THE SURGICALIST: A
NEW CONCEPT IN ON-CALL CARE
Your emergency department can turn away no one that is the
reality of, but what is being done to
soften the economic impact.
Welcome to the Clinician’s Roundtable. I am your host,
Dr. Shira Johnson, and joining us today to discuss the economic impact of
delivering ED care is Dr. John McConnell, who has his PhD from Stanford
University, but he is also an Associate Professor of Emergency Medicine at
Oregon Health And Science University. He has been working on a committee
formed by The Institute of Medicine to solve the on-call crisis in Palm Beach
County. His research is focused on emergency and trauma care, behavior and
health sciences, and health policy.
DR. SHIRA JOHNSON:
Dr. McConnell welcome to ReachMD.
DR. JOHN MCCONNELL:
Thank you, nice to be here.
DR. SHIRA JOHNSON:
First of all what is your role in department of emergency medicine
and how did you get there? There is not too many people who study economics
that work in the ER.
DR. JOHN MCCONNELL:
Right, I am sort of an odd bird. Our emergency department
at Oregon Health & Science University has a research group and I am an
economist as part of this group and so I do research and look for grants to do
research and some of my research is on emergency care and that turned out to be
a good place to go. There is a lot of interest in health economics and not
many people have focussed on emergency care service of nice fit for me after
graduate school.
DR. SHIRA JOHNSON:
And you are very timely doing this right now, right?
DR. JOHN MCCONNELL:
Yeah, I have lot of interest in health economics in general
and especially the uninsured and how they relate to emergency care.
DR. SHIRA JOHNSON:
Now emergency departments in America have had the same
economic crisis that American's face. In fact they may have been facing it
longer with budget cuts what are some of the strategies that you have explored
to solving the problem of subspecialty coverage.
DR. JOHN MCCONNELL:
In other sort of may be 5 ways that hospitals are sort of
dealing with this. You know one is just to go without call and that
unfortunately is happening so we know that lot of hospitals are dropping 24/7
coverage for some other hospitals and in Oregon it has been a large number. It
has been over a third of hospitals that have done that. The second strategy is
to pay stipend so you pay physicians receive 1000 or 2000 dollars a night to
agree to carry beeper and be on-call. Third is to guarantee pay for physicians
say at a medicare rate for any patient they see, who is uninsured so that the
physicians know that they are getting paid. A more sort of recent shift is to
employ physicians or specialists like a hospitalist model, but employing
surgeons instead of primary care physician. And then other things that are
being used here and there are some more frequent hiring of local attendant
physicians to come in and cover call gaps and then in some cases interest in
regionalization.
DR. SHIRA JOHNSON:
Now surgicalists come in. They are paid by the hospital
stipend correct, and they are on their on-call.
DR. JOHN MCCONNELL:
Yes.
DR. SHIRA JOHNSON:
And then they see patients that need surgeons emergently
correct.
DR. JOHN MCCONNELL:
Yes.
DR. SHIRA JOHNSON:
Is it cost effective to higher surgicalists?
DR. JOHN MCCONNELL:
Yes, it’s a good question. I think it depends on the
hospital size and how many patients they see and how many surgeons they have to
employ, but in some ways its becoming more cost effective because of these
other changes and so you could imagine that say 3 years ago hospital might look
may be lets say well, I can hire 3 surgeons for a million dollars, but if I
higher them I am only going to bring an extra 700,000 dollars in terms of the
revenue that I could capture from those physician services, so I will be losing
300, 000 dollars and so I wouldn't do that, but today you know the option might
be to do that and lose 300,000 dollars or to not do that, but still end up
losing 500,000 dollars that should be paying in stipends and so I think what
hospitals are seeing is well may be I make money or I break even, but its
better than not having that money and paying out these stipends.
DR. SHIRA JOHNSON:
You worked on a committee out of Palm Beach County to solve
their on-call crisis. Can you tell us something about that project?
DR. JOHN MCCONNELL:
That was a couple of years ago and that was sort of one of
the early canary in the coalmine places where this is becoming a real issue.
When Palm Beach turned I didn't realize that still I went down there, but this
is one of the richest counties in the US and perhaps the richest county in the
US. This is where Donald Trump has one of his famous houses and it’s a nice
place and near there the focus was people were looking for lot of different
solutions and nobody really sort of proposed a surgicalist model or at least
not widely. The focus then was really to try to see if you could regionalize
call and it seems to make sense. You know, you would think in an urban area
may be you don’t need a hand surgeon to be on-call at every single hospital
every night of the week, so may be you can find a way for 1 hand surgeon group
at 1 hospital to take call for the whole region and so that was the emphasis
that’s we talked about. There was a lot of money put into there sort of, you
know, money used sort of form committee and buy consultants and things like
that, but it never really got of the ground. I think that kind of there is a
lot of challenges there, but it is sort of speaks to some with difficulty of
regionalization that this was an area with a lot of money, a lot of focus, but
they still couldn’t make it work.
DR. SHIRA JOHNSON:
You have part time ED coverage, some nights you have hand
surgery or OB/GYN some nights you don't and you are a guide, who has worked in
the ED that’s when you get stuck because you are not on they don't have anybody
covering that service and you are placed in a position that many of us have
been in we have to try to transfer that patient who may or may not have funding
to another facility, who probably doesn't want to accept them. It's not safe
for the patient, it's challenging for the doctor, and mistakes get made and
people get sued.
DR. JOHN MCCONNELL:
Yes, I am an economist, so I do not work clinically, but I
work with people who do and it’s a real headache. It's been really hard for
them, I mean, you know, I hear these horror stories of them being on the phone
for hours trying to locate a particular specialist to take care of the patient
and it can be very difficult.
DR. SHIRA JOHNSON:
You applied this solution in Oregon and did it work there.
DR. JOHN MCCONNELL:
I can't take credit for applying any solutions here, but I
can tell you what Oregon has done and what they have done is sort of use a
blend of these things. In some cases hospitals have gone without coverage and
some cases they have done stipends. The trend has generally been to move away
from stipends, towards guaranteed pay, towards employing physicians and I think
it's working, but it's amazing how quickly this is changing. It’s a very
dynamic situation and so you know it's working, I don't if it's hit equilibrium
yet.
DR. SHIRA JOHNSON:
So what are some of the other issues you have worked on with
Oregon policy makers where you think may be your work has made a difference?
What could we learn from you have already researched and been through.
DR. JOHN MCCONNELL:
Well, you know, I do some work on emergency department care and
then some sort of general policy care. One project that I just worked on was
looking at medicaid clients beneficiaries and Oregon was 1 of the first states
to see if they could cut the cost of Medicaid by imposing copayments on some
other medicaid enrollees and so we have good data actually with some good
economic research on how the patients with commercial insurance respond to
copayments and generally they use less services and it reduces the cost of
care, but we hadn't really seen much research on what that looks like for very
poor, very sick people, who might be on Medicaid and so this is sort of
interesting study because the copayments work that's a good way to save money
if they don't than that’s useful and what we found was that the medicaid
clients who had these copayments put on them they pay pullback service, they
use less services just like commercial patients, but when they went they were
sicker so they had fewer visits, but when they went their visits were more
expensive and they had more inpatient admissions and so in the end the economic
gain from fewer visits was offset by more expensive care when they needed it
with some sort of disturbing suggestion so some good evidence the copayments
weren’t good there.
DR. SHIRA JOHNSON:
If you are just tuning in, you are listening to the
Clinician's Round Table. I am your host, Dr. Shira Johnson, and joining me to
discuss managing the economic impact of ER medicine is Dr. John McConnell.
So, with all that’s going on today with loss treating
economy, how is the current economic crisis going to effect physicians,
emergency departments, and health care across the board given the challenges we
have already had?
DR. JOHN MCCONNELL:
In general, it is sort of help for the sort of think about
where we are going in the economy without thinking too much about the health
care and I think the best guess looking at economist to do more of this macro
economic policy prediction. You know I think we are looking at pretty severe
recessions sort of like something that we had in 1982 and this has been a long
time since we have had anything that bad, so I think it is going to be
difficult and in 2009 is not going to be great, 2010 is going to be probably
little bit better, but not great and I think by 2011 may be things will come
around if our sort of current policies work.
DR. SHIRA JOHNSON:
Now, because you are an economist we are hanging on your
every word.
DR. JOHN MCCONNELL:
Right, right.
DR. SHIRA JOHNSON:
So, everybody listening to this want your overall forecast
probably as well as they want you specific ED forecast?
DR. JOHN MCCONNELL:
Well the usual caveat applied to economist looking into the
future there that seems to me to be kind of a reasonable scenario so if people
want to use that as a bench mark I think that’s, you know to me, that seems to
be reasonable. So what is that mean for physicians well. I think in the short
run you are not going to see a lot of changes, but may be over the next year
you can expect that there is going to be more unemployment, which means that
people are going to come off employer covered insurance, there is going to be
more uninsured that are seeking care through the hospital, Medicaid roles will
probably go up. We will probably see more of medicaid patients coming into the
hospital or your practice, but you know the shift from commercial payment to
medicaid payment. You may see more medicaid patients, but they are going to be
paying less. So I think that’s probably what you are going to see. We are
already hearing sort of locally that there are some shifts away from elective
surgery that people seem to be putting that off so you know I think it is going
to affect medical practice. On the other hand, there are other industries that
are sort of more susceptible to changes in economic fluctuations, so you know,
medical care is generally pretty steady relative to other industries.
DR. SHIRA JOHNSON:
So they are putting off elective surgery and we are seeing
that already?
DR. JOHN MCCONNELL:
Yes.
DR. SHIRA JOHNSON:
The patients are going to be sicker coming into the hospital
because they may avoid seeking care if care is going to cost them.
DR. JOHN MCCONNELL:
You may see some of that as well.
DR. SHIRA JOHNSON:
And the other interesting thing is with COBRA. We know that
employer have to provide COBRA for not sure of the days, but certainly number
of months after terminating employment, but COBRA which isn't often spoke about
is outrageously expensive and many patients are not able to continue coverage
at those rates because you are paying the employer half and the employee half
correct?
DR. JOHN MCCONNELL:
Yes, that's right.
DR. SHIRA JOHNSON:
And we don’t have solutions for those built into our system
and as you said jobs are being terminated.
DR. JOHN MCCONNELL:
Right.
DR. SHIRA JOHNSON:
At our county hospital in Miami, the ED was always a
revolving door for the un and the under insured. Is this an issue that again
needs to be addressed in a more aggressive manner than we have in the past
because even when time were good, we still had this problem because the people
come here without healthcare and they are from other countries and they need it
urgently?
DR. JOHN MCCONNELL:
Yeah, I mean, this is sort of the system that we have and,
you know, I think that we saw some of dramatic version of that here in Oregon
when we had a medicaid contraction in 2003, and this is another project I
worked on, but we saw a contraction medicaid program that put about 100,000
people out of 400,000 and the total medicaid population took them off and put
them into the uninsured rank. So we tracked what happened to emergency
departments across the state and what we saw was a average increase in
uninsured patients going to emergency department by over 30% with even higher
increases when you broke it down to some specific diagnosis so lot more people
coming in with mental health issues and substance abuse issues and thinks like
that. So, we know from that experience that, you know as people become more
insured that emergency department is where they go.
DR. SHIRA JOHNSON:
And I heard that whereas previously we know that many mental
health benefits and many substance abuse issues are not covered under insurance
even if you have good working insurance, so they are not covered to a great
degree and if you have anymore knowledge of this please correct me, but I
believe they said 2010 the health care plans are going to be required to cover
substance abuse and mental health need for the patients.
DR. JOHN MCCONNELL:
Yes, that’s a sort of a very strange interesting part of the
emergency financial rescue plan that was just passed. So that was a 700
billion dollar plan with a few other weird things in there.
DR. SHIRA JOHNSON:
This look tacked on.
DR. JOHN MCCONNELL:
This was tacked on so there was a mental health parity thing
that had been always floated around the house and senate and sort of made it up
to a certain levels, but never quite passed and so that passed a lot. States
had sort of parity laws for some of their fully insured groups, but because of
the way that federal laws effect whether or not plan is self insured and self
funded, it didn't affect all of the commercial groups. But yes starting in 2010
there will be mental health parity for everybody with some small exceptions
according to small group employer plans, but should be pretty widespread.
DR. SHIRA JOHNSON:
Thank you very much John.
DR. JOHN MCCONNELL:
Thank you.
DR. SHIRA JOHNSON:
I would like to thank my guest Dr. John McConnell for
joining us to discuss the econimic impact of delivering ED health care. For
complete program guide and podcast visit www.reachmd.com,
and thank you as always for listening.
You are listening to ReachMD XM 160, The Channel for
Medical Professionals.
