Monday, April 28, 2008

The Abuse of Nonprofit Status by some Hospitals

The Wall Street Journal has an interesting article today By Barbara Martinez about nonprofit hospitals. It seems that some nonprofit hospitals are demanding payment up front and refusing treatment to patients who can't pay:

When Lisa Kelly learned she had leukemia in late 2006, her doctor advised her to seek urgent care at M.D. Anderson Cancer Center in Houston.
The Kellys arrived at M.D. Anderson with a check for $45,000 on Dec. 6, 2006. After having blood drawn and a bone-marrow biopsy, the hospital oncologist wanted to admit Mrs. Kelly right away.
But the hospital demanded an additional $60,000 on the spot. It told her the $45,000 had paid for the lab tests, and it needed the additional cash as a down payment for her actual treatment.

Once, Mrs. Kelly says she was on an exam table awaiting her doctor, when he walked in with a representative from the business office. After arguing about money, she says the representative suggested moving her to another facility.

It seems that M.D. Anderson gouged Lisa Kelly:

On one bill, Mrs. Kelly was charged $20 for a pair of latex gloves. On another itemized bill, Ms. Wallack found this: CTH SIL 2M 7FX 25CM CLAMP A4356, for $314. It turned out to be a penis clamp

When a for-profit hospital acts like this it is understandable. These hospitals are, after all, in business to make a profit. What excuse do nonprofit hospitals, which pay no taxes, have?

According to the American Hospital Directory, 77% of nonprofit hospitals are in the black, compared with 61% of for-profit hospitals. Nonprofit hospitals are exempt from taxes and are supposed to channel the income they generate back into their operations. Many have used their growing surpluses to reward their executives with rich pay packages, build new wings and accumulate large cash reserves.

Perhaps all hospitals should be required to pay taxes:

"When you have that much money in the till and that much profit, it's kind of hard to say no" to sick patients by asking for money upfront, says Uwe Reinhardt, a health-care economist at Princeton University, who thinks all hospitals should pay taxes. Nonprofit organizations "shouldn't behave this way," he says.

Thursday, April 24, 2008

Managing Psychiatric Patients in Medical Hospitals

Today's Hospitalist Magazine discusses the challenges of managing psychiatic patients in (medical) hospitals (via Dr. RW):

a young, depressed woman who presents to the ER after a suicide attempt with an overdose of benzodiazepines. The woman is often uninsured, and because there’s no bed at the county mental health facility, she is admitted to—and stays in—the medical ward.

The woman discussed in the above example may languish weeks on the medical ward waiting for a psychiatric bed (at a private psychiatric hospital or at a government psychiatric hospital) to open up- if she's lucky. If she's unlucky and committment paperwork has been filed, she may wait in jail for a psychiatric bed to open up. Assuming she's lucky and she gets to wait in a medical bed, who takes care of her? This role typically falls to the hospitalist (internist), who is often unprepared:

“some hospitalists are not comfortable prescribing the initial dose of certain psychiatric medications, like the newer antipsychotics.” While most hospitalists may be comfortable starting patients on antidepressants, “much further beyond that and their comfort level goes away.”

Of course, a psychiatrist (if available) is usually consulted, but he may only see the patient and leave a note several times a week.

Here are some possible solutions:

1. Reopen psychiatric wards in general hospitals. only 25% of general medical hospitals still have dedicated psychiatric units. Not profitable, so probably won't happen.

2. Open up Med/Psych wards in general hospitals. Not profitable, so probably won't happen. In addition, there are huge insurance issues with Med/Psych wards- mental health care is often covered by a mental health carve out, so the medical insurer and the psychiatric insurer will sometimes each try to deny responsibility for covering the hospitalization.

3. Give psychiatrists admitting/attending privileges at general hospitals and have them be the attending for the patient (after medical stablization). To get psychiatrists to do this, they will have to be subsidized by the hospital like many hospitalists are. Not profitable, so probably won't happen. In addition, there are the insurance issues discussed in #2.

4. The hospitalist groups could hire psychiatric nurse practitioners to help them manage these patients (using some of the subsidy they get from the hospital). Probably the most viable solution.

Monday, April 21, 2008

Hospital Medical Staff Should not be Treated like Employees

Bob Wachter recently wrote about the different disciplinary treatment of doctors and nurses, when both committ a HIPPA violation (in this case, looked at Britney Spears medical records):

of the 53 people caught snooping, 18 of the non-doctors resigned, retired, or were dismissed, while no physicians left the staff.

Wachter acknowledges that nurses, therapists, etc are hospital employees, while physicians have traditionally in private practice and have not been in an employee/employer relationship with the hospital:

These forces quite logically led hospitals to develop two parallel systems of governance, rules, and enforcement: one for physicians, and another for everybody else.

He is in favor of peer review for matters requiring clinical judgement, but feels that
for violations of unambiguous rules and policies...there is no reason that the standards for physicians and other staff should be different.
Here are my thoughts on the matter:
While not excusing the actions of the doctors who looked at Britney's records, I do not think that doctors should be treated like employees (except for the rare cases in which they are actually employees of the hospital). I personally would resign from the medical staff of any hospital that tried to treat its staff physicians in such a matter. Treating doctors the same as hospital employees makes about as much sense as a law firm treating its partners the same as its secretaries. It would make more sense to treat hospital CEO's like the hospital's maintenance staff than to treat doctors like nurses.
Doctors are the ones who send their patients to hospitals. If a hospital doesn't treat me well, I will send the patients who have entrusted themselves to my care to a different hospital (for those who are wondering what type of patients I send to the hospital, given that I am mostly an outpt sleep doc, let me just say that hospitals today do much more than inpatient care- they provide outpt lab testing, imaging studies, sleep studies, etc. I do occasionally help cover a local psychiatric hospital).

Sunday, April 20, 2008

Mississippi Psychiatrist Disciplined

The Clarion Ledger (Mississippi's main newspaper) reports:

A Brandon psychiatrist (Dr. Stanley Russell) who has been scrutinized over three decades for allegedly prescribing large quantities of addictive narcotics should not be allowed to continue practicing even with new restrictions, the mothers of two former patients say.

The board found in its most recent investigation of Russell that he had again violated rules and regulations. It agreed, however, to restrict him from writing prescriptions for any narcotic or habit-forming drugs and to limit him to working at the Region 8 Mental Health Center in Brandon, where he had been a part-time staffer. The consent agreement also calls for his work to be reviewed and his care of patients evaluated.

Dr. Russells's private practice has been closed down and he has been limited to working at the local community mental health center, without the ability to prescribe controlled substances. I have several patients who were previously being treated for their psychiatric problems by Dr. Russell and their opioid addiction by me, in my suboxone clinic. I have ended up taking over the psychiatric care of some of these patients.
(in case any prospective patients are reading this, let me mention that I am no longer accepting new psychiatric and/or suboxone patients, but I am seeing new patients with sleep problems).

Thursday, April 17, 2008

Soccer is a dangerous sport

New research shows that soccer is a dangerous spectator sport:
Dr. Ute Wilbert-Lampen and her associates studied cardiovascular (CV) event rates in the Munich area during the month-long World Cup soccer tournament held there in 2006, and compared them with the rates for the same area during several control periods. On days when the German national team competed, CV event rates spiked, particularly among men and among people with known coronary disease.

I'm going to have to stop going to my kids' soccer games.