Cutting cost without cutting corners

[akdEM]

I'm a very frugal person, and it sickens me to think about the enormous medical bills an emergency department visit can generate. I have no problem ordering expensive, potentially life-saving tests and medicines when they are necessary. But as an ED newbie, what are some of the ways I can help save my patients and our healthcare system some money?

 

For example... if the patient can tolerate PO intake, have them drink water instead of giving everyone an IV bolus... PO meds instead of IV meds whenever reasonable and safe...

 

Any other tips?

[ventana]

do good PE

Do serial exams if CT belly in doubt - document

 

look at old EMR notes - a drug addict coming in with the complaint of RLQ pain for the 18th time does not need a 19th CT

 

but you are stuck doing a lot of work up as you are in the ER and this is our system

 

 

oh yeah, NEVER write name brand drugs, and try to use cheap long old drugs

[db_pavnp]

Can you order your lab tests in a more sequential fashion instead of shotgun blasting your entire DD?

[KMD16]

I'm a very frugal person, and it sickens me to think about the enormous medical bills an emergency department visit can generate. I have no problem ordering expensive, potentially life-saving tests and medicines when they are necessary. But as an ED newbie, what are some of the ways I can help save my patients and our healthcare system some money?

 

For example... if the patient can tolerate PO intake, have them drink water instead of giving everyone an IV bolus... PO meds instead of IV meds whenever reasonable and safe...

 

Any other tips?

Believe me. We all wants to order the least expensive test and save the system. We often times order a lot of test to cover our behind from potential litigation. There are literature on why we ordered too much test in the ED. Do a google search. I think it was written in EMN. Furthermore, significant % of hospital revenue generated by it ED and all the unnecessary test if you'll. My advise, if you're new to the ED as you've indicated. I wouldn't worried about saving the system at this time. Not ordering what may have been the necessary test could get you in trouble. Horn on your skills and find a good mentor. Just my 2 cents.

[db_pavnp]

Can you help me find that paper?

[gbrothers98]

If anyone was truly interested in saving money in the ED, there would be an immediate repeal of EMTALA.

Wont happen unless there is a fundamental shift in healthcare in this country. There are too many conflicts of interest and no political backbone to do so.

Plus the public would not tolerate a lack of services.

 

What has happened instead is cost shifting. The cost of services is shifting more and more to the healthcare consumer. Their share of premiums increases along with deductibles, copays, coinsurances and uncovered services. 

Eventually many employers will stop offering health insurance as a benefit, more consumers will go to the exchanges and over time we will transition to state, federal and regional payers. Pressure from those payers will start being focused not on the elements of the bill such as xray, lab, provider and facility fee but will focus on the overall $$ for the service. 

 

Then you will need to think hard about what you are ordering. 

 

In the scheme of things, you need to know how much stuff costs but you also need to know standards or guidelines of care. You can do all the serial exams on an 80 year old abdominal pain but experience tells me you are taking a big risk not imaging that. Sure you can get away with odt zofran and a popsicle in the dry vomiting healthy young person but who is really healthy and young anymore in the ED? Plus there is throughput to be concerned about. If your ED sees 10k a year, throughput is going to be usually fine just due to volume. You can afford to think, to perform serial exams, to piece together testing in a stepwise manner. See 50k a year and throughput is a big deal. Sometimes the only way to handle that volume is to put protocols in place and move the meat. Protocols dont think about cost, they focus on symptoms and blast away.

 

Last, the ED is not the place to bring your personal beliefs. Much of what you will see will be in direct contradiction of your own beliefs, lifestyle and values. Using your own prism to view the chronic HA pt with a demerol problem, the homeless alcoholic brought in by police, the finger sprain whom called EMS to cut the wait, the 16y/o with bad menstrual cramps, the low income mom who smokes with her 5th child with chronic ear infections, the 94 y/o who wont move to assisted living that fell down the basement stairs on coumadin because she was sure someone was down there, the morbidly obese diabetic who cant understand why no one can fix his heart failure is an exercise in failure that will lead to frustration and burnout. 

 

G Brothers PA-C

[ventana]

Can you order your lab tests in a more sequential fashion instead of shotgun blasting your entire DD?

 

 

sure if you want to not be able to dispo anyone....

tried that method in the past and OMG did it slow things down....

[polarbebe]

sure if you want to not be able to dispo anyone....

tried that method in the past and OMG did it slow things down....

Not to mention the ED nurses breathing down my back for not dispo'ing a patient that suits their timeline/workload. Lol.

[akdEM]

I have had a few patients where I have tried the step-wise approach to ordering labs. It's usually a patient with pretty non-specific but potentially serious complaints, so I try to be thorough. It hasn't really worked out very well. In the end, I end up ordering all the same tests I would have anyway, and the patient is in the department for much longer. So, I'll be avoiding that strategy.

