ANY WILLING PROVIDER – DOES YOUR INSURANCE COMPANY RESTRICT YOUR ACCESS TO A DOCTOR IN IDAHO

Some insurers and their plans still make it difficult for patients to see the doctor of their choice.  The “Any Willing Provider Law” in Idaho mandates that all insurance companies open their doors to any provider, granted the provider apply and follow the terms of the contractual agreement.  It still seems some insurances companies restrict access to doctors and hospitals and make it difficult to get through that open door. 

In the emergency rooms of America, EMTALA took care of that.  It’s definition now is the “layperson’s view of the emergency.”

One case in Idaho went to the Supreme Court already, where the Supremes overruled the lower court, and award costs and a new appeal to a group of cardiologists. 

Isn’t it time all companies and groups representing themselves as gatekeepers to care – that insure patients in Idaho – obey the law?   Patients need to be pro-active knowing their rights.

SUMMARY


AWP laws come in a variety of forms but the most common type prohibits managed care networks from excluding physicians, pharmacists, hospitals, and other health care providers who are willing to accept the network’s terms and conditions from participation. As the term implies, AWP laws require managed care network sponsors to include any provider who agrees to abide by the terms of their contract and accept their payment schedule.

AWP laws adopted around the country differ considerably. Some permit managed care plan subscribers freedom of choice to select any provider in general, and others have choice with respect to pharmacies or even narrow categories of specialists such as chiropractors, optometrists, or psychiatrists. Some AWP laws apply to institutional providers such as hospitals and still others require network sponsors to merely notify subscribers of plan practices.

As best as we can determine at least 17 states have passed some form of AWP law. But, the governors of Maine, Massachusetts, and Vermont vetoed their respect AWP legislation. The laws in nine states apply only to pharmacies and pharmacists. Among these is the Massachusetts proposal which the governor vetoed. The Massachusetts legislature voted to override the veto.

California has an open-panel requirement with respect to health maintenance organizations (HMOs). Minnesota adopted a law that requires managed care plans to expand network providers
and Virginia has an open-panel requirement for preferred provider organizations (PPOs) networks that permit chiropractors, optometrists, podiatrists, and psychologists to join if they agree to terms and conditions.


Idaho (1994)

Idaho enacted an AWP law and grievance procedure. The law includes provisions that specify that (1) any provider who is qualified and willing to meet plan terms and conditions must be allowed to participate as a network provider; (2) termination or nonrenewal of a provider may occur only after written notice of intended breach of contract, and (3) all insurers must have a grievance procedure in place that includes arbitration or other reasonable due process features (HB 886). (Adapted from: olr@po. state. ct. us)

DRUGS IN WORKPLACE – BIGGER CONCERN THAN YOU MIGHT THINK – ARE YOUR COMPANY POLICIES IN PLACE?

DRUGS IN WORKPLACE –  ARE YOU TRYING TO SKIRT THE ISSUE?

A month or so ago the Feds released their workplace data regarding use of drugs while on duty in various jobs and employments. These are the newest data compared to previous studies in mid-nineties.

Industries that continue to have high rates of on the job drug use and use of drugs are those industries in general that continue to have high job turnover rates.

Illicit drug usage among the 18-64 year olds working full-time was the highest in food service and accommodation industry, construction work, entertainment and arts, information services, and management support companies.

The highest rate was 16.9 percent of the food and accommodation employees used illicit drugs in the last month, in the survey.

Construction workers and miners had the highest heavy use alcohol rates at 17.8 percent. Even CEO’s rate was at 8 percent for heavy alcohol usage.

Marijuana continues to lead the pack on illicit drug use for these surveys.

Over 12 percent of the illicit drug users had three or more employers in the past year! Current drug users had twice the rate of missing one or more days in the last month.

Increased rates of illicit drug use were seen in men and lesser paid jobs.

