Re: ER misuse

January 20, 2008

Annie--

Consider the issues here.

Folks are going to do what they want. Until the "real client" here (the insurer, I'm certain the pt wouldn't have paid the $500+ fee) wants to deny payment, you can't stop them.

Advise follow up in the office, then review your follow up availability and explain how more available you can be to them.

Good luck!

Matt in Western PA

ER misuse

Has anybody ever fired a patient for ER misuse?

I just got a faxed ER note. Married couple, 30-something. Both morbidly obese with elevated BPs and glucose intolerance who fail follow my recommendations, but then decide (without calling me at all) to be seen in theERfor very trivial complaints (URI -- basically a common cold from the notes, although the ER got the benefit of doing labs and CXRs on both). And this is the second time in 4 months that they have done this.

I am inclined to dismiss them on principle…even with the specter of P4P, their behavior is socially reprehensible and just pisses me off (‘scuse my French). I have never dismissed anyone for anything other than drug-seeking, abusive behavior, or owing me more than $200 for more than a year, but these two just have my blood boiling.

And it’s not like I don’t offer access…I’m on my way to the office now (8:20 on Saturday night) because a healthy 55 yr old lady just called and told me she has been sick for 2 days but decided RIGHT NOW that she has to be seen and if I don’t want to come in, she will go to the ER.

ARRRRGGGGHHHHH! And it’s 8 degrees out there…

Annie

January 20, 2008

So Annie babe

1. it is colder in kentucky than in MAine?? Ah such a world. Do you even

own anything warm??

No wonder you ar e unhappy.

2 .Did ya ever ask these folks about what goes on for them

Who are those folks anyway? Like what are their lives like?

3 So what if the healthy lady goes to the ER?

I mean if she calls you and you do your wonderful stuff talking to her why

would you go in? Are you penalized

or consumed with guilt?

Your patients just seem to torture you

!

You coming to Rochester in june or just packing for the new zealand trip?

God i worry about you.

ER misuse

Has anybody ever fired a patient for ER misuse?

I just got a faxed ER note. Married couple, 30-something. Both morbidly

obese with elevated BPs and glucose intolerance who fail follow my

recommendations, but then decide (without calling me at all) to be seen

in theERfor very trivial complaints (URI -- basically a common cold

from the notes, although the ER got the benefit of doing labs and CXRs

on both). And this is the second time in 4 months that they have done

this.

I am inclined to dismiss them on principle...even with the specter of P4P,

their behavior is socially reprehensible and just pisses me off ('scuse

my French). I have never dismissed anyone for anything other than

drug-seeking, abusive behavior, or owing me more than $200 for more than

a year, but these two just have my blood boiling.

And it's not like I don't offer access...I'm on my way to the office now

(8:20 on Saturday night) because a healthy 55 yr old lady just called

and told me she has been sick for 2 days but decided RIGHT NOW that she

has to be seen and if I don't want to come in, she will go to the ER.

ARRRRGGGGHHHHH! And it's 8 degrees out there...

Annie

January 20, 2008

Annie,

Don’t sweat it. It’s no skin off your teeth,

really. I laugh when people “threaten me” with, if you can’t

see me now I’ll have to go to the ER. Go, wait 4 hours, get a big

bill. I warn them then can do what they want but insurance may not cover

if not deemed an emergency.

And why are you going out at 8:20 at night to meet a patient who

is not seriously ill? You are not being paid for a concierge practice

that you promise 24/7 accessibility, heck, according to you you are hardly

paid. For crissakes set limits. I hope you are charging for an

Emergency visit and the afterhours code. And I hope this patient is very

special to you.

But frankly, I try to educate patients that it really is OK to

be sick for more than a day before seeking medical attention for a minor

illness that doesn’t even need medical attention.