 

I guess my original post was more concerned with things like drug equivalents that are equally effective but maybe have a large price difference. Part of it is that I do not know what things cost, and this is something I need to seek to find out. For example, is there a large price difference between ODT and IV zofran? Or between 8mg of morphine and 1mg of dilaudid?

 

@gbrothers98: I certainly agree that most personal beliefs have no place in the ED, and I make every effort not to bring them into play. I just feel that providing care that is both safe AND cost effective is something I owe to my patients. I think for a new provider, it is a tough line to walk. And as someone mentioned above, I will definitely err on the side of ordering more tests until my experience base is a lot bigger. I think I understand the gist of what you're saying though. Emergency medicine is an endless void of second guessing and moral grey areas. Trying to provide "perfect" care is only going to leave me more frustrated.

[db_pavnp]

Sorry, my rant wasn't worth it.  Truth is, you know how to reduce costs, but it comes at a price of speed and convenience.  It is convenient to write for testing that has nearly no value if it makes you faster.  Sometimes it breaks the bank and sometimes it probably shoots you in the foot, but that's the ER.  Unless you have individuals whose job it is to provide oversight and review of your DD and ordering habits, no one is holding you responsible for waste.

[gbrothers98]

 

 

I guess my original post was more concerned with things like drug equivalents that are equally effective but maybe have a large price difference. Part of it is that I do not know what things cost, and this is something I need to seek to find out. For example, is there a large price difference between ODT and IV zofran? Or between 8mg of morphine and 1mg of dilaudid?

 

 

There prolly is not too much difference in those types of meds. A lot of what we use in the ED is rather cheap until you start using things like TNK, PCC, TPA. Much of what we use is bought in bulk by the pharmacy in house to be used for inpatient purposes. The issue is how much the facility marks it up. Someplaces dont bother to charge for apap or ibu, others charge. Best to find out from one of those PharmD's at albany where the $$ is. Sometimes meds are just wrapped into a facility charge. You could just be spinning your wheels.

 

What really increases bills is imaging. A dose of dilaudid is peanuts compared to that noncontrast CT you just ordered. 

 

Here are markers that are paid attention to rather than the patients bill and these directly affect you, the provider:

Time to provider

Time to disposition

72 hr returns

Radiology variances

Other quality assurance measures such as appropriate eval of chest and abd pain dependent upon department and facility

Patient and staff complaints

 

I dont worry about cost when I eval a patient. I focus on what I am evaluating and the specific patient. If I think they need fluids to get better rather than a popsicle, there we go. Same if I think they do need that cbc even though their dr ran one 2 weeks ago. All my testing has a purpose and a justification based upon my knowledge base and experience. Anecdotally whenever I listened to that little voice that said dont order that, its too expensive, they dont need it.....they did.

 

I look at being in the ED as 2 simple things. Make people feel better. Hunt down the bad things that can hurt people. I coat all that with a good dose of probability and experience. I concern myself thinking about the things that matter more like does this 2 year old really need a head ct rather than the few sheckels I will save when I give phenergan IM rather than zofran IV.

 

I admire your desire to save the system some $$ but you are in training and at an institution and in a department where it likely does not matter. The state of NY will only pay so much for your patient, the patient wont see a bill and no one counts on you or your department to make any money....that's what the cardiac cath lab is for.

 

Dont take my sarcasm to heart, I am with you. You are just likely too early in the upcoming changes to be as concerned as you are.

 

G Brothers PA-C

[KMD16]

^ well said. Couldn't have agreed. Exactly my point. The OP shouldn't focus on saving the system at this early stage in his/her career. Too risky. It would get you in trouble.

[Boatswain2PA]

One unnecessary CT costs $600, plus the unknown cost of the cancer due to the radiation. 

One necessary, but not performed, CT can very easily equal a million bucks and the end of your career.

$1,000,000 / $600 = 1,666 unnecessary CTs to equal one necessary but missed one.

Don't worry about overtesting until you have great clinical gestalt, and/or we drown all of the lawyers.

 

[db_pavnp]

I don't suppose anyone managed to find that article mentioned earlier?

 

I'm curious, what you guys think your itemized bills look like?  Drugs, labs, scans, etc...

[db_pavnp]

I checked a psych protocol lab set.  $2,400 even.  That's for labs alone for anyone acting weird.  They add up.  Another thousand if you thought they might have taken aspirin or acetaminophen and have a tummy ache.  If you want to save money, have a good, evidence based DD and reduce laboratory ordering with clinical skills.