About half of the full-time workers report that their company does pre-placement drug testing. Protective services had the highest rate (76%) of this type of testing, while legal occupations had the lowest (14%) reported in the study.

Only one-third of the workers reported random drug testing policies by their employers.

ONLY one-third of the workers reported they would be less likely to work for companies with random testing programs in place.

NO DIVING IN LAKES OR RIVERS – “FEET FIRST” PRETTY PLEASE

Over the many years as an Emergency Physician working with trauma and teaching, many patients have presented by ambulance and private car with water diving injuries.

This summer there have been injuries related to diving into the lakes and rivers.

log.jpg

Years ago, not sure if it still is going, was a program I believe by the Neurosurgeons College called “Feet First.” This program tried to educate parents and kids on the value of not diving into water in the lakes and rivers.

A few years ago, going up the Spokane River, I heard a boat literally rip its outdrive off by a “deadhead.” Imagine if that boat would have let the occupants dive in that area “to cool off” only hitting the submerged log.

boatonriver.jpg

When a person dives into the water, all the force is decelerated, into the skull onto the brain. But more importantly, the cervical spine “the neck” gets flexed or extended quite rapidly and dramatically. Then as the flexion or extension is exaggerated, the force (weight) of the body from the height of the dive is literally driven into the spinal vertebrae.  This force is so great it can fracture (break) the neck, rupture the ligaments that hold them in place, and dramatically injure – even push bone fragments into the spinal cord itself.  Thus, paraplegia or quadriplegia ensues….never to walk or move again!

Facial injuries of jaw fractures, nasal fractures, lost teeth, eye injures and even skull fractures, as well as lacerations of all of the above-do occur.  Head injury is commom.

Risk of drowning is high when these injuries occur.  Risk of additional injury is high as “helpers” try to get the victim out of the water…in a “layperson” way…without EMS techniques or even lifeguard techniques.

These are  just plain sad cases.  So preventable.  So life options limiting.  So challenging for the victim, their family, their friends, and their doctors.  Can you imagine how hard it is to hear, “Your child is paralyzed.”

 So castMD says:

NO DIVING IN RIVERS OR LAKES 

FEET FIRST IS THE RULE!

EMERGENCY PHYSICIAN IN IDAHO SUED FOR ER CARE – PARENTAL RIGHT TO REFUSE vs STANDARD OF COMMUNITY PRACTICE

er.jpgAn Idaho case in Boise is coming down the legal pipeline. This case is significant as the plaintiff is support by the Center of Individual Rights group.

According to my understanding these are the general issues.

The baby was presented to the ER for evaluation and treatment.  The baby was ill. The baby was five-weeks old. The mother consented to evaluation on this sick infant. The mother agreed to labs and iv fluids.  ivbaghanging.jpg

The rub came when the baby required a spinal tap and iv antibiotics for evaluation and treatment, immediate or early, to limit the diagnostic possibilities and to provide early treatment for a potential devastating and possible deadly meningitis.

The mother evidently refused.

The Emergency Physician evidently requested protective custody for this infant to proceed. The hospital, the police, the courts agreed with the Emergency Physician and allowed the doctor to proceed.

Now about 5 years later, an entire community to protect this baby is being sued, as the baby and the mother’s rights were violated.

The defense of the doctor, hospital, and police state that the temporary custody allowed the proper diagnosis and treatment of this infant. Infants are tough diagnositc dilemmas naturally.

Courts have upheld even traditional medicine over holistic and alternative methods in cases of seriously or potentially seriously ill or injured children. Of course, that is with needed medical support clinically.

This case will be watched closely by all Emergency Physicians, Emergency Rooms, Law Enforcement Officers, and Courts.  If plaintiffs win this case, a significant shockwave will start a sunami of “hands-off” litigation and will create a mountain of defensive medicine procedures, especially in documentation of refusal of treatment and the risks involved. 

