The Senate decided to close debate on the “doc fix”, setting the stage for the death spiral of Medicare.  Already paying below market rates, expect that a substantial number of physicians walk away, as they face a river of red ink from practices being asked to work for free (or less).

June 17, 2010 — In a last-minute shock to physicians, the Senate voted today against postponing a scheduled 21% reduction in Medicare reimbursement to physicians and other health providers.

A compromise proposed by Sen. Max Baucus (D-MT) was defeated largely along party lines, with no Republican support. The compromise was put forward after the Senate had rejected a $140 billion finance package yesterday that would have delayed the cut in Medicare payments to physicians until 2012, along with measures to extend unemployment benefits and provide $24 billion to states to cope with their Medicaid programs.

The lower-spending compromise bill, dropping the total cost to $118 billion and the overall deficit impact from $79 billion to $55 billion, would have delayed the planned Medicare cuts and provided a 2.2% raise for physicians through November 30, rather than for the 19 months mandated by the earlier bill.

The implications are pretty big…as we head into time where boomers will be hitting Medicare, we won’t have many docs left to serve them.  From the revenue side, this adds years to “Medicare coverage” while gutting the access to actual physician services.  Why?  Physicians have already stopped accepting money from government programs in Medicaid…and now Medicare payments move into this realm of providing services at a lower price than it costs to deliver them.

I expect a number of physicians to either drop Medicare or retire.  This is one way to limit dollars spent, but by cutting off the program at the knees.

The American Medical Association (AMA) warned that unless Congress restores the cuts, physicians will limit the number of Medicare patients they treat. A survey of 9000 members revealed that 17% of physicians — and 31% of those in primary care — would take such action because Medicare rates are too low.

I’m all for cutting the total cost of Medicare and know there are a number of incentives we can change to do this.  But I’ve always favored disruptive change that rewards better performance over legislative change bringing force without necessarily allowing for workable solutions or caring about the collateral damage.

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Congratulations to new Massachusetts Senator Scott Brown.  We saw health care concerns drive the election of a Republican in the bluest of states.

Yet, most people want health care to be reformed…its not that we don’t want change…its that the current approach to ObamaCare looks to lock out change and lock in an insurance model that people can neither comprehend nor afford nor trust.  As Albert Einstein once remarked, “Insanity is doing the same thing over and over again and expecting different results.”

So what is the right model for health reform?  My humble suggestion is that our nation yearns for Health Assurance, not just Health Insurance.  What does that mean?

A system designed around Health Assurance is designed to minimize the disruption and pain of illness through a strong focus on prevention while also improving wellness through a drive to improve everyday abilities and function. The specific priorities for a Health Assurance System are to, over a person’s lifetime optimize their Vitality.  The objectives of such a system would be:

1) Care for you when Seriously Ill

• Provide best practice care
• Provide financial support
• Return you to full physical and mental function where possible

2) Manage Chronic Illness

• Provide comprehensive program to address disease across medical and non-medical concerns
• Reverse disease where possible. If not possible, slow progression.
• Actively work to achieve best outcomes in affordable way with minimal inconvenience/ easiest approach to engage
• Monitor disease progression and intervene where outcomes impacted

3) Prevent Illness

• Understand your risk profile and priorities
• Create an action plan to reduce the most addressable risks in a cost effective manner
• Educate and Engage you in risk reduction

4) Enhance Wellness

• Understand your functional health and priorities
• Create an action plan to improve the highest priority functions
• Engage you in Wellness activities
• Introduce you to interesting Wellness resources and communities

My definition of health reform would be the move to a Health Assurance system as defined above.  What do you think?  I’ll follow up shortly with thoughts on what the specific elements of that system would be…and how this would look different from the insurance model centered in sick care and procedures that we utilize today.

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Cancer as parasite is an analogy I’ve been aware of, but I’ve never seen a cancer spreading between animals as a direct parasite (generally contagious spread is a result of viral hijacking causing changes in DNA that then leads to cancer).

Interesting — and potentially a disruptive way to think about cancer biology.

Scientists Report Findings on Origin of a Cancer in Tasmanian Devils – NYTimes.com.

The Tasmanian devil, the spaniel-size marsupial found on the Australian island of Tasmania, has been hurtling toward extinction in recent years, the victim of a bizarre and mysterious facial cancer that spreads like a plague.

