Malpractice, Malpractice, Health Care and Health Care and

“Me”“Me”Cindy Allen, MSHS, RT-R, RDMS, RVTCindy Allen, MSHS, RT-R, RDMS, RVT

Clinical Applications Specialist, Clinical Applications Specialist, SonoSite, Inc. SonoSite, Inc.

Consultant, GCUS Consultant, GCUS

““There are no There are no facts, only facts, only

interpretations."interpretations."Friedrich Wilhelm Friedrich Wilhelm

Nietzsche Nietzsche

1844 – 19001844 – 1900

Healthcare Cost Healthcare Cost Containment Containment

Estimated > 2.4 Trillion dollar industry Estimated > 2.4 Trillion dollar industry Hospital charges were $873 billion in Hospital charges were $873 billion in

2005, 2005, $943 billion in 2006, $70 billion change in 1-$943 billion in 2006, $70 billion change in 1-

year! year! Agency for Healthcare Research and Agency for Healthcare Research and Quality, 2008Quality, 2008

45-47 million uninsured in the US 45-47 million uninsured in the US (estimated)(estimated) ≥ ≥ collective population of GA, SC, NC, TN, collective population of GA, SC, NC, TN,

VA, KY, MD, DC (estimated 2008) VA, KY, MD, DC (estimated 2008)

Objectives Objectives

Define liability, negligence and Define liability, negligence and malpractice. malpractice.

Review the etiology of malpractice Review the etiology of malpractice Identify statistics from the Identify statistics from the

government and research articles government and research articles Recognize areas of risk for ultrasoundRecognize areas of risk for ultrasound Suggest improvements in day-to-day Suggest improvements in day-to-day

flowflow

Malpractice Malpractice

Professional misconduct Professional misconduct encompassing an unreasonable encompassing an unreasonable lack of skill or unfaithfulness in lack of skill or unfaithfulness in professional or fiduciary duties. professional or fiduciary duties.

Malpractice Liability Malpractice Liability

Has grown much faster than overall Has grown much faster than overall health care inflation. health care inflation.

Most Common Targets: Most Common Targets: Obstetrics Obstetrics NeurologyNeurology Emergency room careEmergency room care

Konig, Health Care News, January 2006 Konig, Health Care News, January 2006

Bureau of Economic Bureau of Economic Analysis Analysis

1929 – 1945 1929 – 1945 Household Household

Budget - 23% foodBudget - 23% food ““Ready to eat” - Ready to eat” -

luxury. luxury. ““Eating out” - rare. Eating out” - rare. Staples - Staples -

“Groceries” (flour, “Groceries” (flour, sugar. etc.) sugar. etc.)

Health care – 4% Health care – 4%

1955 - 20051955 - 2005 Household Household

Food ↓ 22% to 10%Food ↓ 22% to 10% ““Eating out” - taken for Eating out” - taken for

granted. granted. ““Ready to eat” - Ready to eat” -

normal.normal. “ “Staples” hold paper Staples” hold paper

together. together.

Spending on health care Spending on health care quadrupled 5% to > quadrupled 5% to > 20%20%

Medical Negligence Medical Negligence

Medical negligence is a Medical negligence is a breach of duty to behave breach of duty to behave reasonably and prudently reasonably and prudently under the circumstances that under the circumstances that causes forseeable harm to causes forseeable harm to another. another.

Errors in MedicineErrors in Medicine

Define: “the failure of a Define: “the failure of a planned action to be planned action to be completed as intended or the completed as intended or the use of a wrong plan to use of a wrong plan to achieve an aim”achieve an aim” To Err is Human: Building a Safer To Err is Human: Building a Safer

Health SystemHealth System. Washington, D.C.: . Washington, D.C.: National Academy Press, 1999National Academy Press, 1999

Malpractice InsuranceMalpractice Insurance

TortTort law is the name given to a body of law is the name given to a body of law that addresses, and provides law that addresses, and provides remedies for, civil wrongs that do not remedies for, civil wrongs that do not arise out of contractual duties. arise out of contractual duties. Malpractice Insurance has been Malpractice Insurance has been referred to as a “Tort Tax.” referred to as a “Tort Tax.”

A person who is legally injured may be able A person who is legally injured may be able to use tort law to recover damages from to use tort law to recover damages from someone who is liable, for those injuries. someone who is liable, for those injuries.

Torts cover intentional acts and accidents.Torts cover intentional acts and accidents.

Health Care Costs Health Care Costs

Physicians spent $6.3 billion dollars Physicians spent $6.3 billion dollars last year on malpractice premiums. last year on malpractice premiums.

The estimate of savings from limiting The estimate of savings from limiting unreasonable awards for non-unreasonable awards for non-economic damages could reduce economic damages could reduce healthcare costs 5-9% per year.healthcare costs 5-9% per year. This would cover 2.4-4.3 million This would cover 2.4-4.3 million

Americans. Americans. http://aspe.hhs.govhttp://aspe.hhs.gov

Medical Claims Medical Claims

Only 1.53% of those injured by Only 1.53% of those injured by medical negligence file a claim.medical negligence file a claim. Estimate: 98,000 deaths/yearEstimate: 98,000 deaths/year

57-70% of claims result in no 57-70% of claims result in no payment to the patient. payment to the patient.

