including expertise, experience and so on.

John Cogan, in his Wall Street Journal piece, “The Millionaire Retirees Next Door” (5/12/11), argues that

Under the federal government's fee-for-service Medicare program, every time a senior citizen meets with his physician or health-care provider for a check-up, lab tests or surgery, somebody other than the patient foots most of the bill. That such a program should produce runaway costs is hardly surprising. Over the years, the government has expanded the type of services covered, such as prescription drugs, and it has assumed a greater portion of the program's finances. Medicare premiums paid by senior citizens once covered half of the cost of physician and related services. They now cover one-fourth. Copayments once covered nearly 40% of these services' costs. They now cover only 20%.

In the case of non Medicare recipients, we all know that private health insurance is not increasing the amount of the tab that they are picking up. Rather, we as the consumers are. Nevertheless, think of how much more competitive healthcare in this country would become if we knew the cost of care going in?
 

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“Inpatient or Outpatient? the Battle to Control Costs,” (Philadelphia Inquirer, 12/26/10 by Michael Vitez) is an excellent critique on how health insurance companies act as the invisible hand behind health care decisions of doctors in the hospital setting.

The article puts into context the conflict between hospitals and health insurance carriers, describing a medical situation involving Randy Klein, who presented to Abington Memorial Hospital with a serious gastro-intestinal condition acquired from eating oysters on a cruise. Her attending physician at Abington, Dr. Steve Fisher, felt Randy’s pain and gastrointestinal condition merited an extended inpatient stay at the hospital. Randy’s insurer, Independence Blue Cross, however, disagreed with Fisher, only clearing Randy as an outpatient and agreeing to pay Abington for an outpatient’s stay.

Keep in mind that these “pay versus no pay” decisions are played out behind the scenes at every hospital, day in and day out. It is a battle for payment by hospital billing personnel with insurance carrier representatives conducted outside of earshot of the patient or the patient’s family. Doctors in hospitals make decisions on whether to grant inpatient stay based on an insurance company guide book called InterQual. This is an encyclopedic reference which insurers use to determine a medical patient’s needs based on two criteria: is the patient sick enough, and is the hospital doing enough? If the guidelines in InterQual indicate either of the answers to be no, then the patient is only cleared for payment for observation, which is no longer than a 24 hour hospital stay, no matter how serious the condition.

In the Inquirer article, Randy Klein’s doctor, Dr. Steve Fisher, said the following of InterQual: “It has been absolutely pushed in our lives. It should, in my opinion, have absolutely no bearing on clinical medicines, but it’s something that the payers have imposed upon us. It’s something that we have to pay attention to. I guess I thought we were still allowed to override the dame thing. It shouldn’t be gospel. It should be a suggestion.”

Like Dr. Fisher, Abington Memorial Hospital’s chief of staff, Dr. John J. Kelly, has also made clear the tension between carriers and hospital billing staff (all experts in interpreting InterQual), saying, “it actually costs us more money to do observation… [and] what they’re asking us to do sometimes is dangerous, I think.”

With insurers looming over their shoulders, hospitals feel pressure to offer better and faster treatment for a growing number of outpatients, for less money.

In November, the Delaware Valley Healthcare Council released the results of a survey given to its member hospitals. From 2008 to 2009, physicians increased by more than 20 percent their direct admissions to observation while insurers increased by about 25 percent their downgrade to observation. Since hospitals are losing money each time a patient is downgraded, they are now simply sending more patients straight to observation.

In Randy Klein’s case, Abington eventually got payment for about  half of what it anticipated.

With health insurance carriers limiting doctors’ say in our medical care,  how much of a say can patients have in their own care? It is a slippery slope.

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In early October, Governor Ed Rendell  highlighted the improvements in Pennsylvania's medical malpractice system. A looming issue, however, is whether he will agree to extend the Mcare fund.

In Pennsylvania, doctors and hospitals are required to carry $1 million in medical malpractice insurance. The first $500,000 is through private insurers, while Mcare provides an additional $500,000.

The Pennsylvania House proposed legislation to postpone the phase-out of the Mcare Fund for seven years. The bill was approved by the Senate, and now just requires approval from Rendell. Rendell has expressed his support for the bill, but wants to review the bill’s provisions. The extension of the Mcare Fund has been endorsed by  professional groups, including the Pennsylvania Orthopedic Society and the Pennsylvania Association for Justice, two organizations that are rarely on the same page concerning political issues.

The Mcare Fund was established in 2002 as a way to combat the high medical malpractice premiums charged by insurance companies and paid by physicians and hospitals. The medical malpractice system in Pennsylvania has undergone various changes since the Mcare Fund was put into place in 2002. In his press release, Rendell pointed to an almost 20% decline in insurance rates for the primary level of coverage in the private market. Additionally, there is more competition in the private insurance market with more than 21 new carriers. As a result, more and more doctors and hospitals have an adequate amount of medical malpractice insurance and they are paying less for it.