I have a Medicaid patient whose parents are bringing him to the

ER about 5 times a month for trivial complaints after cancelling appointments

at the office and being seen at least once a month. Last sheet I got was

for “wrist pain”. He told me last month that the school made

him go as someone had stepped on his hand and it got all swollen and turned

black. I saw him 2 days later and saw a perfectly normal wrist without

even a bruise and full ROM without pain. Exactly how swollen and black

could it have been. I guaranty that if they had the threat of losing

their free medical care for abuse of the ER or they were held responsible for

nonemergent care, this abuse would stop happening.

The reason ERs are overburdened in my neck of the woods is not

the lack of primary care doctors but the abuse by patients wanting care when

they want it and not understanding what “emergency” really means

and then complaining about having to wait when they feel so awful. Then

stay home!!!

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Annie Skaggs

Sent: Saturday, January 19, 2008 8:29 PM

To:

Subject: ER misuse

Has anybody ever fired a patient for ER

misuse?

I just got a faxed ER note.

Married couple, 30-something. Both morbidly obese with elevated BPs and glucose

intolerance who fail follow my recommendations, but then decide (without

calling me at all) to be seen in theERfor very trivial complaints (URI --

basically a common cold from the notes, although the ER got the benefit of

doing labs and CXRs on both). And this is the second time in 4 months

that they have done this.

I am inclined to dismiss them on

principle…even with the specter of P4P, their behavior is socially

reprehensible and just pisses me off (‘scuse my French). I have never dismissed anyone for anything other than

drug-seeking, abusive behavior, or owing me more than $200 for more than a

year, but these two just have my blood boiling.

And it’s not like I don’t

offer access…I’m on my way to the office now (8:20 on Saturday

night) because a healthy 55 yr old lady just called and told me she has been

sick for 2 days but decided RIGHT NOW that she has to be seen and if I

don’t want to come in, she will go to the ER.

ARRRRGGGGHHHHH! And it’s 8 degrees

out there…

Annie

January 20, 2008

annie, why oh why do you spoil your patients?

and who the hell takes care of you?

g

>

> Has anybody ever fired a patient for ER misuse?

>

> I just got a faxed ER note. Married couple, 30-something. Both

morbidly

> obese with elevated BPs and glucose intolerance who fail follow my

> recommendations, but then decide (without calling me at all) to be

seen in

> theERfor very trivial complaints (URI -- basically a common cold

from the

> notes, although the ER got the benefit of doing labs and CXRs on

both). And

> this is the second time in 4 months that they have done this.

>

> I am inclined to dismiss them on principle.even with the specter of

P4P,

> their behavior is socially reprehensible and just pisses me off

('scuse my

> French). I have never dismissed anyone for anything other than drug-

seeking,

> abusive behavior, or owing me more than $200 for more than a year,

but these

> two just have my blood boiling.

>

> And it's not like I don't offer access.I'm on my way to the office

now (8:20

> on Saturday night) because a healthy 55 yr old lady just called and

told me

> she has been sick for 2 days but decided RIGHT NOW that she has to

be seen

> and if I don't want to come in, she will go to the ER.

>

> ARRRRGGGGHHHHH! And it's 8 degrees out there.

>

> Annie

>

January 20, 2008

> And it's not like I don't offer access…I'm on my way to the office now (8:20

> on Saturday night) because a healthy 55 yr old lady just called and told me

> she has been sick for 2 days but decided RIGHT NOW that she has to be seen

> and if I don't want to come in, she will go to the ER.

I don't understand the threat here? What happens if she goes to the ER?

> ARRRRGGGGHHHHH! And it's 8 degrees out there…

77 deg F. today outside for me.

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

January 20, 2008

Actually, having read this

http://edition.cnn.com/2008/HEALTH/01/15/ep.emergency.room/index.html#cnnSTCText

and then about Edith , I guess it's good to try and keep as

many patients as possible out of ER.

>

> > And it's not like I don't offer access…I'm on my way to the office now (8:20

> > on Saturday night) because a healthy 55 yr old lady just called and told me

> > she has been sick for 2 days but decided RIGHT NOW that she has to be seen

> > and if I don't want to come in, she will go to the ER.

>

> I don't understand the threat here? What happens if she goes to the ER?

>

> > ARRRRGGGGHHHHH! And it's 8 degrees out there…

>

> 77 deg F. today outside for me.

>

> --

> Graham Chiu

> http://www.synapsedirect.com

> Synapse-EMR - innovative electronic medical records system

>

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

January 20, 2008

AnnieAgain from Kentucky, that is a little much.I agree, it is great to keep people out of the ER. But, there's really nothing you can do if they are bound and determined to go, even if it is totally inappropriate.Good work trying but we aren't omnipotent ( SURPRISE!). Your infrastructure is there, you are available, and if they choose not to accept that that would be up to them. Too bad despite after proper orientation they can't seem to figure out how to take advantage of a great thing. (I'm assuming you did explain your system to the ER abusers in florid screaming detail after the first episode?...) The woman with the cold - does she have terrible anxiety about ? avian flu, pneumonia, sepsis, flesh eating bacteria? Anyway you don't need to see her. If she doesn't want to wait, I probably also would say.... OK you can go if you feel that you need to, but I think you have a cold, an ER visit is not necessary. Oh by the way you may have to wait 6 hours, and I don't know what your ER copay is....Yes, I 'd be happy to see you in the morning at a mutually agreeable time....What does say, doesn't he back you up with this?LynnHelping your favorite cause is as easy as instant messaging. You IM, we give. Learn more.

January 20, 2008

I need to read you link, but even without looking at that, what happens is:

it costs a fortune to the health care system, which ultimately we all pay

(but I worry that P4P will make me(doctors) pay more than anyone else); A

load of unnecessary tests are done (this lady had strep, so exam and rapid

strep screen were all that were really needed, but in the ER she would've

had a CBC with manual diff, a Comprehensive Metabolic Panel, a Sed Rate and

CRP and a chest XRay. I've been there myself- when you work for the

ER/hospital, they push for more billable services AND to justify billing for

emergency services at all, you have to put on a show that the person looked

really sick; my favorite all time ER story is when I was called by the

director and COMMANDED to get Xrays of a lady's feet. She had called to

complain that I wasn't going to order Xrays. Her complaint/reason for

visiting the ER was that her feet hurt. It was midnight on Saturday and she

had been dancing for 4 hours in new shoes that were a half size too small,

" but they were sooooo cute and they were half price! "

Then when she left the ER she would've had a referral to infectious disease

and a followup with the primary care doctors employed by the hospital. This

particular lady would have called me to ask if I really thought she needed

to go to those appointments, but a number of my patients have ended up not

being my patients anymore after an ER visit, or at least I don't see them

for a year or so, when they finally jump of the specialty-go-'round.

Another of my patients went to the ER with sore knees. Her main problem was

that she was >90 (I forget now exactly how old, but >90). She lived alone,

had no family except her sister who was about the same age. She was getting

more and more afraid of being alone. She had sore knees, had trouble

standing up, and panicked and called 911. 12 hours later she had had Xrays

of her knees (OK so far), but from there it got horrible: they xrayed her

Lspine and Cspine...they CT scanned her head (she might be demented) they

called ortho, who stuck needles in both her knees (got almost nothing and it

was sterile...duh!) they did a boatload of bloodwork, and when they saw the

WBC was about 3 (right where it had been for the last 8 or 10 years) they

called heme-onc and she got a bone marrow biopsy. She was admitted and they

gave here gobs of narcotics so she got constipated. They did a CT of her

abdomen and pelvis. They gave her too many drugs in general, and she got

confused....so she got a neurology consult and they decided an MRI and an LP

were necessary.... We call this game " Squeeze as many Medicare dollars out

of her before she dies as we can " ...she was in the hospital for a week or

so, discharged to a nursing home and then died a few weeks later, probably

stll with sore knees. I didn't know about any of it until she went to the

nursing home...the hospital didn't notify me and she didn't call.

The smart-ass couple that started this thread might deserve that sort of

abuse, but they don't have medicare... but you asked " what happens if she

goes to the ER? " and that's the sort of thing that happens. Not every time,

but too often for comfort.

Now, no one has answered my question: Have you dismissed people over this

sort of thing. It would be easiest to just ignore it, and most likely they

are not going to come see me again anyway... they have gone to the ER for

all the care they are willing to accept for the last 6 months anyway. But I

am still the PCP of record, so if anybody is going to get dinged for their

misbehavior it will be me. I am wondering if I should officially discharge

them so I can fight the P4P black marks when they come.....

Anybody starting to " clean up " their patient panels?

Annie

Re: ER misuse

Actually, having read this

http://edition.cnn.com/2008/HEALTH/01/15/ep.emergency.room/index.html#cnnSTC

Text

and then about Edith , I guess it's good to try and keep as

many patients as possible out of ER.

> On Jan 20, 2008 2:29 PM, Annie Skaggs

wrote:

>

> > And it's not like I don't offer access.I'm on my way to the office now

(8:20

> > on Saturday night) because a healthy 55 yr old lady just called and told

me

> > she has been sick for 2 days but decided RIGHT NOW that she has to be

seen

> > and if I don't want to come in, she will go to the ER.

>

> I don't understand the threat here? What happens if she goes to the ER?

>

> > ARRRRGGGGHHHHH! And it's 8 degrees out there.

>

> 77 deg F. today outside for me.

>

> --

> Graham Chiu

> http://www.synapsedirect.com

> Synapse-EMR - innovative electronic medical records system

>

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

January 20, 2008

Have 'em come in as follow up and discuss how much more available you are and more focussed your care can be for their "nonemergent" emergencies.

I'd also explain how ore uncompfortable you are about their getting "emergent" non-emergency care that really hasn't helped them.

Encourage them to call you FIRST before ER visit, as it can SAVE THEM TIME (and copays, which are higher for ER visits).

Always ALWAYS let them "off the hook" to go to ER with emergencies that are significant.

If they keep going to ER (sounds like they are which prompted all of this), I'd NOW explain to them that on review of their record, you "aren't a good fit" for their needs, and give them 30 days to find a new MD, only willing to provide emergency care.

Curiously enough, I've discharged about 12 people in the last 20 years, and usually I do it in person -- have pt sign off my typed EMR note for their record and give them a copy. It's not unreasonable for you to tell them that you "just aren't a good enough fit" for them, and give them notice. They're doing it anyway and be done with it.

What about your late evening visit on a Saturday?