Cost to defend a claim on average: Cost to defend a claim on average: $24,669 $24,669

Jury trials: average $4.7 million Jury trials: average $4.7 million http://aspe.hhs.govhttp://aspe.hhs.gov Student Doctory Network Student Doctory Network

Liability ED Liability ED

A 15-year Emergency review A 15-year Emergency review Causes/missed diagnoses: appendicitis, Causes/missed diagnoses: appendicitis,

myocardial infarction, fracture, infection, myocardial infarction, fracture, infection, aneurysm, and cerebrovascular disease. aneurysm, and cerebrovascular disease. Ann Ann Emerg MedEmerg Med 2007;49[2]:196. 2007;49[2]:196.

Failure to order indicated tests: 58 % Failure to order indicated tests: 58 % Incorrect interpretation of tests: 37 % Incorrect interpretation of tests: 37 % Most of the missing tests were imaging, such Most of the missing tests were imaging, such

as ultrasound, radiographs, or CT as ultrasound, radiographs, or CT Glauser, Jonathan MD, MBA. The Etiology of Malpractice. Glauser, Jonathan MD, MBA. The Etiology of Malpractice.

Emergency Medicine News. Volume 30(7), July 2008, p 6–7Emergency Medicine News. Volume 30(7), July 2008, p 6–7

Contributing Factors Contributing Factors Excessive workload - 23 percent of casesExcessive workload - 23 percent of cases Handoffs - 24 percent of cases with error Handoffs - 24 percent of cases with error

and bad outcome. and bad outcome. Lack of supervision Lack of supervision Fatigue Fatigue Patient-related factors Patient-related factors In one of six missed diagnoses, test results In one of six missed diagnoses, test results

did not reach the correct clinicians. did not reach the correct clinicians. Glauser, Jonathan MD, MBA. The Etiology of Glauser, Jonathan MD, MBA. The Etiology of

Malpractice. Emergency Medicine News. Malpractice. Emergency Medicine News. Volume 30(7), July 2008, p 6–7Volume 30(7), July 2008, p 6–7

Liable for Medical Liable for Medical Negligence Negligence

Duty – to provide care Duty – to provide care Deviation from the Standard of Care Deviation from the Standard of Care Damages - forseeable harm Damages - forseeable harm Direct correlation - damages must Direct correlation - damages must

occur from the breach of the alleged occur from the breach of the alleged standard of medical care. standard of medical care.

A liability of malpracticeA liability of malpractice

Physician-patient relationship Physician-patient relationship Breach of Standard of CareBreach of Standard of Care

Most often contested Most often contested Negligent Act must have cause Negligent Act must have cause

injury injury Proximate cause Proximate cause

Patient must have sustained an Patient must have sustained an injuryinjury

Standard of Care /Three Standard of Care /Three Words Words

ReasonableReasonable – not extreme, not excessive, – not extreme, not excessive, moderate, not demanding too much moderate, not demanding too much possessing good sound judgment, well possessing good sound judgment, well balanced sensible balanced sensible

OrdinaryOrdinary – common, lacking in excellence, – common, lacking in excellence, not distinguished in any way from others, not distinguished in any way from others, not above but rather below average, not above but rather below average, somewhat inferior level of qualitysomewhat inferior level of quality

AverageAverage – typical, usual, a representative – typical, usual, a representative type, mediocre, run-of-the-mill, so-so, type, mediocre, run-of-the-mill, so-so, midway between the extremes, lack of midway between the extremes, lack of distinction. distinction.

Insurance for the Insurance for the Sonographer Sonographer

SDMS 1M/6MSDMS 1M/6M $20 Student $20 Student $98 Full Time $98 Full Time

EmployedEmployed $190 Part-time $190 Part-time

Employed Employed $293 Self-employed $293 Self-employed

ASE – no current ASE – no current offering offering

SVU 1M/3M SVU 1M/3M $29.50 Student $29.50 Student $90.00 Full-Time $90.00 Full-Time

Employed (W-2)Employed (W-2) $90.00 Part-time $90.00 Part-time

Employed (W-2) Employed (W-2) $176 Self-$176 Self-

Employed (1099) Employed (1099)

Apology LawApology Law

Allows health care providers to Allows health care providers to apologize and offer expressions of apologize and offer expressions of grief without their words being grief without their words being used against them in court. used against them in court.

Goal: encourage communication Goal: encourage communication Disadvantage: court system Disadvantage: court system Virginia has an apology law. Virginia has an apology law.

http:www.sorryworks.net/lawdoc.phtmlhttp:www.sorryworks.net/lawdoc.phtml

Apology Law Apology Law

More than 30 states have enacted laws More than 30 states have enacted laws making apologies for medical errors making apologies for medical errors inadmissible in court. Patients may still inadmissible in court. Patients may still sue for malpractice; they simply have to sue for malpractice; they simply have to make their case without bringing up the make their case without bringing up the apology. apology. American College of Physicians Ethics American College of Physicians Ethics

ManualManual, 3rd ed. American College of , 3rd ed. American College of Physicians, Philadelphia. 1993, and “Doctors Physicians, Philadelphia. 1993, and “Doctors who say they're sorry.” May 22, 2008. who say they're sorry.” May 22, 2008. New New York TimesYork Times [editorial]. [editorial].