Who has the right to refuse treatment of an infant and who has the right to treat that infant? Should the law allow medical morbidity and mortality even in the face of “lay person” judgement?

er.jpg

(castMD commentary with EM News review contribution)

HEAD INJURY – WHY NOT WEAR THE HELMET

Recently, during a Fourth of July parade, many bikers, cyclists, gymnasts, cheerleaders, rollerskaters, Shriners’ clowns, speed-skaters, and even horseriders were watched with such intensity…and were applauded for their acts, high flying or racing speed. BUT……..Why not wear a helmet?

Some states have passed and then repealed helmet laws. There has been some emphasis on kids with bicycles to wear helmets, and some push to wear helmets during down-hill skiing. BUT…..Why not wear the helmet always?

Is it a personal right NOT to wear a helmet? Is it a business right then for taxpayers, insurers, employers, disability companies and worker comp programs to refuse coverage retrospectively for such injuries and morbidity when someone does NOT wear a helmet? What about a seat-belt? What about smoking, drinking, obesity, and lack of exercise? Sounds far fetched?

Well, back to the parade…..

The Emergency Departments see generally over 2 million head trauma victims annually in the United States.  It is the leading cause of death in persons under 25 years old, with over 50,000 persons dying yearly from head injury.

Head injury crosses all boundaries of socio-economics, ethnicity, financial burden, and coverage.  Just ask the attorney that fell from the bus he was watching a parade from…a little too much partying possibly…Ask his wife who was unrecognized by this smart man after hitting his head.  Life as it was…over…New rules, new learning, new start – ALL difficult to say the least.  Career, family, dreams, and hopes all snuffed due to the head injury.

Some patients have intra-cranial bleeding from their head injury, which is about 5-10%.   This means there is bleeding either in the brain itself, or around the brain under the skull.  Each of the types of bleeding is extremely serious.  Some do not need surgery, while other types of head injury with bleeding inside the skull require immediate life-saving procedures and surgeries. 

High risk groups for “closed” (no external injury) head injury that need a CT scan, which now is the standard, are kids under 6 months, elderly, persistent vomiting, neurological or mental changes, alcohol abuse or overuse, prolonged loss of consciousness and those on blood thinners.  The medical legal world has driven the doctors to scan more often defensively, even with minor head injury.  This has been pushed by successful litigation for what appears minor, only later to be a significant injury.

Even the NFL has now taken up the banner.  It is evident now that boxers and football players with repeated or recurrent head injuries have shown brain disability later in life.  Most of the athletic associations understand now that head injury, even minor, is not to be taken lightly.   Even many of the “rough and tough” rodeo cowboys now wear helmets with the rodeo association.  The bronco-busters are leading the pro charge.

So what’s up with the ultimate boxing and cage fighting until loss of consciousness?  Should insurers, payors, and hospitals be forced to insure these programs and their victims? 

Long term complications of concussion, (which ranges from a confusion with loss of consciousness to complete coma)  are many.  Memory difficulties exist, and may stay persistent.  Dizziness, a general feeling of weakness or lack of energy may continue for months to years.  Headache is common, as well as a problem of focusing on projects or things that require intense thought.  Amnesia, or ability to remember is certainly a problem many victims of head injury encounter.  This retrograde (backwards) memory loss can be devastating.  Thus the attorney’s wife….sobbing….and wondering….

Generally there are three classes of initial head injury in evaluation and prognosis.  They are:  mild, moderate, and severe.  This category is really of doctor’s category based on an initial scoring designed by Glascow.

castMD in a previous post discussed more about head injury.  Please see the following link if you wish to read more about concussion and sports

http://www.castmd.com/?p=93

But head injury is a very serious matter…So teach your kids to wear their helmets by wearing yours.  Consider the no helmet-no activity rule for this. 

As for what the future will bring for insurance coverage for dangerous behavior regarding helmets is still up in the air…..but many insurance companies require a rider or no insurance coverage for trampolines now…..too many broken necks and spinal cord injuries!

I remember the little boy as he was lying there.  Absolutely beautiful 4 year old.  Unconscious.  Comatose.  Scheduled for long-term care preparation and surgeries.  No sign of external injury.  “Just a closed head injury…..”

“SICKO” – WILL IT HELP MAKE THE DIAGNOSIS AND TREATMENT?

AFTER LISTENING THIS PAST FEW DAYS TO SOME NEWS, CASTMD FIGURED THE SYSTEM IS TOO BROKEN NOT TO COMMENT.  MIKE MOORE’S DOCUDRAMA OF THE U.S. HEALTHCARE SYSTEM IS AT LEAST A STARTING POINT…AGAIN….A NEW KIND OF DOCTOR EXPOSED

A FRIEND OF MINE SAVED A PATIENT’S LIFE.   IN SURGERY, THE PERSON ALMOST DIED. THIS ANESTHESIOLOGIST WANTS TO GET PAID BY THE PATIENT’S INSURANCE COMPANY. SOUNDS SIMPLE?

THE PATIENT HAD TO BE TRANSFERRED FROM THE SMALLER HOSPITAL TO A TERTIARY CENTER (A LARGER TEACHING TYPE HOSPITAL) AND LATER UNDERWENT ANOTHER SURGERY. NOW THE INSURANCE COMPANY WILL NOT PAY THE FIRST HOSPITAL AND THE ANESTHESIOLOGIST. THEY DEMAND MORE PAPERWORK, SAYING IT WAS THE SAME SURGERY. SO THE BATTLE OF HEALTHCARE PAYMENTS GOES ON! GENERALLY, DESPITE THE ONLINE DIRECT SUBMISSION OF BILLING TO MEDICAID, MEDICARE, AND OTHER INSURANCE COMPANIES, PAY IS SLOW.

WHAT HAPPENS THEN, IS THE PATIENT GETS BILLED, THE EXPLANATION OF BENEFITS GOES OUT AND EVERYONE INVOLVED IS SENDING DOCUMENTS AND PHONECALLS TO EVERYONE ELSE. SO IT GOES. SO MUCH LOST EFFORTS, EXPENSES, AND WORK…TO GET PAID.

ALL THAT MONEY COULD BE FOR HEALTH AND WELLNESS AND PREVENTION. INSTEAD YOU HAVE FAMILIES BEING BANKRUPTED BY MEDICAL BILLS. THIS HAS BECOME ANOTHER CREDITOR ATTACKING YOUR CREDIT RATING, YOUR PROPERTY, YOUR LIVELIHOOD, AND YOUR HARD-EARNED DOLLARS. MANY HOSPITALS HAVE LAW FIRMS NOW FILE LITIGATION AND SUE THE PATIENTS FOR PAYMENT.

WE SPEND THE MOST ON HEALTH IN THE INDUSTRIALIZED WORLD, YET WE HAVE HIGH INFANT MORTALITY, A SHORTER LIFE EXPECTANCY, AND NEARLY 45 MILLION KNOWN ABOUT PERSONS WITHOUT ANY INSURANCE COVERAGE TO ADEQUATELY PROTECT THE FAMILY OR THEMSELVES.

THE DIRECTOR OF THE G.A.O. (GENERAL ACCOUNTING OFFICE) WAS ON TV THE OTHER DAY. HE SAID IT IS TOO LATE IF WE DO NOT CHANGE NOW. HE IS IMPORTANT. HE IS THE UNITED STATES’ CPA BASICALLY. HE IS MEETING WITH BUSINESS LEADERS, COMPANIES, AND OFFICIALS TO TRY TO GET THE MOMENTUM UP TO CHANGE HOW WE DO THINGS. HE SAID THAT WITH THE BABY-BOOMERS COMING “ON LINE” IN JANUARY 2008, THE GOVERNMENT HAS CREATED A SYSTEM OF INCOMPATIBLE EXPENSE. WITH MEDICARE, MEDICAID, AND SOCIAL SECURITY FOR THE BOOMERS, THE SYSTEM WILL BUST.  SOON!   2020 OR SOONER!   WHY?  HE HAS GIVEN UP ON CONGRESS !!!

