Originally Posted By TomSawyer Hospital administrators don't hover in the ED looking for patients without insurance or ability to pay. Registrars take the info and enter it - there isn't any supervisor or manager watching all of the entries looking for potential deadbeats. The ED screwed up, pure and simple. Whether the RN didn't tell the doctor or the doctor didn't bother looking at the chart it was a screw up. This story has a lot more to do with the stresses of a busy ED than it does with administration. I've worked in health care long enough to know that no one told the ED to discharge the patient because they couldn't pay, especially in a hospital that provides a lot of charity care.
Originally Posted By TomSawyer Skinner, your conspiracy theory might make sense except for a few things: 1. This is a non-profit hospital that provides a lot of charity care. 2. No hospital administrator wants to invite CMS, the Department of Health, and The Joint Commision because of an incident like this. It's far more expensive to deal with the regulatory and licensing agencies than it is to just write off someone's care. 3. There are a ton of resources available to hospitals that identify an Ebola patient from state and federal agencies. If they had admitted the patient to the floor he likely would have been on a plane to Atlanta within 12 hours anyway. 4. No administrator wants the PR nightmare that this has caused, and the resulting loss of confidence in the skills of the nursing and medical staff. You're thinking like a lawyer here, seeing malfeasance rather than a non-litigable error.
Originally Posted By skinnerbox <<Hospital administrators don't hover in the ED looking for patients without insurance or ability to pay. Registrars take the info and enter it - there isn't any supervisor or manager watching all of the entries looking for potential deadbeats.> Yes, there are administrators whose job it is to get the patient to sign forms promising payment if the other party responsible for paying (insurance, et al) doesn't do it. I've seen it with my own eyes. I've experienced it firsthand. I've had "case managers" show up at my bedside in the ER while I had all kinds of IV tubes sticking out of me and whacked out from abdominal pain, expecting me to sign my life away for their ridiculous charges in case Medicare didn't pony up the bucks. Which, in San Francisco, is about $3300 for 4 bags of IV fluid therapy and medication for nausea/vomiting. Medicare paid for all but $330. And for someone who doesn't have insurance, you still have to sign your life away so they can take you to court with a binding contract in case you fail to make timely payments for services rendered. Well, for foreign visitors who aren't citizens, how exactly is the hospital expected to collect their debt when the patient recovers and returns to their home country? It's not like the hospital will be able to sue them offshore. This is why many tourists or non-nationals showing up in the ER without insurance or obvious means to pay are quickly patched up and stabilized and kicked to the curb. If you didn't read my previous post with the links to actual cases where hospitals have been caught kicking the non-insured out the door too soon, then you need to educate yourself. These private for-profit organizations have figured out numerous ways to get around regulations and still refuse needed services to those in desperate need of them. And in the case of foreign patients, they're at huge risk of being shown the door because there is no cheap or easy way for the hospital to go after them for non-payment.
Originally Posted By fkurucz >>I've had "case managers" show up at my bedside in the ER while I had all kinds of IV tubes sticking out of me and whacked out from abdominal pain, expecting me to sign my life away for their ridiculous charges in case Medicare didn't pony up the bucks.<< I have had the same experience. And even after my insurance was verified they hounded me to cover the copay while I was still had tubes in me. They had a mobile cash register on wheels, complete with a credit card reader, which they wheeled into my room. They also offered to knock $10 off the copay if I paid up on the spot.
Originally Posted By TomSawyer I looked at your four links, Skinner. The first two are general articles referring to research that says that patient dumping is still happening despite EMTALA, but the articles don't give specific examples. It would be good to know what kinds of hospitals the patients were being dumped from and what the situation was. The third article references a policy by a for-profit health system that requires payment for non-emergent treatment AFTER a patient has already been seen in an Emergency Department and found to have a non-emergent condition that could be treated in an urgent care or primary care clinic. That isn't patient dumping. The fourth article refers to medical practices rather than emergency departments. The people getting guarantor forms signs are not administrators. They are patient reg staff. And getting forms signed while you are receiving treatment is nothing like you are accusing the hospitals of doing - you are still getting the treatment. They aren't discharging you.
Originally Posted By fkurucz >>The people getting guarantor forms signs are not administrators. They are patient reg staff. And getting forms signed while you are receiving treatment is nothing like you are accusing the hospitals of doing - you are still getting the treatment. They aren't discharging you.<< Well, yeah ... I signed the papers promising to pay. And the mobile cashier ... a really nice touch. Nevermind that my insurance had already agreed to cover the lion's share of the costs, they came in and badgered me to pay like I was some kind of deadbeat, like it would kill them to mail me a bill for the copay.
Originally Posted By skinnerbox <<They had a mobile cash register on wheels, complete with a credit card reader, which they wheeled into my room. They also offered to knock $10 off the copay if I paid up on the spot.>> YIKES!! It's like emergency health care meets the Apple Store. =8^0 The big thing for me regarding this situation of sending the patient home the first time he showed up, is how this Dallas hospital kept changing its official explanation for why this happened. That smells really suspicious to me, especially since they claim they haven't found the cause for the screw up. Really? You have no idea why you sent this man home? With established protocols and procedures already in place? He told the nurse he was from West Africa and had been there in the past four weeks. She put this information into the computer for anyone reading his file to see. The hospital first claimed the nurse failed to tell the attending physician the patient was from West Africa. They recanted a few days later. (Probably after she retained a lawyer for falsely blaming her.) Then the hospital claimed the attending physician didn't see the inputted info from the nurse because of a software problem. That story was recanted the next day. (Probably after the software firm or IT group who wrote/maintained the program retained a lawyer for falsely blaming them.) Eventually, the hospital basically threw up its collective hands and claimed "we don't know why" the patient was released and sent home. And unfortunately for him, medical experts are now predicting his death soon, stating that treating him the first time he showed up would have given him a decent shot at survival. Sorry, but "we don't know why he was sent home" isn't a good enough answer. There are protocols and procedures in place in each and every hospital with regard to communicating patient history and symptoms. Sure, I could see where a software glitch might have prevented the nurse's intake info from getting into the file. But the hospital claims that didn't happen. OK, so what *did* happen? If the info about his recent travel to West Africa was in his file... why the hell did you release him? Lack of the ability to pay on the part of the patient combined with the lack of ability to sue for non-payment on the part of the hospital is the only logical explanation I can come up with for this screw up. He told the nurse. The nurse put it in his file. The doctor had access to that file. But they sent him home anyway. No ER doctor would have been that blatantly stupid with the Ebola crisis so heavily reported in the news for the past month. The hospital hedged its bet and made a financial decision and has been lying about it ever since.
Originally Posted By Mr X Without delving too much into this (because I'm really not that familiar with it honestly, since I live in a socialist hellhole with that unthinkable single payer deal mucking up my life), I did have one thought as far as that mobile payment deal is concerned, and that is - why is it so different than it used to be? I mean, sure it's easy to accuse those 'evil' hospital admins of being greedy and whatnot, and you can certainly point to the astronomical costs, but it has always been expensive, right? What I'm wondering is, is there a lot more instances these days of people promising to pay, and then just blowing it off? I mean, they don't go around demanding payment here in Japan? They send you a bill. But then again, hotels don't require credit card imprints either. They *trust* you to pay your charges like a proper customer should. Just sayin...
Originally Posted By TomSawyer The US healthcare system is screwed up. No question. The idea of running a for-profit healthcare system in which the patient is the third party to a financial arrangement between the health care provider and the health insurance company is about the worst way you can design health care. Make the insurance company and the health care provider for-profit and it gets even worse. I know a lot of ED nurses and emergency physicians. I hang out with them at lunch. I am on environment of care and safety committees with them. I've questioned some of them after adverse events. This was two people dropping the ball. If you want to blame administration, you should blame them for cutting staffing levels to the point that nurses can't take breaks and to using outsourced companies to provide physicians to EDs. Most nurses I know are overworked because staffing levels are so low. My niece, a nurse in a step down unit, told me that she didn't get a lunch break in the last two days on her 12 hour shift. This was an ED nurse and and ED doc who saw what appeared to be flu symptoms and who just filed the patient under another patient who was wasting their time with something that should have gone to urgent or primary care. They had probably already made up their mind when the patient mentioned that he'd been in West Africa. They didn't feel like they had the time to deal with it because there were other patients who seemed to be higher acuity next door and in the waiting room. The ED staff dropped the ball, and the hospital's safety department dropped the ball by not priming the nursing staff to call in the nursing supe and safety team if a patient presented with flu symptoms who had recently been in certain parts of Africa. This isn't a conspiracy or an example of patient dumping. It's an example of what happens when you cut back on nursing staff and when you have a long history of letting patients use the ED has a primary care clinic.
Originally Posted By RoadTrip It varies by hospital. Although in other locations I have been confronted with the portable register and asked to pay the co-pay while in the ER, that has not been the case at the hospital I live closest to now... Cox South in Springfield. I present my insurance card when I first check in and that is the last I hear about anything money related until I receive a bill for my $90 co-pay a month or so later. That actually surprised me. When I see my primary care doc or specialists in the Cox system, they always expect the co-pay to be paid at the time of your visit.
Originally Posted By SuperDry <<< What I'm wondering is, is there a lot more instances these days of people promising to pay, and then just blowing it off? >>> Well, sure. The numbers of people that have to declare bankruptcy in the US due to healthcare bills is legendary. An often-overlooked facet of this is that of such people, over half of them HAD health insurance at the time they got sick. But copays, coverage limits, and uncovered procedures and medications can still exhaust your finances. Not to mention people that are no longer able to work because they're sick, thus lose their jobs, and with it their employer-provided health care. Healthcare debt is not prioritized in any way in a bankruptcy (unlike a tax bill, student loan, or mortgage), so they often just get discharged with little or none of it paid. Then, there's another large set of people that continue to work and have coverage, but simply don't have any extra money to pay the copays. The recession that started with the housing collapse of 2008 is still affecting a very large number of people, many of which are now in a semi-permanent situation of living paycheck to paycheck and not having extra money for "discretionary" spending like healthcare copays. And, for the 40%+ of people that already have bad credit ratings, the threat of sending (another) bill to collection has almost no impact. I suppose to separate out these types of patients, a healthcare provider could do a quick credit check on the patient, and require payment up front only for those with bad credit, but this would be highly ironic in effect: the only people not required to pay up front would be those that could easily do so.
Originally Posted By skinnerbox Even if my little conspiracy theory isn't true that this private for-profit Dallas hospital kicked him to the curb for lack of insurance (which I still believe is plausible)... the fact that a mistake of this magnitude was made still scares the crap out of me. The Bay Area nurses speaking out now about our lack of pandemic preparedness are spot on. We are not prepared whatsoever in this country to handle diseases of this nature. Look at how poorly hospitals responded to Enterovirus D68 in the beginning, allowing several children to die. Now imagine a more deadly disease that affects more than just children. We've weaponized our local law enforcement for the possible terrorist attack involving explosives or heavy artillery. But what about biological weapons? What have we done to prepare against that? Militarizing the police doesn't do anything to counter that kind of terrorism. And we're far more likely to experience this kind of warfare that what is taking place in Syria or Iraq with ISIS. One individual from West Africa with Ebola slipped through the cracks at a large urban hospital. It's not as though he was showing up at an urgent care center in the middle of rural farmland. This kind of medical F up should have never happened in a major US city. It's bad enough when medical personnel accidentally give a patient a red band medication or the wrong limb is amputated by a distracted surgical team. Those kinds of mistakes should never be made, but unfortunately, are made every day. But this kind of mistake? Totally and completely preventable. There should have been a protocol already in place should someone like Mr Duncan show up in his local ER after traveling to a known hot zone. We are a globally connected nation, with most of the busiest airports in the world. Our borders are proudly porous because that's how democracy rolls. But because they're so porous, we absolutely need safeguards against agents that could potentially decimate large swathes of the population in a matter of days. We are not prepared. And we have zero excuse now to remain that way.
Originally Posted By RoadTrip No matter what protocols and procedures are in place, medical personnel are human and occasionally eff things up. All hospitals now have procedures in place to assure that the proper side of the body is operated on. And mistakes still get made occasionally. I will agree that preparation for this should probably receive greater emphasis. We have never faced a really major event, so I think it has been kind of "out of sight, out of mind". This experience will undoubtedly change that. In fact it will probably bring far more awareness than the event where a medical worker was brought back into this country for treatment. In that case everything went right, no one was exposed, and the patient recovered within a few weeks. And it rapidly fell out of the headlines.
Originally Posted By TomSawyer This was a major screw up, Skinner. No doubt about that. And a big part of the screw up could probably be laid at the feet of the administrators who have been cutting staffing levels and training.
Originally Posted By Kar2oonMan I don't know if this fits this topic exactly, but it's as good a place as any to share it. Last month, we signed up for "Obamacare" coverage in California. (Our benefits were through my wife's job and she was let go after an ownership change at her employer.) I can tell you first hand that the website, as of a month ago, was still awful. The stories you have heard about the problems with it seem very plausible to me after trying, unsuccessfully, to enroll online. You can get just so far, then it gets stuck in a loop. My wife and I, of average intelligence but not computer programmers, were stuck, and it seems to me to be a bug that could be fixed. We wound up contacting a broker who specializes in Covered California policies, and with him, it was all completed quickly and easily. The coverage we have is good, not great and not at the level we had through the employer provided/co-pay plan. Our deductibles and co-pays are higher, prescriptions a little lower. Office visit co-pays went from $30 to $60. It'sd still through our same doctors and pharmacy and hospital, so other than that, it's pricier but not devastatingly so. The other option would have been COBRA, which is about as useless an unemployment "benefit" as you can imagine. Not only do you pay the full cost yourself (while unemployed), they actually add on 1% for administrative fees. Worthless. Obamacare is not perfect, and if the GOP would actually get involved with adjusting and tweaks, it could be great. I am grateful we got it, even though my wife got a new job and we'll soon depart Obamacare and go on that plan. But they have got to get serious about fixing the website, and fast. Open enrollment begins very soon and there's really no excuse to not have a properly functioning website.
Originally Posted By ecdc That's interesting (and bad news) that the website is still struggling. I'm as vociferous a defender of Obamacare as anyone, but I can't believe they botched the website. But it's also a testament to how necessary Obamacare is: people put up with the website and all the problems because being uninsured is just that awful. Seriously, there are few things in America as bad as not having health insurance. Which just makes the GOP all the more pathetic for refusing to do anything to try and make the law better or offer any kind of solution. Jonathan Chait predicted *two years* ago that we'd keep hearing about the Republican replacement plan for Obamacare, and how it would always be just on the cusp of being ready. He was spot on. We've never seen a thing from the Republicans on how to fix our appalling healthcare system.
Originally Posted By skinnerbox I no longer have any doubt that the decision to discharge Mr Duncan after his first ER visit is being deliberately hidden: <a target="blank" rel="nofollow" href="http://thehill.com/policy/healthcare/219933-texas-officials-silent-on-what-went-wrong-with-ebola-patient">http://thehill.com/policy/heal...-patient</a> Texas officials silent on what went wrong with Ebola patient By Sarah Ferris 10/06/14 <> Dallas health officials are keeping quiet about how they initially failed to treat the country’s first reported case of Ebola. At a briefing with reporters Monday, city leaders again declined to provide details about the communication breakdown at Dallas Presbyterian Hospital that led to the release of an Ebola-infected patient. The patient, Thomas Duncan, was brought to the emergency room in an ambulance three days after he released. “I've been concentrating on what we need to do right now to protect Dallas,” said David Lakey, commissioner of the Texas Department of State Health Services. “We’ve got to concentrate on putting plans in place, then we’ll evaluate what happened.” The briefing marked the first time that city officials have taken questions since Dallas Presbyterian Hospital attempted to blame its failure to admit the Ebola-infected patient on its online records system — and then changed its story. In a statement last Thursday, the hospital said it failed to communicate the patient’s travel records — which showed that he was recently in Liberia — because of a faulty electronic records system. The next day, hospital communications officials reversed course and said “there was no flaw.” When asked about his response to the conflicting reports, Lakey acknowledged “obviously that answer got changed several times.” As a result, Lakey said he has stressed the importance of taking accurate travel histories in hospitals across the state. “Before this, [Ebola] seemed remote. It was occurring halfway around the world. Many folks may not have taken the travel history as seriously as it should have been,” Lakey said. Lakey, along with Dallas Mayor Mike Rawlings, also declined to answer questions about the patient’s treatment, deferring to the hospital communications team. The hospital confirmed Monday that it had begun treating Duncan with an experimental Ebola treatment, but Lakey declined to provide details about the drugs. He also declined to answer questions about the costs of the patient’s care and who was footing that bill. Lakey was also asked whether Duncan, who remains in critical condition, would be in better health if he was not initially turned away because staff believed he had a low-grade fever. “Would the first three days have made a difference? I don't know,” Lakey said. <> Of course he knows it would have made a difference! The sooner you start treatment, the better chance you have to keep the upper hand on the progression of the disease. That's true for any infectious agent, lethal or otherwise. The longer you wait, the bigger the virus load your immune system has to deal with. Honestly. What a stupid CYA statement for a medical professional to make! And they still don't know why the man was released from the hospital? Is there no paper trail for the decisions that were made? All hospitals have copious treatment records to protect themselves from 'frivolous' malpractice lawsuits. And since Dallas Presbyterian admitted their software wasn't dysfunctional, the nurse's intake notes about Mr Duncan coming from Liberia were readily available to hospital staff. If the attending physician stupidly gave Mr Duncan antibiotics and sent him home because he hadn't read the entire file, then he/she should be suspended with their license revoked. If the hospital administrator decided to discharge Mr Duncan from lack of insurance, then the hospital should be investigated on criminal charges and have its license revoked. It's not like you need more than a few fingers to count the possibilities. Either the attending physician screwed up or the hospital administration screwed up. One or the other. Nurses don't have the authority to discharge, and she put the travel info in Mr Duncan's file. The decision to discharge sits squarely on the heads above the nurse: the attending physician or the hospital manager. It's just that simple. The CDC sent Ebola warnings to every US hospital weeks ago. No excuse for ER personnel not to recognize the signs and symptoms. Either the doctor didn't read the entire file about traveling in West Africa, or the hospital administration made a calculated financial decision not to treat a non-insured patient. Either way, Dallas Presbyterian is deliberately covering up what they already know. And numerous hospital heads should roll as a result.
Originally Posted By RoadTrip That is exactly the type of thinking that led conservatives to conclude that there was an Obama administration conspiracy to cover-up the truth about Benghazi, which has been shown to be absolutely false. In the early stages of a crisis communication can be garbled, and the left hand doesn't always know what the right hand is doing or saying. At times it is better to say nothing until all the facts have been discovered and documented. That appears to be what they are doing in Dallas. At this point the primary objective is to cure Mr. Duncan, not to satisfy the demands of Monday morning quarterbacks. That is as it should be.
Originally Posted By skinnerbox <<At times it is better to say nothing until all the facts have been discovered and documented. That appears to be what they are doing in Dallas.>> Nonsense. First the hospital claimed the nurse failed to report that the patient had been traveling in West Africa. But two days later, the hospital retracted that story and instead claimed it was a computer software glitch. Then the next day, the software glitch story was retracted for the "we don't know what happened" BS excuse. Sorry, RT, but the hospital does not get a free pass on this one. They know perfectly damn well what happened by now. Either the ER doctor screwed up and didn't read Mr Duncan's entire file... ... or the hospital administration ditched him because he didn't have insurance. This is not an ugly crime scene with dozens of possible leads. Either the doctor released him or the hospital administration overruled the doctor and released him. Both scenarios are likely and easy to determine. The hospital is covering up the truth.
Originally Posted By RoadTrip It is not necessarily that simple. All we have heard from is hospital spokesmen or women. We have heard nothing from anyone directly involved with the case. They first said that a nurse must have left it out of the report. Lord knows, you never want to blame a DOCTOR for anything. Then they decided there wasn't yet enough hard evidence to support that conclusion either... perhaps the doctor just claimed he never saw anything. So they decide they better walk that one back. What the hell... blame it on a software glitch. No one really likes or trusts computers anyway. Then they realized what the hell they did. By saying it was a software glitch, they were saying that software relied on for proper workflow for EVERY patient walking through the door was perhaps compromised, and needed information was not being delivered for many patients. Oh God, they've got to walk that one back too. That is potentially the most widespread danger of any "fault" they've given so far. So they did what they should have done in the first place... admit that at this point they just don't know. Can they know in the future? Of course they can. Review all relevant database entries, including any backups made shortly after the incident occurred, just to make sure nothing was modified after the fact. Interview everyone involved in the situation. Then decide what happened: 1) The nurse didn't report something. 2) The nurse reported it but the doctor didn't read it. 3) The doctor read it, but failed to grasp the significance of what he/she read. 4) There really was a software glitch. OR 5) The administration ditched him because he had no insurance. At the present time, any of the five are about equally as likely.