In 2009, Rendell stated that he would not seek to renew the Mcare Fund and that the reform of medical malpractice was complete. He did not see any need for further improvements. Despite this declaration, the Mcare Fund is likely to be extended. Rendell is said to have some reservations on certain language that returns unspent money to hospitals instead of rolling it over into the next year's fund.  It is clear, however, based on the changes to the system, including the requirement of a certificate of merit and stricter venue rules, that Pennsylvania has succeeded in driving down the rates that insurers have charged doctors and hospitals for malpractice coverage.

Update: Governor Rendell , in fact, on October 22, 2010, vetoed the bill which would have extended the Mcare Fund.

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Almost immediately after President Obama signed the sweeping health care bill into law this week, 14 state attorneys general filed a cause of action in Federal District Court in Florida challenging the law. Among them were Pennsylvania State Attorney General Tom Corbett. Joining him were state attorneys general from Florida, South Carolina, Nebraska, Texas, Michigan, Utah, Alabama, South Dakota, Idaho, Washington, Colorado and Louisiana. Virgina's attorney general filed a separate suit in Federal District Court in Virginia. All of the attorneys general were Republicans, with the exception of the attorney general from Louisiana, James Caldwell, a Democrat.

The gist of the lawsuits are that, according to the attorneys general, the new law violates the Constitution by forcing the individual states to act without providing the financial resources to pay for what thew law requires. "The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty, that all citizens and legal residents have qualifying health care coverage," the lawsuit reads.

Sounds like political posturing to me. That said, whether you agree with the health care law or not, the passage of the health care bill may be one of the most important votes from Washington in our lifetimes.  It will have broad changes to how insurance companies do business in this country.

I personally don't see how the attorneys general; who filed these cases are going to win the day. More problematic, however, is the fact that they are not legislators. What if the majority of the citizens in their individual states like the changes to health care that has now become the law of the land? By challenging the constitutionality of the health care law, are the attorneys general perhaps overreaching their mandate? Did the attorneys general have an obligation to poll the citizens of their states to see where the populace stood on the issue before using taxpayer funds to challenge the law's constitutionality?

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Betsy McCaughey wrote an interesting article in The Wall Street Journal recently (October 29, 2009) in which she interviewed various physicians to get their their take on the health care reform debate. Dr. Seymour Cohen, an oncologist,  said the following in the article regarding the issue of shifting resources from specialty to primary care.

Dr. Cohen: "Let's talk about specialization for a moment. . . . We don't go to our general attorney when we have a patent problem, but they're telling us to do this now in medicine. We have different types of engineers, even journalists. There's a financial writer, there's a sportswriter . . . . Now in health care we're telling everybody, 'you just go to the guy who's your general doc. He's going to know everything and maybe we'll find a specialist for you if the panel decides maybe you're sick enough to need a specialist.' It really doesn't make sense at all."

In a letter to the editor a few days later Rebecca M. Patton, MSN, RN,  President of the American Nurses Association wrote in response:

"Currently, the system is built so that health-care providers can charge for each test and procedure performed, instead of being rewarded for the overall care of the patient.  We need to re-form the health-care system away from the nation's current emphasis on (more costly) acute care come up to one that focuses more heavily on providing primary and preventive care, or more bluntly-to treat the patient rather than the illness.  This does not eliminate specialist care when it is needed.  However, better primary and preventive care would greatly reduce the demand for costly specialist care."

Specialists physicians are not used to being  targets in the health care cost -reduction-debate.

However, the flaw in Dr. Cohen's argument is that he does not mention that he gets paid by a gatekeeper. It doesn't matter if the gatekeeper is an insurance company or the government (Medicare). He, or any other physician specialist, has to please the gatekeeper, or he doesn't get paid. In exchange, the physician specialist gets a guaranteed rate of pay for a set procedure code (and a steady stream of patients). 

Not so with the comparative professions he uses by way of example, be they attorneys, engineers or journalists. I get paid directly by my clients, not from an insurance company. A sportswriter gets paid directly for the paper he works for. That allows for a certain amount of flexibility. I can choose the types of cases I want to work on, and the journalist can write on the subjects he wants to. To get paid I don't need to complete a health insurance claim form and wait for approval by the insurance company before they issue payment. On the other hand, I certainly am not guaranteed a steady stream of clients.

It's not that I don't sympathize with the plight of the specialist physicians. But I agree with Nurse Patton. To lower health care costs we must have a system in place that treats the whole patient first. Certainly primary care/general practice physicians, underpaid for the work they do under the present system, will be the financial beneficiaries of such a change. But that GP isn't going to be performing knee surgery on a patient, so, as I see it, the specialist is safe.

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