Matt in Western PA

RE: ER misuse

I need to read you link, but even without looking at that, what happens is:it costs a fortune to the health care system, which ultimately we all pay(but I worry that P4P will make me(doctors) pay more than anyone else); Aload of unnecessary tests are done (this lady had strep, so exam and rapidstrep screen were all that were really needed, but in the ER she would'vehad a CBC with manual diff, a Comprehensive Metabolic Panel, a Sed Rate andCRP and a chest XRay. I've been there myself- when you work for theER/hospital, they push for more billable services AND to justify billing foremergency services at all, you have to put on a show that the person lookedreally sick; my favorite all time ER story is when I was called by thedirector and COMMANDED to get Xrays of a lady's feet. She had called tocomplain that I wasn't going to order Xrays. Her complaint/reason forvisiting the ER was that her feet hurt. It was midnight on Saturday and shehad been dancing for 4 hours in new shoes that were a half size too small,"but they were sooooo cute and they were half price!"Then when she left the ER she would've had a referral to infectious diseaseand a followup with the primary care doctors employed by the hospital. Thisparticular lady would have called me to ask if I really thought she neededto go to those appointments, but a number of my patients have ended up notbeing my patients anymore after an ER visit, or at least I don't see themfor a year or so, when they finally jump of the specialty-go-'round.Another of my patients went to the ER with sore knees. Her main problem wasthat she was >90 (I forget now exactly how old, but >90). She lived alone,had no family except her sister who was about the same age. She was gettingmore and more afraid of being alone. She had sore knees, had troublestanding up, and panicked and called 911. 12 hours later she had had Xraysof her knees (OK so far), but from there it got horrible: they xrayed herLspine and Cspine...they CT scanned her head (she might be demented) theycalled ortho, who stuck needles in both her knees (got almost nothing and itwas sterile...duh!) they did a boatload of bloodwork, and when they saw theWBC was about 3 (right where it had been for the last 8 or 10 years) theycalled heme-onc and she got a bone marrow biopsy. She was admitted and theygave here gobs of narcotics so she got constipated. They did a CT of herabdomen and pelvis. They gave her too many drugs in general, and she gotconfused....so she got a neurology consult and they decided an MRI and an LPwere necessary.... We call this game "Squeeze as many Medicare dollars outof her before she dies as we can"...she was in the hospital for a week orso, discharged to a nursing home and then died a few weeks later, probablystll with sore knees. I didn't know about any of it until she went to thenursing home...the hospital didn't notify me and she didn't call.The smart-ass couple that started this thread might deserve that sort ofabuse, but they don't have medicare... but you asked "what happens if shegoes to the ER?" and that's the sort of thing that happens. Not every time,but too often for comfort.Now, no one has answered my question: Have you dismissed people over thissort of thing. It would be easiest to just ignore it, and most likely theyare not going to come see me again anyway... they have gone to the ER forall the care they are willing to accept for the last 6 months anyway. But Iam still the PCP of record, so if anybody is going to get dinged for theirmisbehavior it will be me. I am wondering if I should officially dischargethem so I can fight the P4P black marks when they come.....Anybody starting to "clean up" their patient panels?Annie-----Original Message-----From: [mailto: ] On Behalf Of Graham ChiuSent: Sunday, January 20, 2008 2:22 AMTo: Subject: Re: ER misuseActually, having read thishttp://edition.cnn.com/2008/HEALTH/01/15/ep.emergency.room/index.html#cnnSTCTextand then about Edith , I guess it's good to try and keep asmany patients as possible out of ER.On Jan 20, 2008 5:47 PM, Graham Chiu <compkarorigmail> wrote:> On Jan 20, 2008 2:29 PM, Annie Skaggs <askaggsfayettefamilymed>wrote:>> > And it's not like I don't offer access.I'm on my way to the office now(8:20> > on Saturday night) because a healthy 55 yr old lady just called and toldme> > she has been sick for 2 days but decided RIGHT NOW that she has to beseen> > and if I don't want to come in, she will go to the ER.>> I don't understand the threat here? What happens if she goes to the ER?>> > ARRRRGGGGHHHHH! And it's 8 degrees out there.>> 77 deg F. today outside for me.>> --> Graham Chiu> http://www.synapsedirect.com> Synapse-EMR - innovative electronic medical records system>-- Graham Chiuhttp://www.synapsedirect.comSynapse-EMR - innovative electronic medical records system

January 20, 2008

Annie,

First off I wouldn’t take it as a personal failure that

you can’t convince everyone of the proper use of the ER. Secondly,

we are not currently being “dinged” for this kind of

behavior. It is the patient’s behavior not yours.

That being said, I encourage every doctor to discharge patients

they can’t stand. You can’t stand this couple, they piss you

off, your style of medicine doesn’t suit their needs. They are

causing you grief and distress, so discharge them already. It really doesn’t

matter what the reason is. Remember that 5% rule or something, 5% of

patients cause 90% of grief. You can’t be unbiased and neutral to

them, that is apparent. No reasons, no guilt. Just simply say that

it appears you are not the right PCP for them and that you suggest they find another,

30 days emergency care,etc, etc. Call you insurance to find a

participating doctor you cans switch to and let me know where to send your

records. End of story.

Have I discharge a patient for this reason? No, not that I

can remember. But I have discharged patients for using me as a referral generator

and for just not getting along with them. I feel it is a disservice to

treat people who make me groan and who turn my stomach.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Annie Skaggs

Sent: Sunday, January 20, 2008 12:31 PM

To:

Subject: RE: ER misuse

I need to read you link, but even without

looking at that, what happens is: