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A Not Very Good Proposal to Reduce Emergency Room Visits

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By JIM PURCELL

A recent article posits that an Anthem company, Blue Cross and Blue Shield of Georgia (BCBSGA), is poised to “punish” its members for “unnecessary” emergency room (ER) visits by charging subscribers the entire bill for unnecessary ER visits.  This is a variation on a theme which has been playing out in virtually every state and every insurer:  how do we reduce the number of unnecessary emergency room visits? 

Of course, expecting a lay person to be able to parse out what is medically necessary for ER care and what is not is probably expecting too much.  Example:  I’m playing softball, slide into third base (at my advanced age), and jam my leg.  I’m not sure if it is a bruise, sprain, tear, or a break.  But it hurts like hell.  It’s 7:30 PM on a Tuesday.  What are my options?

Option A:  I could limp home, medicate with ibuprofen and a few beers, and hope it gets better.  When it does not, or next morning when I awake and am unable to ambulate out of my bed, what do I do then?  But of course, the pain might subside over a few days also.  My mom’s healthcare advice of wait and see might work.

Option B:  Call my primary care physician (PCP), who is closed for the day with a message that “if this is a medical emergency, dial 911.”  That’s helpful.

Option C:  Seek a free standing urgi-center and go there.  They likely will order x-rays, etc.  Is BCBSGA saying you can’t go there?  Unclear.

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#MomInHospital

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By Bob Wachter, MD

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

First a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.

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