Now Australian scientists say they have discovered how the cancer originated. The finding, being reported Friday in the journal Science, sheds light on how cancer cells can sometimes liberate themselves from the hosts where they first emerged. On a more practical level, it also opens the door to devising vaccines that could save the Tasmanian devils.

The cancer, devil’s facial tumor disease, is transmitted when the animals bite one another’s faces during fights. It grows rapidly, choking off the animal’s mouth and spreading to other organs. The disease has wiped out 60 percent of all Tasmanian devils since it was first observed in 1996, and some ecologists predict that it could obliterate the entire wild population within 35 years.

When the tumor disease was discovered, many scientists assumed that it was caused by a rapidly spreading virus. Viruses cause 15 percent of all cancers in humans and are also widespread in animals.

But subsequent studies failed to turn up a virus. Instead, Anne-Maree Pearse and Kate Swift, of the Department of Primary Industries, Water and Environment in Tasmania, discovered something strange about the tumor cells. The chromosomes looked less like those in the animal’s normal cells and more like those in the tumors growing in other Tasmanian devils.

In 2007, Dr. Belov and her colleagues compared DNA from 26 sick and healthy Tasmanian devils with DNA from the tumors. They found that cancer cells from different animals shared distinctive genetic markers not found in the animals themselves.

Have you visited a MinuteClinic or other retail health clinic?  This approach to health care is transparent (prices clearly posted and generally cheaper than physician visits), convenient (located in a pharmacy or other retailer), and customer-friendly (walk-in appointments easy to find).

So why are these clinics, which customers love, struggling?

The answer is surprisingly simple: Medicare (and by proxy, other health insurers) have created a payment system that starves innovators because:

1. they can’t charge more for providing better service
2. there’s no reward for customers who select a cheaper service
3. they can’t even bill customers for innovations that achieve better results and reduce the need for further services

The Centralized Structure of Medical Payments:

Medical payments are based on the Soviet-style assumption that all physicians provide services that are essentially equivalent– the core payment model uses a central committee to define what can be paid for and how much.  This has led us to a system that has undervalued relationships, quality, and service and systematically overvalued procedures and specialty care vs. primary care.  How this works is outlined below:

Medicare pays physicians for services based on submission of a claim using one or more specific CPT® codes. Each CPT® code has a Relative Value Unit (RVU) assigned to it which, when multiplied by the conversion factor (CF) and a geographical adjustment (GPCI), creates the compensation level for a particular service.  — American College of Radiation Oncology

Defining where payments come from can be pretty confusing to average people, as you can see from the sentence above.  The formula that defines payment for a submitted claim is:

submitted CPT code for visit  => (assigned RVU x F/NF factor) x CF x GPCI = payment

Confused yet?  Let’s break it down

• Claim: After your visit, the physician submits a “claim” to the insurance company/ government to have them reimburse an agreed upon amount for the billable services provided during the visit
• Certified Procedural Terminology (CPT) code: The CPT code defines the services a physician is allowed to bill, and are maintained by the American Medical Association.  CPT codes define the interactions that a physician may bill an insurance company.  We’ll explore the limitations of these definitions below
• Relative Value Unit (RVU): The RVU is a number assigned to each CPT code to assign a relative definition of productivity to each code (and amount paid for performing them). Different numbers are assigned to procedures performed in a Facility (F) vs. not in a facility (NF).  Per Kevin, MD, a colonoscopy CPT code may be weighted at 8 RVU while a 15 minute office visit receives 0.7 RVU.  Thus, the colonoscopy is reimbursed at 11 times the rate of the office visit.  The low RVUs assigned to primary care have led to primary care physicians having significantly lower income than specialists.
• Conversion Factor (CF): The dollar figure assigned to each RVU, ~$36 in 2009.  This number is set by statute (the Sustainable Growth Rate) and limited to an overall budget, which can be changed by act of Congress.  The higher the overall spend, the lower the CF without an act of Congress.  This Congressional change in the CF has been referred to as the “Doc Fix” and in 2010 would avert a 21% reduction in physician fees, with an expected impact of $245B over 10 years.
• Global Practice Cost Index (GPCI): Geographic adjustment for the cost of providing care in different parts of the country

How the Centralized Payment Structure Locks out Innovators

1. Physicians can’t charge more for better service:

Ever wonder why physicians make you come into the office rather than make house calls, deliver phone consultations, answer questions via email, or any use other familiar modern-day approach?  The tight definitions for the services provided and paid for (the combination of CPT codes and the RVUs used to pay for each) has arbitrarily rewarded more complex office visits and eliminated payment for other approaches of delivering service.  It also has rewarded specialists over primary care and resulted in a shortage of Primary Care Physicians relative to higher-paid specialists.  Medicare also specifically prohibits patients for paying for better service through its prohibition of “balance billing“.  Why should a physician donate their time to provide un-reimbursed house calls, emails, or phone consults?  We’ve seen that they don’t outside of a few exceptions who are forced to donate more of their time for work performed on behalf of the government at rates already below the cost of providing them.

