Alternative pay models shouldn’t set off kickback fears, hospitals say

From Modern Healthcare:

Hospitals have urged HHS’ Office of Inspector General to recognize that payments between providers in the same alternative pay models do not violate federal anti-kickback laws, warning they may not participate in the programs otherwise.

Alternative pay models can violate anti-kickback laws because they can include incentives and shared savings payment agreements to reduce the cost of care, which could influence a provider to use a certain vendor, refer patients to specific facilities or order more services that are paid for by federal healthcare programs.

But providers told the OIG that the laws are too broad and they’re getting in the way of the move to value-based care.

Mississippi hospital ends ER fee for nonemergencies

From Becker’s:

Southwest Mississippi Regional Medical Center in McComb is ending a policy that required patients to pay $200 upfront for nonemergency services in the emergency department, according to the Enterprise-Journal.

The policy, implemented in January 2017, was ended because of  changes to computer systems and procedures, according to the report.

“Now, when people needing primary care come into the emergency room, they go to the primary care system and not the emergency department,” Norman Price, the hospital’s CEO, told the Enterprise-Journal.

When the $200 emergency department fee was  implemented, half of the hospital’s 50,000 emergency department visits were for nonemergency services, according to Mr. Price. He told the Enterprise-Journal many of the nonemergency visits also weren’t paid for, and the hospital, amid diminishing Medicaid reimbursement, was subsidizing contracts with companies that provide emergency department physicians.

Pittsburgh trauma doctor ran into active shooting, risking his life as he saved others

From the Daily Record:

He stopped his truck in the front yard of a house near the synagogue. He spotted a fellow SWAT officer and together they sprinted toward the place of worship.

This is the part when Murray turns off his emotions. He talks about how he was trained for moments like this. During drills, SWAT teams respond to scenes where mannequins are covered in fake blood and brains. They prepare for mass casualties and bombs. They train for what they might see.

“Was it horrific inside the synagogue? Yes. Are we trained for that? Yes,” Murray said.

Minn. ER Patients Were Unwittingly Injected With Ketamine for Experiment: FDA Report

From the Daily Beast:

The Food and Drug Administration released a statement Monday saying the agency is investigating a Minneapolis hospital for allegedly breaking ethics rules by giving patients drugs, including the club drug ketamine, for a research study without their consent. Hennepin County Medical Center is being investigated for at least four studies that have been approved since 2014. In at least one of the studies, paramedics “agitated” patients without their consent to study ketamine’s role as a sedative, the FDA said. The agency is following up on body-camera footage from this summer from the same hospital that showed Minneapolis police officers instructing the hospital’s ER staff to inject people in custody with the drug, according to BuzzFeed.

A Sense of Alarm as Rural Hospitals Keep Closing

From the New York Times:

Hospitals are often thought of as the hubs of our health care system. But hospital closings are rising, particularly in some communities.

“Options are dwindling for many rural families, and remote communities are hardest hit,” said Katy Kozhimannil, an associate professor and health researcher at the University of Minnesota.

Beyond the potential health consequences for the people living nearby, hospital closings can exact an economic toll, and are associated with some states’ decisions not to expand Medicaid as part of the Affordable Care Act.

Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so.

Suboxone 101: The Skinny on This Opioid-Dependence Drug

From ACEP Now:

Suboxone is a sublingual (SL) film dosage form containing a partial opioid agonist (buprenorphine) and an opioid antagonist (naloxone) for treating opioid dependence.1 It is a Schedule III Controlled Substance that was originally approved by the U.S. Food and Drug Administration (FDA) in August 2010. It should be used as part of a complete treatment plan that includes psychosocial support and counseling.

The impact of emergency department patient‐controlled analgesia (PCA) on the incidence of chronic pain following trauma and non‐traumatic abdominal pain

From Anaesthesia:

The effect of patient‐controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi‐centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44–56%) patients were included in this follow‐up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24–54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient‐controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control – patient‐controlled analgesia) −8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7–23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient‐controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI −30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.


Tips on Treating Medical Emergencies at End of Life for Patients Who Don’t Want Resuscitation

From ACEP Now:

Today, there’s wide acceptance of palliative care and its aggressive symptom management, especially at the end of life. We’ll highlight four cancer emergencies that need to be recognized and managed by emergency physicians: 1) spinal cord compression, 2) pathological fracture, 3) superior vena cava syndrome, and 4) hypercalcemia of malignancy.

Feds loosen telehealth rules for Medicare Advantage plans

From Axios:

New proposed regulations, authorized by President Trump’s budget deal from earlier this year, would open the door for Medicare Advantage companies to cover telehealth services for all enrollees starting in 2020.

Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses

From JAMA:

Importance  Insurers have increasingly adopted policies to reduce emergency department (ED) visits that they consider unnecessary. One common approach is to retrospectively deny coverage if the ED discharge diagnosis is determined by the insurer to be nonemergent.

Objective  To characterize ED visits that may be denied coverage if the ED coverage denial policy of a large national insurer, Anthem, Inc, is widely adopted.

Design, Setting, and Participants  A cross-sectional analysis of probability-sampled ED visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample occurring from January 1, 2011, to December 31, 2015, was conducted. Visits by commercially insured patients aged 15 to 64 years were examined. Those with ED discharge diagnoses defined by Anthem’s policy as nonemergent and therefore subject to possible denial of coverage were classified as denial diagnosis visits. The primary presenting symptoms among denial diagnosis visits were identified, and all visits by commercially insured adults presenting with these primary symptoms were classified as denial symptom visits.

Main Outcomes and Measures  Each visit cohort as a weighted proportion of commercially insured adult ED visits. The proportion of each visit cohort that received ED-level care, defined as visits where patients were triaged as urgent or emergent, received 2 or more diagnostic tests, or were admitted or transferred, was also examined.

Results  From 2011 to 2015, 15.7% (95% CI, 15.0%-16.4%) of commercially insured adult ED visits (4440 of 28 304) were denial diagnosis visits (mean [SD] patient age, 36.6 [14.0] years; 2592 [58.7%] female and 2962 [63.5%] white). Among these visits, 39.7% (95% CI, 37.1%-42.3%) received ED-level care: 24.5% (95% CI, 21.7%-27.4%) were initially triaged as urgent or emergent and 26.0% (95% CI, 23.8%-28.3%) received 2 or more diagnostic tests. These denial diagnosis visits shared the same presenting symptoms as 87.9% (95% CI, 87.3%-88.4%) of commercially insured adult ED visits (24 882 of 28 304) (mean [SD] patient age, 38.5 [14.1] years; 14 362 [57.9%] female and 17 483 [68.7%] white). Among these denial symptom visits, 65.1% (95% CI, 63.4%-66.9%) received ED-level care: 43.2% (95% CI, 40.2%-46.4%) were triaged as urgent or emergent, 51.9% (95% CI, 50.0%-53.9%) received 2 or more diagnostic tests, and 9.7% (95% CI, 8.8%-10.6%) were admitted or transferred.

Conclusions and Relevance  Anthem’s nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient’s perspective. This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial.