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The health insurance giant’s ‘avoidable E.R.’ policy has their insured customers playing doctor and deciding between the emergency room or toughing it out at home or at urgent care.

Anthem, the second largest health insurance provider in the country, is under fire from doctors, hospital groups, health policy experts, politicians, and especially its customers for a new policy that aims to cut back on E.R. visits. The policy is now in effect for Anthem customers in Connecticut, Georgia, Indiana, Kentucky, Missouri, Ohio and New Hampshire. According to an Anthem spokesperson, the idea behind the policy is to help keep healthcare costs down for everyone. The company says that 5% of all E.R. visits are unnecessary and that (unneeded) emergency care costs 10 times more in an E.R. than it does in an urgent care or retail healthcare setting.


E.R. Flu Visits Not Covered Under Policy

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An April 10th report by a Goldman Sachs analyst has been making the rounds in the media. The report, entitled “The Genome Revolution,” advised pharmaceutical companies to consider making and selling drugs that treat, not cure, diseases. Why? Making drugs so effective that they eradicate a condition or disease isn’t a profitable business model in the long run.


Drug Companies Hold Our Future in Their Hands

The opioid crisis has put a national spotlight on drug companies for their role in creating and distributing drugs that have caused many in this country to spiral into devastating addiction. These companies have the knowledge and financial means to create drugs that can destroy lives. They also have the ability to save lives and help many struggling with diseases and conditions live pain-free, symptom-free, or at least better than they would without pharmaceutical intervention. Cancer patients are living longer and people with debilitating or problematic conditions and diseases are able to manage and treat symptoms, thanks to big pharma. Drug companies are not all bad. Except that we must remember that they are, at their core, a business. And businesses exist to make money.

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The American College of Obstetricians and Gynecologists (ACOG) just released guidelines advising all OBs in this country to change the way they care for mothers in the 3 month period following childbirth. Instead of the traditional 6 week postpartum visit, the new guidelines recommend seeing all mothers no more than 3 weeks following childbirth, or within 3 days if the mother had severe hypertension during pregnancy, childbirth or immediately following. ACOG also recommends a 12 week final visit that assesses the mother’s overall health and well-being, with attention focused on future family planning, sexual issues, and emotional stability. ACOG’s guidelines also urge OBs to discuss the long term risks associated with certain conditions suffered during pregnancy, such as preeclampsia and gestational diabetes. After leaving the hospital, many mothers feel as though their health and needs are essentially forgotten. We know now that overlooking a woman who has just given birth can have tragic consequences.

More Mothers Die in America Than Other Developed Countries

A 6 month long NPR/ProPublica investigation last year found that the maternal death rate in the U.S. is higher than in any other developed country and that it is on the rise. Black mothers fare the worst.  A black mother is 3 to 4 times more likely to die during pregnancy, childbirth, or during the postpartum period than a white mother. Our blog has previously touched on the reasons why: black women have higher rates of heart disease and other health conditions that impact pregnancy, and they are subjected to more stress than white women.

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The University of Illinois at Chicago and Dr. Nagamani ‘Mani’ Pavuluri, widely considered an expert on bipolar disorder in children, have both been accused of violating medical ethics during a clinical study that studied the affects of lithium on children suffering from bipolar disorder. This past November, Dr. Pavuluri and UIC were ordered to repay all $3.1 million granted to them by the National Institute of Mental Health (NIMH), something many experts say is unprecedented.

Doctor Violated Protocol  

Dr. Pavuluri’s study took place between 2009-2013 and involved 103 children, some as young as 10 years old. The aim was to examine how a young brain functioned during a manic phase of bipolar disorder, then compare it to the brain after an 8 week course of lithium. After an initial review of Dr. Pavuluri’s grant application for the study, she was told by NIMH to correct several things before they would approve her for a grant. Dr. Pavuluri amended her application to correct the below listed flaws and was approved for $3.1 million in funding to conduct her research. However, she was found to have violated each of the things she specifically agreed to change in order to receive funding.

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A study of 440 emergency department doctors found that examinations are less thorough when ERs are so crowded that patients are treated in the hallway. Conducted at a 2015 Boston medical conference, the study revealed that 75% of physicians surveyed copped to obtaining less thorough medical histories of patients under these circumstances. Of that 75%, nearly all admitted that they also changed their standard procedure for conducting a physical exam.

Women who presented with genital or urinary problems were found to be the most underserved group, with the majority of doctors admitting that these issues impacted the way they conducted a physical exam or took a patient’s medical history. Interestingly, the majority of physicians surveyed also said that even in a private room, the presence of someone else known to the patient impacted the questions they asked and the way in which they went about an exam.

The issue of privacy is multilayered. In addition to the majority of doctors being surveyed acknowledging that the presence of others affects their practice of medicine, patients also are believed to withhold information when spouses, family members, friends, and strangers are present.

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It seems unbelievable, but it’s true: Last year, the Illinois Department of Financial & Professional Regulation (IDFPR) did not conduct a single National Practitioner Database (NPDB) background check on any physician applying for a license in the state. Information obtained from the NPDB is considered a fundamental part of the review process in granting a physician a license. The federally-sponsored database includes information on infractions, including citations for improper conduct by state medical boards and hospitals. Information regarding malpractice lawsuits are also included. By federal law, these groups must submit physician data to the NPDB, something other databases containing physician information cannot claim.

It’s Always About Money

According to a Chicago Tribune investigation, half of penalties handed out by the IDFPR in 2012 were for actions another state’s medical board had already disciplined them for. 100 physicians were disciplined based on another state’s information. That same year, less than 30 doctors were penalized after being cited for failure to diagnose a patient or committing some other form of medical error or oversight within Illinois. According to experts, the reason is due to costs. It is easier to go after a physician when another state has already done the leg work and the IDFPR simply does not have the time, nor resources to do a thorough investigation.

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Each year, an estimated 795,000 people have a stroke. Strokes are classified as either ischemic or hemorrhagic, with ischemic strokes afflicting 87% of those who suffer. Clots in vessels that lead to the brain cause an ischemic stroke and evidence has shown that quick recognition and treatment of this type of stroke is the most critical element in predicting long term outcomes. Since 1996, the FDA “gold standard” treatment for an ischemic stroke is tPA, or tissue plasminogen activator. This drug, given by IV within 3 (or sometimes 4.5) hours of the stroke’s onset, opens blocked blood vessels by dissolving the clot. Rapid treatment with tPA can prevent brain cell death caused by lack of blood flow to the brain. In other words, the drug has been shown to substantially decrease the neurological aftermath of a stroke. Both the American Heart Association and the American Stroke Association call for the use of tPA in patients who don’t have contraindications. Yet, almost 30% of all ischemic stroke patients are not given this drug.

Side Effects in Some Tainting Benefits for Others

tPA is certainly not for every stroke patient. The drug is only meant to be used in patients who arrived at the hospital within 3 hours of the onset of an ischemic stroke and have been cleared by a trained physician.

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There are just over 5,600 federally accredited, Medicare-approved, surgical centers in the United States. Considered a more affordable, less-hassle option than having surgery performed within a hospital, patients should be aware of the risks involved, including the inability of their medical team to save their life in case of an emergency.

Without a federal database that tracks the number of adverse events or number of deaths during or immediately following procedures at these facilities, little is known about the outcome of surgeries performed there. In years past, the only negative chatter surrounding surgical centers seemed to be news stories of botched procedures performed at plastic surgery centers by unskilled medical professionals or those masquerading as one. It wasn’t until 2014 and the death of Joan Rivers at a New York City surgical facility that many realized these facilities were often ill-equipped to handle medical emergencies, despite numerous doctors and surgeons being on site. This month, a joint Kaiser Health News (KHN) & USA Today investigation revealed that at least 260 people have died since 2013 after having a routine procedure performed at a surgical center in the United States.

Joan Rivers Case Highlights Surgical Center Flaws

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It sometimes feels like no amount of facts and figures will ever be able to bust the myth that medical malpractice lawsuits, greedy lawyers, and Americans looking for a payday are responsible for the majority of lawsuits and for driving up the costs of healthcare and medical insurance. We’ve frequently discussed the actual drivers behind high medical malpractice premiums for doctors, as well as the reasons behind climbing health insurance premiums and the costs of medical care and tests (please see the related posts linked below for more information).

Today, we’d like to address the latest figures released regarding lawsuits filed in this country and again attempt to set the record straight on these so-called ambulance chasing lawsuits.

According to data compiled by the National Center for State Courts (NCSC) for the year 2016, the latest data available, contract disputes are responsible for the majority of civil cases in state courts, representing 47% of civil cases filed. Other NCSC data revealed:

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A February 16th article in Crain’s Chicago Business covered the increase in opioid-related overdoses and their impact upon hospitals in Illinois. The number of overdoses is rising, but so are the costs associated with treating these patients. Between January-September 2016, the number of opioid-related emergency room visits was 77% higher than that same time period just a year before. Nationwide, the average cost of an intensive care unit stay for an overdose was $58,517 in 2009. In 2015, the average cost per ICU stay jumped to $92,408.

A representative for Cook County Health and Hospital System told Crain’s that they estimate they spent $25 million last year treating between 4-5,000 patients with opioid-related illnesses. As a point of comparison, they treated 1,000 of these patients in 2006.

Loretto Hospital says that 1 out of every 3 patients in the emergency room is there to be treated for an opioid-related issue. They also estimate that nearly 40% of the patients admitted for treatment are later readmitted, something that costs them more than just writing off a single visit. Readmission rates have been a major quality indicator for hospitals and under the Center for Medicare and Medicaid Services “Readmissions Reduction Program,” hospitals who have high readmittance rates will see reduced payments from Medicare and Medicaid. For many hospitals, Medicaid reimbursements make up a large chunk of their revenue.