2. Customers see no reward for choosing a cheaper option:

The perverse other side of fixed rates is that the customer, who is charged up front with premiums, and who pays set amounts for the service coded doesn’t benefit from choosing a cheaper alternative.  Why would you care to find the physician charging 25% less for an equivalent service (because they found a faster or cheaper method of getting the same results)?  The answer is that people don’t — they don’t even know what the prices for the services are (even after they receive their EOB (Explanation of Benefits)

3. Innovators who achieve better results up-front (and reduce the need for future services) reduce their own revenue:

I interviewed a hospital executive who dramatically reduced the rate of birth injuries occurring in their delivery rooms (they took their rate from 3-4 in 10,000 births to 0 over ~60,000 births).  By saving families the suffering related to their injured baby’s stay in the Neo-natal Intensive Care Unit (NICU), they were rewarded by a $5M cut in their reimbursement (because they did not need to deliver those services).  Rather than scaling these services, innovators who accomplish these higher quality revenue-reducing approaches face the wrath of hospital executives who need to stem the bleeding before it closes the entire facility.

In future posts, we’ll explore how RVUs and CPTs are set by committees and why this prevents higher value alternatives and has destroyed primary care.

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Doctor Availability Declining with Cuts (via Health Care BS)

Are Primary Care Physicians (PCPs) finally willing to say no to the Fee for Service Medicare approach that has destroyed their practices and profession?

The Mayo Clinic in Arrowhead, Arizona fires a shot across the bow, by informing patients that they will no longer accept Medicare for their primary care doctor visits as of Jan 1 (via Dr. Wes and AZcentral.com)

The discrepancy between what Medicare pays and our cost of providing care acutely impacts the sustainability of our primary care practice. Medicare reimbursements do not cover our actual costs of providing care, and therefore we have recently had to make some difficult decisions that will impact the Arrowhead Family Medicine practice.

Existing Medicare reimbursement (even prior to the cuts required without the “doc fix” considered savings under the health reform bills) doesn’t pay for actual care.  Primary care docs have essentially been volunteering their services to Medicare patients.  Perhaps explaining why, as the Baby Boom approaches, the number of gerontologists continues to fall relative to demand (what do we expect when reimbursement is poor and elderly patients are complex?).

your physician at Mayo Clinic Family Medicine – Arrowhead will no longer accept Medicare as reimbursement for your care. This change will not impact any other services provided at Arrowhead or any other Mayo facilities. Medicare will still be accepted for laboratory, X-rays, Anticoagulation Clinic and specialty care (such as Cardiology or Neurology) at Mayo Clinic

IE, it is family practice and primary care that is being reimbursed at an unprofitable level (even if subsidized by the specialty care departments for referrals).  Specialty care itself remains lucrative…so let’s jump straight to more expensive specialist-based medicine and tests.

Primary care costs estimated at $1500/yr are to come out of pocket…whereas Medicare will happily pay for all the bad things that happen if and when primary care doesn’t work:

An annual administrative fee of $250 which will be collected each year. (This will cover the administrative expense of providing you with appropriate prescription refills and phone inquiries for minor needs as they arise throughout the year.)

Normal fee rates for office visits. (Depending on the type of exam, fees may range from $175 to $400 per visit.)

Patients will be expected to come into the office for the number of visits appropriate to their medical conditions, which include a complete physical exam at appropriate intervals. If you pay the administrative fee, have a physical, and come in three other times per year, your annual costs are estimated to be approximately $1,500

I’m glad physicians are rebelling now…I left primary care due to that system having been destroyed by an inane reimbursement model.  Is cash the answer?  Perhaps…but hopefully the politicians won’t block our ability to choose to put our own money where it will pay doctors (and other care providers) for the everyday services people want and benefit from most.

Whole letter below:

Dear Patient,

Changes are occurring at Mayo Clinic Family Medicine – Arrowhead that could affect your access to primary care. Please review the following information carefully:

The discrepancy between what Medicare pays and our cost of providing care acutely impacts the sustainability of our primary care practice. Medicare reimbursements do not cover our actual costs of providing care, and therefore we have recently had to make some difficult decisions that will impact the Arrowhead Family Medicine practice. Effective January 1, 2010, the physicians at Mayo Clinic Family Medicine – Arrowhead will opt out of participating in Medicare, meaning that Medicare will no longer reimburse for the services they provide.

Therefore, beginning January 1, 2010, your physician at Mayo Clinic Family Medicine – Arrowhead will no longer accept Medicare as reimbursement for your care. This change will not impact any other services provided at Arrowhead or any other Mayo facilities. Medicare will still be accepted for laboratory, X-rays, Anticoagulation Clinic and specialty care (such as Cardiology or Neurology) at Mayo Clinic.

Because of this change, as a currentMedicare patient, should you choose to continue receiving your primary care at Mayo Clinic Family Medicine – Arrowhead, you will be required to pay for your care out-of-pocket. Neither your physician nor you will be permitted to seek reimbursement from Medicare for care you receive. We will not be able to bill Medicare for the physician office visit services you receive at Arrowhead, nor will you be able to submit the bill to Medicare for later reimbursement. Again, laboratory, X-ray, and specialty services will remain covered. Only the office visit will change to an out of pocket expense.

Costs you should anticipate paying out-of-pocket include:

An annual administrative fee of $250 which will be collected each year. (This will cover the administrative expense of providing you with appropriate prescription refills and phone inquiries for minor needs as they arise throughout the year.)

Normal fee rates for office visits. (Depending on the type of exam, fees may range from $175 to $400 per visit.)

Patients will be expected to come into the office for the number of visits appropriate to their medical conditions, which include a complete physical exam at appropriate intervals. If you pay the administrative fee, have a physical, and come in three other times per year, your annual costs are estimated to be approximately $1,500.

By maintaining your primary care with Mayo Clinic you will be assured continued care by a physician you know and trust. You will also have guaranteed access into primary care, an important resource that has become more difficult to obtain in recent years. In addition, by continuing your primary care with your Mayo Arrowhead physician, you will have continued coordinated specialty care at Mayo Clinic and be assured that your medical record will remain intact.

To continue seeing your Mayo Clinic Arrowhead physician for your primary care please complete and sign the enclosed letter of agreement and bring it with you to your first appointment in 2010 along with the $250

administrative fee. If you have questions and would like to speak to someone directly about this change, please call Sue Stevens at 623-376-8985 to talk over the phone or to set up an appointment to meet in person.

Unfortunately, you will not be able to transfer your primary care to another Mayo facility. However, you always have the choice of seeking primary care elsewhere in the community. If that is your choice, to assist you with this transition, we will forward a copy of your Mayo medical record to the office of your new physician, free of charge. To do this, a written request is required. Please complete the enclosed release of information form and return it to:

ROI, Medical Records Department

Attn: Theresa Ferrato

Mayo Clinic

13400 East Shea Boulevard

Scottsdale, Arizona, 85259

A partial list of family medicine physicians in the west Valley who are accepting new patients is included. Please contact the Maricopa County Medical Society at 602-252- 2015 or online at www.mcmsonline.com/ for an additional list of physicians.

We are deeply sorry that we have had to make this decision in order to maintain access to primary care at Mayo Clinic in Arizona. While we know that change is difficult and can be disruptive, we hope that you will understand the challenges that have contributed to our need to make this decision. Throughout this and other changes we have made to our practice, we remain committed to being able to provide care to our patients.

If you have questions regarding this transition or primary care at Mayo Clinic, please call Sue Stevens at 623-376-8985. We appreciate your understanding and we hope that you will choose to remain in our practice.

Sincerely,

Richard L. Engle, M.D.

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Lake Wobegon was a place where “all the women are strong, all the men are good looking, and all the children are above average.”  We all recognize that Lake Wobegon is a quaint fiction; so why then do we act as if our doctors and hospitals come from a place where all are superhuman and there are no below-average doctors or hospitals?

A recent article in the WSJ highlights the benefits of using top-rated hospitals…that by making transparent the success rate of various procedures in Pennsylvania, companies that work with the best performing hospitals find significantly better outcomes for their employees…and save lots of money.

Although at times premium care can be exorbitant, there’s evidence some in Pennsylvania saved money using top-rated hospitals. Hershey Co. offered workers medical coverage based on the state agency’s reported outcomes, and cut the company’s expenses by 50% over several years. The Philadelphia police union’s benefits-management company says it uses the state reports to steer officers to the best hospitals; as a result, it say its costs fall about 17% below those of comparable plans.

Tom Lamb, administrator of Philadelphia police health benefits, says he frequently explains to members why they should go to hospitals with better outcomes. “If an officer’s 7-year-old daughter has to go in for surgery,” he says, “I’ll sit down with the father and say, ‘Are you just going to shake your head yes when your pediatrician wants to send her to his golfing buddy?’ ”

So what is keeping us from seeing the tremendous shift of patients from sub-par to above-average performers?  In a word…its a coverup.  Data allowing consumers to objectively understand performance have been kept from them…so that there is no objective way to compare performance.  Payment via claims is locked into a group discount model…better performers see no rewards financially or through transparency.  Reputation tends to be based on institution rather than individual performance…and so varies tremendously between physicians.

It is differentiation…and the celebration of better performance that pushes the rest of our economy to offer better, more segmented value propositions to sophisticated consumers.  Why, when it comes to our health, are we left to hope that we get lucky and get someone above average?

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Was struck today that I have heard very little about the role of Medigap in the current health insurance debate…despite massive discussion of Medicare, Medicare Advantage, payment reform…etc.  In addition, it highlights how difficult it is to sort through the tangled web of money and influence…not sure how much I believe it, but its certainly food for thought.

This thought was triggered by Michelle Milkin’s post on AARP’s dependance on royalties from selling sponsored insurance plans:

A Hill source summed it up for me this way: “AARP has endorsed a huge reduction in funding of Medicare Advantage, which touches over 10 million middle-lower income seniors. If Medicare Advantage funding is reduced, and seniors are forced out of the program, they become potential buyers of the heavily-promoted and very profitable Medicare Supplement program sponsored by AARP (MediGap is 70% of AARP’s annual income). Medicare Supplement is a huge source of revenue to AARP. At a minimum, AARP should be required to disclose this every time they discuss Medicare Advantage.

Since AARP makes a substantial amount of money on a competing product that serves to drive up demand by eliminating co-pays, deductibles, and other elements of cost-sharing for a flat premium; it would make a bit more sense as to why they’re willing to sacrifice the Medicare Advantage improvement in benefits.  Per Bloomberg:

Laupus stumbled onto something that many members of the world’s largest seniors’ organization don’t know: The group, formerly called American Association of Retired Persons, collects hundreds of millions of dollars annually from insurers who pay for AARP’s endorsement of their policies.

The insurance companies build the cost of these so-called royalties and fees, which amounted to $497.6 million in 2007, into the premiums they charge AARP members, according to AARP’s consolidated financial statement for that year.

AARP uses the royalties and fees to fund about half the expenses that pay for activities such as publishing brochures about health care and consumer fraud — as well as for paying down the $200 million bond debt that funded the association’s marble and brass-studded Washington headquarters.

In addition, AARP holds clients’ insurance premiums for as long as a month and invests the money, which added $40.4 million to its revenue in 2007.

‘Fatting the Coffers’

“At the end of the day, it’s all about fattening the coffers of the organization,” says Thomas Orecchio, who was chairman of the Arlington Heights, Illinois-based National Association of Personal Financial Advisors until September. AARP, he says, is sponsoring insurance for its members at inflated prices.

“It’s the dirty little secret,” he says.

During the past decade, royalties and fees have made up an increasing percentage of AARP’s income, rising to 43 percent of its $1.17 billion in revenue in 2007 from 11 percent in 1999, according to AARP data.

So what of Medigap?  Here’s a comparison to Medicare Advantage in terms of how each may add upon the basic Medicare entitlement.

Medicare Advantage vs. Medigap

Members pay an upfront premium with Medigap to eliminate co-pays, co-insurance, deductibles, and other financial restraints on services.  This seems a little odd, when you think that the reason these were put in place was to reduce unnecessary utilization.

So why then isn’t Medigap part of the overall health reform debate in addition to Medicare Advantage?

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Sustainable health reform requires a solid foundation…unfortunately the proposals we’re seeing out of Washington create a more elaborate house of cards, as we continue to create an elaborate health care ponzi scheme.  The House that built Medicare has already saddled our country with Trillions in unfunded liabilities.  The proposals we see look to continue to reward a medical-industrial complex that creates and manages diseases rather than focusing on optimizing the health of people.

So what are the criteria of a sustainable health system?

1. Individuals receive fair value for premiums: Cost-shifting is a major foundation for today’s system.  We take money from the healthy to subsidize the sick.  We negotiate group discounts, undercutting the individual/ small group market.  This creates a phenomenon where insurers cherrypick the young and healthy who overpay and try to avoid the older or sicker who underpay.  THIS IS MADNESS.  Auto insurance has a system where we each pay based on our actuarial risk.  This is the only sustainable approach to health insurance…and may take a multi-year, lump-sum payout type approach.
2. Health Insurance is actual insurance (ie doesn’t insure pre-existing): Insurance, by definition, is a premium paid against a risk.  You can’t insure something that has already happened.  By creating an insurance structure to “insure” what has already happened, we’re looking only to pass cost off to someone else…and the insurance model is the most expensive way to pass along these subsidies.
3. Comprehensive services exist to Actively Manage Chronic Conditions: Chronic conditions (pre-existing) need active management.  We need to have tiers of services that are coordinated and judged against their impact, convenience, and cost.  Those doing the best job at reducing existing risk need to be rewarded…and today are marginalized with a PMPM (per member per month) approach that doesn’t reward the best management of risks.
4. Subsidies occur Transparently: Health care can be expensive and may require government intervention.  However, in an atmosphere where these subsidies are hidden, the subsidized payments tend to be used for many other things than providing the best care for the individual being served.  PCPs should be paid market value for Medicare patients, allowing a thriving primary care landscape (as opposed to starving the PCPs which has resulted in a declining number of gerontologists as we face the baby boom retirement…while numerous specialists will inflate the overall treatment bill).
5. Retail Competition based on Differentiation: Providers are allowed to compete…and price, quality, service approaches, and service levels are all part of the mix.  Is there any reason why we should pay the same amount for an overnight housecall as a 6 minute office visit with an hour’s wait?  There’s a reason why higher levels of convenience and service are not available today.  By the same token, a visit to a nurse practitioner just out of school probably shouldn’t cost the same as the world’s expert on your disease… Until we acknowledge that its ok that innovators are allowed to pursue either higher-priced models for better care or lower priced models for “good enough” high-volume care, we won’t see the innovations that will drive service excellence and efficiency in the same markets.

I’m all for fairness and equality and everyone having access to an affordable health system.  I’ve laid out the principles that I think create a sustainable system that doesn’t take advantage of anyone or just try to play “pass the cost potato”.  For those who disagree, what criteria would create a SUSTAINABLE system that incented efficient care?

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When I was a kid, I hit my head a fair bit, including getting knocked out once at football practice.  Initial care involved an evaluation, but scans weren’t the norm.  Now that they’ve become increasingly common in the evaluation of head injuries in youth, have we gained much?

The  Value of CT Scans in Youths Is Questioned in this study in the Lancet (article in NYTimes).

The study, one of the largest of its kind, enrolled 42,412 children ages 18 and younger who sought emergency care at dozens of medical centers after suffering mild head injuries in bike collisions, car crashes, falls and other accidents. Of the total group, 14,969 of the children, or just over one-third, had CT scans, but only 780 of the scans, or about 5 percent, picked up traumatic brain injuries, the study found.

The paper, published online in the Sept. 15 issue of The Lancet, offered a list of six indicators that could be used to determine whether a child was at risk for a serious brain injury, with a separate list for children under 2. The highest risk factors for children of all ages are an altered mental state and signs of a skull fracture.

Other factors to consider are loss of consciousness and whether the child was involved in a serious incident like a car crash. Vomiting and headaches are predictors in older children, while swelling of the scalp and abnormal behavior are warning signs in younger children.

The surprising stat to me was that after triage, only 5% of those who received a CT scan actually showed an issue (we’ll ignore potential false positives).

42,412 went to the emergency room

14,969 had a CT scan (35%)

780 showed traumatic brain injury (1.8% of ER visitors, 5.2% of those scanned)

It would seem that better triage would get us closer than a 1 out of 20 hit rate.  But in the current environment, why would a medical staff take the time to run through the 6 indications and risk a bad outcome?

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