[gbrothers98]

I checked a psych protocol lab set.  $2,400 even.  That's for labs alone for anyone acting weird.  They add up.  Another thousand if you thought they might have taken aspirin or acetaminophen and have a tummy ache.  If you want to save money, have a good, evidence based DD and reduce laboratory ordering with clinical skills.

That is all well and good....until the psychiatric hospital refuses to take your psych patient because they aren't 'medically cleared'. I have argued with psychiatrists, crisis screeners, intake nurses, PAs and NPs who still want those labs and that there is no such thing as 'medically cleared'. So you can spend time thinking...to no avail because some obstacle downstream trumps your clinical judgement without an ounce of reasonableness and they have your n#ts in a vise.

GB PA-C

[db_pavnp]

So because one time someone insisted upon a stupid test, you decided to run the same stupid test on every patient who walks in the door for all eternity?

[True Anomaly]

That is all well and good....until the psychiatric hospital refuses to take your psych patient because they aren't 'medically cleared'. I have argued with psychiatrists, crisis screeners, intake nurses, PAs and NPs who still want those labs and that there is no such thing as 'medically cleared'. So you can spend time thinking...to no avail because some obstacle downstream trumps your clinical judgement without an ounce of reasonableness and they have your n#ts in a vise.

GB PA-C

 

I seriously miss my old hospital where we had such a great relationship with the psych ED that if someone showed up with SI/HI but little to know medical complaint- or even if they had some medical complaint- it was entirely up to us what their medical screening exam would be and/or any testing that was needed before we sent them over for their psych eval.  Now everyone with SI/HI at my new place requires all the "standard testing" which chews up a lot of time and money.  But it's true- if the psychiatrists won't accept your patient without these tests, then you can't fight the battle in the trenches- it has to be done in conferences between the heads of the institutions to come up with better protocols for these patients.

[gbrothers98]

brain freeze

[gbrothers98]

So because one time someone insisted upon a stupid test, you decided to run the same stupid test on every patient who walks in the door for all eternity?

Spoken like someone who doesnt know what they are talking about.

This isnt one time this is all the time.

In 20 years of medicine, I have had to do a lot of stupid things to get patients cared for.

Thank me instead of calling me an idiot whomever you are.

George Brothers PA-C

[Guest Paula]

Oh yeah, I remember a few patients  who needed medical clearance before going to the psych ward.  This was in the few years I worked ER locums.  So we had to run all the screening labs, urine tox screen, alcohol screen, acetaminophen levels,etc. even when not indicated or they would not be accepted for care anywhere in the state.   

[winterallsummer]

You want to save money in the ED? Then work hard to address PTs social issues and set up pcp f/u. The money to be saved is in PTs getting pcp care and having their chronic issues managed so they don't come in with a disaster. There are younger PTs who a proper U/S can be done instead of CT but good care comes before saving money, and sometimes you have to get the CT anyway.

[ohiovolffemtp]

As a side note: what are your psyche clearing labs?  Where I work it's: UA, UDS, U preg if female & still has uterus & age < 60, CBC, BMP, EtOH, salicylate & acet levels.  Any indication of cocaine/crack use adds 12 lead & troponin.  Then it's H&P by provider and eval by ED social services - who are trained in psyche eval.  We have a huge substance abuse problem among our psyche patients, so that's the motivation.

[medic25]

As a side note: what are your psyche clearing labs?  Where I work it's: UA, UDS, U preg if female & still has uterus & age < 60, CBC, BMP, EtOH, salicylate & acet levels.  Any indication of cocaine/crack use adds 12 lead & troponin.  Then it's H&P by provider and eval by ED social services - who are trained in psyche eval.  We have a huge substance abuse problem among our psyche patients, so that's the motivation.

 

For most patients; H&P, fingerstick glucose and breath alcohol.  UCG if female, urine dip if elderly.  We generally are only getting bloodwork, ekg, etc. if there seems to be a medical indication for it (e.g.chest pain, known ingestion).  Our ED has a separate psych ED, so if there are any problems post-clearance it's easy enough to send them back out to the medical side.

[db_pavnp]

Spoken like someone who doesnt know what they are talking about.

 

You know what, I had written a lot more on the subject and deleted it because I don't perceive it as worth it.  Just read the thread and the sense of defeatism is obviously very strong.  For a guy who speaks eloquently on many subjects on this board, I am a bit surprised to see you basically advocate doing nothing but be part of the problem of over utilization of resources.

 

Let me assure you that the subservients you work with are intimately aware of your personal ordering habits and laboratory over utilization is a LOT more expensive than I think most recognize.  Ironically, while pharmacy products experience the same 10-20 fold markup in the ED that everything else does, at least they usually start valued at pennies.  Unfortunately, this topic is obviously a nerve for most providers and probably more-so for PA/NPs under the thumb of MDs claiming over utilization of resources so I no longer expect discussion of value on the subject.