Review the Review the etiology of etiology of

malpracticemalpracticeObjective 2Objective 2

Etiology of Malpractice Etiology of Malpractice

Battery – injury by assault or inadequate Battery – injury by assault or inadequate care care

Negligence – below standard of care Negligence – below standard of care Wrongful Death Wrongful Death Loss of a Chance of Recovery or Survival Loss of a Chance of Recovery or Survival Res ipsa loquitur Res ipsa loquitur (the thing speaks for (the thing speaks for

itself)itself) Lack of Informed Consent (considered Lack of Informed Consent (considered

battery) battery)

Etiology of MalpracticeEtiology of Malpractice

Abandonment Abandonment Breach of Privacy and Breach of Privacy and

Confidentiality Confidentiality Breach of Contract or Warranty to Breach of Contract or Warranty to

Cure Cure Products or Strict Liability for Drugs Products or Strict Liability for Drugs

and Medical Devices and Medical Devices Actions of Health Care Providers Actions of Health Care Providers

Etiology of MalpracticeEtiology of Malpractice

Negligent Referral Negligent Referral False Imprisonment (Restraints) False Imprisonment (Restraints) Defamation Defamation Failure to Warn or Control (Safety) Failure to Warn or Control (Safety) Negligent Infliction of Emotional Negligent Infliction of Emotional

Distress Distress

Etiology of MalpracticeEtiology of Malpractice

Failure to Report Failure to Report Infection control Infection control Battered children Battered children Elder abuse Elder abuse

Fraud and Misrepresentation Fraud and Misrepresentation Loss of consortium Loss of consortium

Defensive Medicine Defensive Medicine

A 2005 survey of 844 physicians: A 2005 survey of 844 physicians: 88% have been sued (National Ave: 88% have been sued (National Ave:

25%) 25%) 92 % have ordered tests, performed 92 % have ordered tests, performed

diagnostic procedures or referred to diagnostic procedures or referred to specialist for the sake of assurance specialist for the sake of assurance

33% reported using imaging 33% reported using imaging technology in clinically unnecessary technology in clinically unnecessary circumstances. circumstances.

http://www.healthblog.org/2008 http://www.healthblog.org/2008

Specific to Sonography Specific to Sonography

Average pay-out $300,000 (1990)Average pay-out $300,000 (1990) Abnormal finding. In 40% of the cases, an Abnormal finding. In 40% of the cases, an

abnormality was found at deliveryabnormality was found at delivery Sonography report inaccurate- 67% Sonography report inaccurate- 67% Image quality problems – 30% Image quality problems – 30% Not following ACR guidelines – 10% Not following ACR guidelines – 10% Incorrect patient demographic – 5%Incorrect patient demographic – 5%

Radiologists held liable - 60% Radiologists held liable - 60% Brennan, AJR, 1998Brennan, AJR, 1998

Examples of When a Examples of When a Sonographer is Liable Sonographer is Liable

Physically molesting a patient. Physically molesting a patient. Letting a patient fall, causing injury. Letting a patient fall, causing injury. Giving the patient or accompanying Giving the patient or accompanying

doctor a wrong diagnosisdoctor a wrong diagnosis Revealing confidential information about Revealing confidential information about

the contents of the sonogram or disclosing the contents of the sonogram or disclosing any information that has adverse affects any information that has adverse affects on the patient. on the patient.

Clinical Sonography. Roger Sanders and Tom Clinical Sonography. Roger Sanders and Tom Winter. 2007Winter. 2007

Recognize areas Recognize areas of risk Specific to of risk Specific to

UltrasoundUltrasoundObjective 3Objective 3

Shortage Shortage

Shortage of physicians and personnel Shortage of physicians and personnel ~6% imaging personnel~6% imaging personnel

Shorter exam time expectationsShorter exam time expectations Residents are specializing in higher Residents are specializing in higher

reimbursement areasreimbursement areas Demand for primary care physicians Demand for primary care physicians

Retiring physicians creating need Retiring physicians creating need

Demands on Demands on Physicians/Providers Physicians/Providers

Less time per patientLess time per patient Driven by reimbursement basis fee Driven by reimbursement basis fee

per service (office and outpatient) per service (office and outpatient) Learning new computer systems Learning new computer systems

Computer Order Entry Systems Computer Order Entry Systems Electronic Medical Records Electronic Medical Records PACSPACS

Matrix for standard of care Matrix for standard of care

Changes to Residency Changes to Residency Programs Programs

July 1, 2009: patient load restrictions July 1, 2009: patient load restrictions In 2003, work hours were cappedIn 2003, work hours were capped

Cost of hospital care and hospital Cost of hospital care and hospital medicine groups (HMG’s) expected to medicine groups (HMG’s) expected to increase increase

Hospitalist to see more patients Hospitalist to see more patients Experience level of new graduates Experience level of new graduates

expected to diminish expected to diminish No additional reimbursement plannedNo additional reimbursement planned

Resident Restrictions. Hospitalist. 2009; 13(1) 23-Resident Restrictions. Hospitalist. 2009; 13(1) 23-24 24

Traditionally Traditionally

As a delegated, supervised agent, As a delegated, supervised agent, sonographers malpractice risk was lower:sonographers malpractice risk was lower: Not considered an independent Not considered an independent

provider provider NP, PA, MD, DO, PTNP, PA, MD, DO, PT

““Supervised” by licensed person Supervised” by licensed person insulates riskinsulates risk

Implication is the employer is Implication is the employer is responsible if employer is named. responsible if employer is named.

As professional image As professional image increases: increases:

Reduction in Reduction in supervision/requirements supervision/requirements

Revision from direct to general Revision from direct to general supervision (Medicare) supervision (Medicare)

Focus and attention increases Focus and attention increases Expectation increases Expectation increases ↓ ↓ supervision, ↑ risk supervision, ↑ risk

Decisions on Image, not on Decisions on Image, not on Interpretation Interpretation

Increased reliance on the Increased reliance on the Ultrasound Image Ultrasound Image Digitized world Digitized world Interventions based on Ultrasound Interventions based on Ultrasound

imageimage Ultrasound more frequently used in Ultrasound more frequently used in

guidance or interventional guidance or interventional procedures procedures

No “fail-safe”No “fail-safe”

Preliminary Preliminary ReportsReports

A Preliminary Report A Preliminary Report

Is not considered legally hazardous as long Is not considered legally hazardous as long as the sonographer does not attempt to as the sonographer does not attempt to make a diagnosis. make a diagnosis.

If working with a sonologist, the sonologist If working with a sonologist, the sonologist is responsible for correcting the is responsible for correcting the sonographer film/techniques: gallbladder sonographer film/techniques: gallbladder sludge, pseudohydronephrosis, missing sludge, pseudohydronephrosis, missing pathology – not moving patient, missing pathology – not moving patient, missing pathology due to transducer frequency. pathology due to transducer frequency.

Clinical Sonography. Roger Sanders and Tom Winter. Clinical Sonography. Roger Sanders and Tom Winter. 20072007

Areas of Risk – Areas of Risk – Preliminary Reports Preliminary Reports

AIUM on OB-GYNAIUM on OB-GYNA preliminary report is a A preliminary report is a written or verbal report written or verbal report released prior to being released prior to being signed by the physician signed by the physician responsible for giving responsible for giving the final interpretation. the final interpretation.

Prelim: OB-GYNPrelim: OB-GYN

Preliminary reports for fetal Preliminary reports for fetal biometry, biophysical profiles, biometry, biophysical profiles, and viability can be given by a and viability can be given by a sonographer who is ARDMS-sonographer who is ARDMS-registered in that specialty, if registered in that specialty, if the results are normal and the the results are normal and the final report is complete within 2 final report is complete within 2 hours; hours;

AIUM on OB-GYN Prelims. AIUM on OB-GYN Prelims.

The preliminary report is The preliminary report is equivalent to a worksheet. equivalent to a worksheet. Limitations: Limitations: Cannot have Cannot have recommendations/ recommendations/ impression. impression.

Labeled "Preliminary Labeled "Preliminary Report." Report."

AIUM on OB-GYN AIUM on OB-GYN Prelims.Prelims.

A written policy for A written policy for communicating the differences communicating the differences and changes that arise between and changes that arise between the preliminary and final report the preliminary and final report must be in place. must be in place.

Verified final reports must be Verified final reports must be available within 24 hours of available within 24 hours of completion of the exam.completion of the exam.

Preliminary Reports – Preliminary Reports – ICAEL ICAEL

The ICAEL strongly discourages The ICAEL strongly discourages the use of sonographer the use of sonographer prepared preliminary reports, prepared preliminary reports, worksheets or verbal reports worksheets or verbal reports that would be used for the that would be used for the purpose of clinical management. purpose of clinical management. The Newsletter, September 2004, Volume The Newsletter, September 2004, Volume

7, Issue 2 7, Issue 2

Preliminary Reports – Preliminary Reports – Vascular Vascular

Vascular technologists Vascular technologists frequently report critically frequently report critically important data that they have important data that they have collected directly to treating collected directly to treating physicians for their use in the physicians for their use in the care and treatment of patients.care and treatment of patients. Society of Vascular Technologist and Society of Vascular Technologist and

Society of Vascular Surgery Society of Vascular Surgery

Requested changes to Requested changes to Bureau Labor and Statistics Bureau Labor and Statistics

for Vascular for Vascular

SVU and SVS SVU and SVS For 2010 Outlook revision For 2010 Outlook revision Separation from Separation from

Cardiovascular Cardiovascular

Proposed Description of Proposed Description of Vascular Technologist Vascular Technologist

Occupation Occupation Conducts tests, using judgments formed Conducts tests, using judgments formed from a review of the images and data from a review of the images and data obtained through the testing modalities, obtained through the testing modalities, to maximize the utility of the diagnostic to maximize the utility of the diagnostic tests. The testing consists of noninvasive tests. The testing consists of noninvasive ultrasound procedures, performed to ultrasound procedures, performed to provide diagnostic information regarding provide diagnostic information regarding the physiology and functioning of the the physiology and functioning of the patient's veins and arteries for diagnostic patient's veins and arteries for diagnostic purposes. Completes patients' medical purposes. Completes patients' medical histories, performs a limited physical histories, performs a limited physical examination, and provides a summary of examination, and provides a summary of findings to aid the physician in diagnosis findings to aid the physician in diagnosis and treatment.and treatment.

http://www.svunet.org/advocacy/comments/7-15-08-SVU-SVS.pdfhttp://www.svunet.org/advocacy/comments/7-15-08-SVU-SVS.pdf

Identify statistics Identify statistics from the from the

government and government and research articles research articles

Objective 4Objective 4

Costs of HealthCare Costs of HealthCare

In 2008, health care spending in In 2008, health care spending in the United States reached $2.4 the United States reached $2.4 trillion.trillion. Keehan, S. et al. “Health Spending Projections Keehan, S. et al. “Health Spending Projections

Through 2017, Health Affairs Web Exclusive W146: 21 Through 2017, Health Affairs Web Exclusive W146: 21

February 2008.February 2008. Health care spending is 4.3 times the Health care spending is 4.3 times the

amount spent on national defense.amount spent on national defense. California Health Care Foundation. Health Care Costs California Health Care Foundation. Health Care Costs

101 -- 2005. 02 March 2005. 101 -- 2005. 02 March 2005.

Gross Domestic Product Gross Domestic Product In 2008, the United States will spend In 2008, the United States will spend

17 percent of its gross domestic 17 percent of its gross domestic product (GDP) on health care.product (GDP) on health care. Keehan, S. et al. “Health Spending Projections Keehan, S. et al. “Health Spending Projections

Through 2017, Health Affairs Web Exclusive W146: Through 2017, Health Affairs Web Exclusive W146: 21 February 2008. 21 February 2008.

Comparison: Comparison: 10.9 % - Switzerland 10.9 % - Switzerland 10.7 % - Germany10.7 % - Germany 9.7 % - Canada 9.7 % - Canada 9.5 % - France 9.5 % - France

Organization for Economic Cooperation and Organization for Economic Cooperation and Development. Development.

The Uninsured The Uninsured

Although estimated 46 million Although estimated 46 million Americans are uninsured, the Americans are uninsured, the United States spends more on United States spends more on health care than other industrialized health care than other industrialized nations, and those countries provide nations, and those countries provide health insurance to all their citizens.health insurance to all their citizens. California Health Care Foundation. California Health Care Foundation.

Health Care Costs 101 -- 2005. 02 March Health Care Costs 101 -- 2005. 02 March 2005. 2005.

Expensive Expensive

National surveys show that the National surveys show that the primary reason people are primary reason people are uninsured is the high cost of health uninsured is the high cost of health insurance coverage insurance coverage The Henry J. Kaiser Family Foundation. The Henry J. Kaiser Family Foundation.

Employee Health Benefits: 2008 Annual Employee Health Benefits: 2008 Annual Survey. September 2008. Survey. September 2008.

Employers Expense Employers Expense

Health insurance expenses are Health insurance expenses are fastest growing cost for employers. fastest growing cost for employers.

Increased health costs correlate to Increased health costs correlate to drop in health insurance. drop in health insurance.

25% of housing problems attributed 25% of housing problems attributed 1.5 million foreclosures on homes 1.5 million foreclosures on homes

/year/year

Cost to Employees Cost to Employees Workers pay $1,600 more in premiums Workers pay $1,600 more in premiums

annually for family coverage than they annually for family coverage than they did in 1999.did in 1999.

The annual premium a health insurer The annual premium a health insurer charges an employer for a health plan charges an employer for a health plan covering a family of four averaged covering a family of four averaged $12,700 in 2008. $12,700 in 2008. Workers contribution average: $3,400. Workers contribution average: $3,400.

12% more than 200712% more than 2007..

The Henry J. Kaiser Family Foundation. Employee Health The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008 Benefits: 2008 Annual Survey. September 2008

The Self-insured The Self-insured

Approximately 17 million Americans.Approximately 17 million Americans. Individual policy applications rose Individual policy applications rose

18% in fourth quarter 2008 with 18% in fourth quarter 2008 with ehealthinsurance (compared to ehealthinsurance (compared to 2007). 2007).

Individual insurance companies are Individual insurance companies are increasing rates nationwide 8%-56%. increasing rates nationwide 8%-56%.

Julie Appleby, USA Today Friday February Julie Appleby, USA Today Friday February 20, 2009 20, 2009

Medical Expense and Medical Expense and Bankrupcy Bankrupcy

A recent study by Harvard University A recent study by Harvard University researchers found that the average researchers found that the average out-of-pocket medical debt for those out-of-pocket medical debt for those who filed for bankruptcy was $12,000.who filed for bankruptcy was $12,000. 68 % had health insurance. 68 % had health insurance. 50 % of all bankruptcy filings were 50 % of all bankruptcy filings were

partly due to medical expenses. partly due to medical expenses. Himmelstein, D, E. Warren, D. Thorne, and S. Himmelstein, D, E. Warren, D. Thorne, and S.

Woolhander, “Illness and Injury as Contributors to Woolhander, “Illness and Injury as Contributors to Bankruptcy, “ Health Affairs Web Exclusive W5-63, 02 Bankruptcy, “ Health Affairs Web Exclusive W5-63, 02 February , 2005. February , 2005.

More costs to physicians More costs to physicians - ICD-10 - ICD-10

Implementation moved to 2013 Implementation moved to 2013 Requires adoption of 5010 electronic Requires adoption of 5010 electronic

transaction standards under the transaction standards under the Health Insurance Portability and Health Insurance Portability and Accountability Act. Accountability Act.

Estimate: average cost of moving to Estimate: average cost of moving to ICD-10 for a three-physician practice ICD-10 for a three-physician practice will be $84,000 will be $84,000

Medicare – two tier Medicare – two tier payment payment

Technical Component - Usually the Technical Component - Usually the larger of the two components larger of the two components Performing an imaging study Performing an imaging study Usually the larger of the two componentsUsually the larger of the two components Equipment, Supplies Equipment, Supplies

Professional Component Professional Component Interpretation/Report Interpretation/Report SupervisionSupervision LiabilityLiability

Payment – Direct Cost Payment – Direct Cost

Direct cost is the basic cost of Direct cost is the basic cost of performing the procedure performing the procedure Non-physician clinical staffNon-physician clinical staff Medical equipment Medical equipment Medical supplies Medical supplies

This is a major determinant in how This is a major determinant in how much doctors are paid for specific much doctors are paid for specific procedures. procedures.

Direct Cost Direct Cost

When direct cost is When direct cost is high (CT, MRI) due high (CT, MRI) due to cost to buy, to cost to buy, maintain and use, maintain and use, doctors get paid doctors get paid more to use it more to use it

Other variables: Other variables: Time Time Effort Effort Skill Skill Stress of a Stress of a

procedure procedure Liability insurance Liability insurance

expenses expenses

Independent Diagnostic Independent Diagnostic Testing Facilities, IDTF Testing Facilities, IDTF

(CMS) (CMS) Designed to limit unnecessary Designed to limit unnecessary

utilization of imaging services utilization of imaging services Required a supervising physician on Required a supervising physician on

site with proficiency in the test being site with proficiency in the test being performedperformed Interpreted by many as supervised by a Interpreted by many as supervised by a

radiologist. radiologist. Was not implemented, October Was not implemented, October

2008. 2008.

Three No-Cover Events Three No-Cover Events

Jan. 15 2009 Jan. 15 2009 The Centers for Medicare & The Centers for Medicare &

Medicaid Services Medicaid Services End pay for surgeries involving End pay for surgeries involving

three major errors. three major errors. Incorrect patient Incorrect patient Incorrect body part Incorrect body part Incorrect surgical procedureIncorrect surgical procedure

Complications – 2006 Complications – 2006

Complication of device, Complication of device, implant or graft 27.4 million, implant or graft 27.4 million, 2.9% of nations bill 2.9% of nations bill

Complications of surgical Complications of surgical procedure or medical care procedure or medical care 14.5 million, 1.5% of nations 14.5 million, 1.5% of nations billbill

Implication – Implication – Hospitalizations 2006Hospitalizations 2006

Most expensive Most expensive conditions/percentage of national bill: conditions/percentage of national bill: Coronary artery disease (5.6%) Coronary artery disease (5.6%)

1.2 million stays, $53 Billion 1.2 million stays, $53 Billion Acute Myocardial infarction (3.7%) Acute Myocardial infarction (3.7%) Congestive heart failure (3.5%) Congestive heart failure (3.5%) Pregnancy and delivery (5.1%)Pregnancy and delivery (5.1%) Newborn infants (4.0%)Newborn infants (4.0%)

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.jsphttp://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.jsp

American Recovery and American Recovery and Reinvestment Act of 2009. Reinvestment Act of 2009.

Provision of $20 billion in health IT adoption Provision of $20 billion in health IT adoption incentives. incentives.

Expected transformation of the practice of Expected transformation of the practice of medicine if implemented properly. medicine if implemented properly.

Establishment of a system of Medicare/Medicaid Establishment of a system of Medicare/Medicaid bonuses/penalties to encourage health IT adoption bonuses/penalties to encourage health IT adoption

Incentives for health professionals, including Incentives for health professionals, including physicians, who use health IT to a sufficient physicians, who use health IT to a sufficient degree and who see a relatively high volume of degree and who see a relatively high volume of patients. patients.

Goal is to develop health IT standards to improve Goal is to develop health IT standards to improve health care quality, efficiency and consistency. health care quality, efficiency and consistency.

Deadline: 2014 Deadline: 2014

Radiation Exposure Radiation Exposure Concerns Concerns

Informed Consent Informed Consent Risk not mentioned – Expert knows best Risk not mentioned – Expert knows best

unheard (by the patient) and unspoken (by unheard (by the patient) and unspoken (by the doctor)the doctor)

Radiation risk understatedRadiation risk understated Equivalent of 500 chest X-Rays (64-slice Equivalent of 500 chest X-Rays (64-slice

Cardiac CT)Cardiac CT) Full Disclosure Full Disclosure

Comparision to background radiation for Comparision to background radiation for year year

Institute for Energy and Environmental Institute for Energy and Environmental Research (IEER) Research (IEER)

Recommending New GuidelinesRecommending New Guidelines Women are 52% more likely to get Women are 52% more likely to get

cancer from the same amount of cancer from the same amount of radiation dose compared to men radiation dose compared to men

A female infant has about a seven A female infant has about a seven times greater chance, according to times greater chance, according to Arjun Makhijani, Ph.D.Arjun Makhijani, Ph.D. AuntMinnie.com January 13, 2009AuntMinnie.com January 13, 2009

Radiation Exposure Radiation Exposure

Natural Radiation – such as radonNatural Radiation – such as radon Average person in the US receives 3 mSv of Average person in the US receives 3 mSv of

Natural Radiation Natural Radiation Chest X-Ray 0.1 mSv or 10 days of natural Chest X-Ray 0.1 mSv or 10 days of natural Mammogram 0.7 mSv or or 3 months Mammogram 0.7 mSv or or 3 months Cardiac CT for calcium scoring 2 mSv or 8 Cardiac CT for calcium scoring 2 mSv or 8

months months An abdominal/spine CT is 10 mSv or 3 years An abdominal/spine CT is 10 mSv or 3 years

Millisievert: One thousandth of a sievert, the unit Millisievert: One thousandth of a sievert, the unit for measuring ionizing radiation effective dose, for measuring ionizing radiation effective dose, which accounts for relative sensitivities of which accounts for relative sensitivities of different tissues and organs exposed to radiation. different tissues and organs exposed to radiation.

(http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray)(http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray)

Non-Clinical Criteria Non-Clinical Criteria Influencing Hospital Influencing Hospital

Choice Choice Keeping patients informed about Keeping patients informed about treatment both during and after visit treatment both during and after visit (77%) (77%)

Conducting scheduled appointments on Conducting scheduled appointments on time(75%) time(75%)

Room appearance (66%) Room appearance (66%) Ease of scheduling appointments (64%) Ease of scheduling appointments (64%) Food and entertainment options in room Food and entertainment options in room

(63%) (63%) Value for the money (62%) Value for the money (62%)

http://healthcare-economist.comhttp://healthcare-economist.com

Pending Pending Legislation Legislation

That I found….That I found….

Oregon Oregon H 2245 (Hunt) Medical ImagingH 2245 (Hunt) Medical Imaging

Changes name of Board of Radiologic Changes name of Board of Radiologic Technology to Board of Medical Imaging; Technology to Board of Medical Imaging; changes name of Board of Radiologic changes name of Board of Radiologic Technology Account to Board of Medical Technology Account to Board of Medical Imaging Account; defines medical Imaging Account; defines medical imaging modality and related terms; imaging modality and related terms; creates categories of medical imaging creates categories of medical imaging modalities; revises various provisions modalities; revises various provisions relating to medical imaging licensees and relating to medical imaging licensees and limited X-ray machine operator limited X-ray machine operator permittees. permittees.

1/16/2009 - Introduced. 1/16/2009 - Introduced.

New Mexico New Mexico H 498 (Steinborn) Health CareH 498 (Steinborn) Health Care Relates to health care; charges the Relates to health care; charges the

New Mexico medical board with New Mexico medical board with promulgating rules for the provision promulgating rules for the provision of technical services for medical of technical services for medical imaging examinations and radiation imaging examinations and radiation therapy treatments.therapy treatments.

02/02/2009 - Introduced. Referred to the House Committee 02/02/2009 - Introduced. Referred to the House Committee on Health And Government Affairs, then to the House on Health And Government Affairs, then to the House Committee on Judiciary. Committee on Judiciary.

The language of this bill creates a second regulatory The language of this bill creates a second regulatory agency on medical imaging without repealing the authority agency on medical imaging without repealing the authority of the existing agency. Additionally grants blanket of the existing agency. Additionally grants blanket exemptions to other allied health practitioners.exemptions to other allied health practitioners.

Connecticut Connecticut

ConnecticutConnecticut H 5635 (Widlitz) The Administration of H 5635 (Widlitz) The Administration of

Ultrasound ProceduresUltrasound Procedures Concerns the administration of ultrasound Concerns the administration of ultrasound

procedures; eliminates the administration procedures; eliminates the administration of ultrasound procedures by nonmedical of ultrasound procedures by nonmedical commercial operations. commercial operations.

01/22/2009 - Introduced. Referred to the 01/22/2009 - Introduced. Referred to the Joint Committee on Public Health. Joint Committee on Public Health.

This bill would prohibit ultrasound for This bill would prohibit ultrasound for entertainment purposes.entertainment purposes.

Virginia – RA House Bill Virginia – RA House Bill H 1939 (Peace) Radiologist AssistantsH 1939 (Peace) Radiologist Assistants

Provides for the licensure of radiologist Provides for the licensure of radiologist assistants as individuals who have met assistants as individuals who have met the requirements of the Board of the requirements of the Board of Medicine for licensure as advanced-Medicine for licensure as advanced-level radiologic technologists and who level radiologic technologists and who are authorized to assess and evaluate are authorized to assess and evaluate the physiological and psychological the physiological and psychological responsiveness of patients undergoing responsiveness of patients undergoing radiologic procedures. radiologic procedures. 01/14/2009 - Introduced. Referred to the House Committee on Health, Welfare 01/14/2009 - Introduced. Referred to the House Committee on Health, Welfare and Institutions. and Institutions.

01/26/2009 - ***Passed by the House. Engrossed. To the Senate01/26/2009 - ***Passed by the House. Engrossed. To the Senate 01/28/2009 - Referred to the Senate Committee on Education and Health.01/28/2009 - Referred to the Senate Committee on Education and Health.

Virginia – RA Senate Bill Virginia – RA Senate Bill S 968 (Blevins) Radiologist Assistants. Duplicate of H 1939. S 968 (Blevins) Radiologist Assistants. Duplicate of H 1939.