IF YOU ADD ON THE NUMBER OF MANDATED ER CARE OF ILLEGAL IMMIGRANTS GOING TO THE EMERGENCY ROOMS, PLUS THE UNDERINSURED, AND THE UNINSURED – IT IS EASY TO APPRECIATE THE PROBLEM.  MANY HOSPITALS’ ERs HAVE CLOSED.  SOME HOSPITALS ARE BEING SOLD FROM NOT-FOR-PROFIT TO FOR-PROFIT SYSTEMS.

WHAT ARE YOU DOING TO HELP TALK IT UP ABOUT HEALTH INSURANCE RATES, HEALTH INSURANCE, AND THE COSTS.  

NO FAMILY SHOULD BE FORCED INTO BANKRUPTCY BY HEALTH ISSUES……

EMERGENCY ROOM VISITS – ILLICIT DRUG ABUSE TOP TEN

poppy.gifAccording to D.A.W.N. which stands for Drug Abuse Warning Network the top ten Emergency Department visits were surprising. Although this list is published openly, it does run about 1-2 years behind.

COCAINE………………………..OVER 448,000

MARIJUANA……………………..OVER 242,000

HEROIN………………………….OVER 164,000

meth-1.pngMETHAMPHETAMINE…………..ALMOST 109,000

ECSTASY (mdma)……………..ALMOST 11,000

PCP………………………………OVER 7500

INHALANTS……………………..OVER 4300

HALLUCINOGENS……………….OVER 3700

LSD………………………………OVER 1800

GHB………………………………OVER 1800

This data is from a reporting system in the United States. Many times, GHB for instance, is gone from detection upon arrival to an Emergency Room. Many inhalants cause death, therefore do not show up in the Emergency Room, but rather the Coroner’s venue. Many times the data is also regionally directed, for instance, in high methamphetamine areas, illicit use might be seen higher in the corresponding Emergency Departments.

To round out this medical commentary today, the United States still has these top ten killers. ecg_evol1.gif

This data is from the 2004 National Center for Health Statistics, the latest full database.  Prevention is the key in almost all of these killers.  With the severe childhood obesity concern in the United States, these data may get thrown in the air, with new issues on top.  For instance, diabetes and asthma may replace the first and second positions due to the issues of childhood health management in general.

HEART DISEASE……………………………………………………………………………27.2%

CANCER…………………………………………………………………………………23.1

CEREBROVASCULAR DISEASES…………………………..6.3%

CHRONIC LOWER RESPIRATORY DISEASES…………5.1%

UNINTENTIONAL INJURY…………………………..4.7%

DIABETES MELLITUS……………………………..3.1%

ALZHEIMER’S DISEASE………………………2.8%

INFLUENZA AND PNEUMONIA……2.5%

KIDNEY DISEASES……………….1.8%

SEPTIC CONDITIONS……….1.4%

NET NEUTRALITY AT RISK- THE BIG DEAL IN YOUR e-LIFE

Sometimes this medical man must make the leap from meth, cocaine, cheese heroin, disability, west nile, herpes, and death…to a topic that is close to the heart and mind.

In the blogger world and the internet world, many brilliant minds exist in a community open source manner, while many other minds (even some the same) coexist in a competitive free market manner. They so far seem to have been a symbiotic relationship at the least.

But a reminder from www.castMD.com now, as it is important. We as bloggers must pay closer attention to this “Net Neutrality” issue. This is how I understand it. Right now, internet is paid for at all levels. About 26 of them. I pay a company to provide access to the net, that company pays the next, the next pays the next…eventually to a major backbone of internet ability. These access points are not “pipes” as one Senator stated in Congress. Everyone gets paid some money along the way…

What may be happening in the telecom companies, is access restriction! Unlike other countries, especially Korea, China, Japan, access is being looked at like your cable or cellphone.

You want what, when, and how fast?

Right now, the IPhone is with AT&T I believe, after Verizon company turned it down due to strict competitive requirements. So, my contract will not allow me to get an IPhone. I cannot get a different phone with ALL the features, because some aspects of cellphones are turned off…or blocked…so the company can RESELL the access to you – EVEN though your cellphone is set for it.

My examples are real but may not be exact for the internet neutrality issue. BUT, what if my SkyNet said you can have only the internet sites that are not commerce related? What about no .com, or .biz sites? But for 100 dollars per month, I can have the .com sites? Or what if a block on all .edu sites was placed for the colleges and universities, unless a million dollars per month is paid by the college or university? Another example is whether or not your access speed would be limited? So, the telecoms give access to the “slow speeds” of uploads and downloads, yet more money for the “real” speeds.

UTube is extremely bandwidth intensive. In the beginning, without the principle of internet neutrality, the telecom ISPs most likely would have restricted bandwidth speed available to their users for viewing the site. Video traffic would slow to a crawl unless the startup business was ready to pay enormous fees to the “gatekeepers” in order to access “their subscribers.” Obviously, a startup in its infancy would not have been able to pay these fees, or would have had to grow slower or die on the vine.   The gatekeepers want to absolute control to all the access to every data pak through the internet network.  Everyone is already paying!

The meeting review on the issue might stimulate your awareness.

FTC ON BROADBAND ACCESS

A review of this issue and faqs is at: SAVE THE INTERNET

THE PRICE AND THE ACCESS RESTRICTION ARE GOING UP !

CHEESE – MARKETING HEROIN FOR YOUR KIDS “SAY CHEESE”

cheese-drug.jpgAs part of my background in pharmacy, emergency medicine, and toxicology, my eye is geared toward new illicit “marketing styles.” One of the latest, yet as usual, older than you think, is “cheese” heroin. This “starter pack” of heroin is REALLY heroin…the DEADLY kind of heroin…the good old toxic illicit heroin.

The difference is in the making of it. The manufacturers of the illicit drug geared for the teens is the mixture of heroin and Tylenol PM©. This multi-drug cocktail of acetaminophen, diphenhydramine (better know as brand name benadryl © and other companies brands) and of course heroin creates a deadly risk. Each item in this mix can be deadly.

As the famed Paracelsus, an earlier father of poisoning stated, “It is not the agent, but rather the dose of the agent. And everything therefore is a poison.”

Acetaminophen remains one of the most toxic poisons if taken in overdose and is the lead cause of death for many years in Europe, while diphenhydramine is again a unique poison in overdose. The anticholinergic side-effects of the drug in overdose creates elevated deathly temperature rise, hallucinations, cardiac instability, agitation, and even death. Heroin for years now continues to plague not only the U.S., but nations around the world. It has enormous addictive potential and leads to severe toxicity, criminality, and occasional deaths on the streets.

Say “Cheese” is a deadly form of a multi-drug extravaganza geared to entice, to addict, and to control your kids. Already in the last 1-2 years, especially in the Texas market, over 20 deaths have occurred. The product appears like Parmesan cheese in structure, yet kills with a vengeance.

paremsan
(grated parmesan)

Say “Cheese” is usually snorted. Why do drug abusers snort? It is because the absorption rate is good. But I have seen those individuals with chronic cocaine abuse, literally rot the nasal septum out…”look Mom, no septum!”

Post-mortem toxicology tests will reveal the deadly three drugs in this mixture…heroin, diphenhydramine, and acetaminophen.

“Cheese” is not a starter-kit for drug use. “Cheese” is a start-kit for deadly teenager activity.

cheese-drug.jpgSAY “CHEESE” MAY BE THE LAST PICTURE TAKEN……..

HUG YOUR KIDS TODAY!