Provides for the licensure of radiologist Provides for the licensure of radiologist assistants as individuals who have met assistants as individuals who have met the requirements of the Board of the requirements of the Board of Medicine for licensure as advanced-Medicine for licensure as advanced-level radiologic technologists and who level radiologic technologists and who assess and evaluate the physiological assess and evaluate the physiological and psychological responsiveness of and psychological responsiveness of patients undergoing radiologic patients undergoing radiologic procedures. procedures. 01/14/2009 - Introduced. Referred to the Senate Committee on 01/14/2009 - Introduced. Referred to the Senate Committee on Education and Health. Education and Health.

02/03/2009 - Passed by the Senate. *****To the House.02/03/2009 - Passed by the Senate. *****To the House.

Washington Washington H 2105 (Cody) Diagnostic Imaging Services H 2105 (Cody) Diagnostic Imaging Services 

Concerns diagnostic imaging services; Concerns diagnostic imaging services; directs the speaker of the house of directs the speaker of the house of representatives and the majority leader of representatives and the majority leader of the senate to convene a work group to the senate to convene a work group to analyze and identify nationally accepted analyze and identify nationally accepted best practice guideline or protocols best practice guideline or protocols applicable to advanced diagnostic imaging applicable to advanced diagnostic imaging services and any decision and support services and any decision and support tools available to implement the guidelines tools available to implement the guidelines or protocols.or protocols.

02/10/2009 - Introduced. Referred to the House Committee on Health Care and Wellness.02/10/2009 - Introduced. Referred to the House Committee on Health Care and Wellness. This bill creates a group to study best practices and develop recommendations for practice This bill creates a group to study best practices and develop recommendations for practice

guidelines protocols for computed tomography, magnetic resonance, positron emissions guidelines protocols for computed tomography, magnetic resonance, positron emissions tomography and cardiac nuclear medicine services. These guidelines and protocols would apply tomography and cardiac nuclear medicine services. These guidelines and protocols would apply to these imaging services paid for by state purchased health care plans.Work group composition to these imaging services paid for by state purchased health care plans.Work group composition does not include a radiologic technologist.does not include a radiologic technologist.

Suggest Suggest improvements in improvements in day-to-day flowday-to-day flow

Ultrasound is a great place to Ultrasound is a great place to be! be!

Objective 5Objective 5

Forbes.comForbes.com

In Pictures: “Jobs That Can Earn In Pictures: “Jobs That Can Earn More Than $100,000 Without More Than $100,000 Without College”College”    Author: Klaus KnealeAuthor: Klaus Kneale

Ultrasound TechnologistUltrasound Technologist 90th Percentile Income: $110,00090th Percentile Income: $110,000 75th Percentile Income: $82,50075th Percentile Income: $82,500

Ultrasound reduces costs Ultrasound reduces costs

Limitation to unreimbursed care will Limitation to unreimbursed care will encourage growth, shying away from $$$ encourage growth, shying away from $$$ procedures. procedures.

Needle guidance proceduresNeedle guidance procedures Biopsy guidance Biopsy guidance Central Line Placement/complications Central Line Placement/complications Reducing amount of anesthesia for nerve Reducing amount of anesthesia for nerve

blocks blocks Foreign body visualizationForeign body visualization Frees more expensive imaging equipment Frees more expensive imaging equipment

Quality vs. Cost Quality vs. Cost

Instant decision on patient care Instant decision on patient care ““Modern day stethoscope” Modern day stethoscope”

Scarce resourcesScarce resources Expensive test overuse, abuse Expensive test overuse, abuse Consumer awareness of radiation Consumer awareness of radiation

exposure/useexposure/use Lawsuits over radiation exposure Lawsuits over radiation exposure

(peds)(peds)

Best protection Best protection

Imaging equipment performance Imaging equipment performance should be evaluated regularly to should be evaluated regularly to ensure good image quality. ensure good image quality. Image phantom checks as suggested. Image phantom checks as suggested. Safety check all cords.Safety check all cords. Follow manufacture Follow manufacture

recommendations for transducer recommendations for transducer care. care.

Best PracticesBest Practices

Document!!Document!! For reimbursement For reimbursement

consideration: all exams consideration: all exams require:require:DocumentationDocumentationCompletenessCompletenessMedical necessity Medical necessity

Documentation Documentation

Edits/Additions appropriately for Edits/Additions appropriately for your institutionyour institutionSingle line to cross out Single line to cross out Add/edit Add/edit Why Why Date Date Initial Initial

Best Protection Best Protection

Follow your Follow your hospital/departmental protocol hospital/departmental protocol for the procedure/exam you are for the procedure/exam you are doing. doing.

Perform in the manner in which Perform in the manner in which you have been trained. you have been trained.

If you have not been trained…. If you have not been trained….

Support Professional Support Professional Organizations Organizations

Thank the organizers of professional Thank the organizers of professional conferences! Support them. conferences! Support them.

Further Reading Further Reading

Berlin, L. Radiologic errors and Berlin, L. Radiologic errors and malpractice: A blurry distinction. malpractice: A blurry distinction. American Journal of Roentgenology. American Journal of Roentgenology. 189:5:517-522.189:5:517-522.

Health Care News Health Care News www.sorryworks.comwww.sorryworks.com www.healthblog.orgwww.healthblog.org Student doctor Network Student doctor Network www.healthcare-economist.comwww.healthcare-economist.com

Thank you! Thank you!

nottootall@comcast.netnottootall@comcast.net

cinsideusono@gmail.comcinsideusono@gmail.com