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Medicaid physicians back in same spot after long-awaited raise expires

Dr. Jaquelin Gotlieb examines a new patient, Jada Smith, 5, at her Stone Mountain office

Dr. Jaquelin Gotlieb, shown examining a patient, says that the Medicaid pay bump is a matter of valuing children.

Dr. Michelle Zeanah is getting a big pay cut this month.

It’s not that the Statesboro pediatrician is seeing fewer patients. Just the opposite.

The 12 rural counties surrounding Bulloch County, where Statesboro is located, have no pediatrician. So Zeanah is very much in demand.

Forty percent of her patients have driving distances of 45 minutes or more. A few come from more than 50 miles away.

Dr. Michelle Zeanah

Dr. Michelle Zeanah

Her pay cut involves the Medicaid program. Reimbursements to primary care doctors under Medicaid just went down in Georgia and many other states.

The Affordable Care Act had awarded primary care doctors treating Medicaid patients a two-year pay increase. It was funded entirely with federal money, and pushed their Medicaid pay to the level of Medicare reimbursement.

But that additional Medicaid reimbursement, which went to family physicians, pediatricians and internists, ended Jan. 1. And doctors will be missing it.

“It allowed us to hire more staff so we could serve more patients,’’ Zeanah says. Without it, she adds, “I will have to work 70 hours a week’’ instead of the current 60.

About 70 percent of her patients are covered by Medicaid or PeachCare (the Georgia version of the child health insurance program).

Medicaid, the federal/state program for the poor and disabled, serves more than 1.5 million Georgians. Most are children.

Before the increase, Georgia primary care doctors had gone more than a dozen years since the last Medicaid pay hike.

A few states, including Alabama and Mississippi, have continued giving their primary care doctors the pay hike by using state dollars to fund it.

But Georgia political leaders, on the eve of the 2015 General Assembly, have shown no signs they’ll appropriate money to reinstate the pay hike. The money that would be needed – an estimated $62 million for a year – is not in the Department of Community Health budget being proposed to Gov. Nathan Deal.

Sasha Dlugolenski, a spokeswoman for the governor, said in an email to GHN in September that Deal was aware of the issue. She called the pay hike expiration “one of the early, blatantly obvious examples of Obamacare unloading costs onto the states. This was a short-term Band-Aid to a long-term problem, and now the states are left holding the bag.”

The federal health law required that the raise be paid for two years, 2013 and 2014. The money actually did not arrive till 2014, but when it did, eligible doctors received the pay hike retroactively to Jan. 1, 2013.

Such delays in the payments occurred in many states, including Georgia, that use managed care in their Medicaid programs.

Practices feel the pinch

The end of the federally funded raise means that Medicaid fees in Georgia will now be reduced by 34.8 percent, according to a recent Urban Institute study.

Some pediatricians describe the pay bump as a children’s health issue. They say children on Medicaid generally have greater health and social needs.

“It’s a matter of valuing children as the future of the state,’’ says Dr. Jaquelin Gotlieb, who practices along with her pediatrician husband, Edward Gotlieb.

“I believe primary care doctors feel a significant responsibility to their patients,” adds Jaquelin Gotlieb, who is 68 and has practiced in Stone Mountain for almost four decades. “That’s why we have hung in there.”

If the pay isn’t restored, she says, “This is going to take some of them and push them over the edge.’’

Dr. Eugene Cindea

Dr. Eugene Cindea

Roughly two-thirds of the Gotliebs’ patients are covered by Medicaid or PeachCare, she says.

Dr. Eugene Cindea, a pediatrician at the Longstreet Clinic in Gainesville, says the extra money “allowed us to expand offerings to patients.”

“It felt good for physicians who were seeing a considerable number of Medicaid patients,” he says.

The goal of the pay hike, Cindea notes, was to increase the number of physicians who accept Medicaid patients.

Without the money, he says, it’s more difficult to devote staff to manage the chronic diseases of children. “It decreases the likelihood that we’ll expand in an underserved area,” he adds.

OB/Gyns were not eligible for the two-year federal pay bump that just ended. Pat Cota, of the Georgia Obstetrical and Gynecological Society, says her organization is asking the state to revive the pay increase and expand it to include OB/Gyns.

The majority of children born in Georgia are covered by Medicaid.




An incentive for doctors

In Alabama, physician participation in Medicaid is a concern. The state says about 22 percent of enrolled primary care physicians now receive 90 percent of all claims payments. The other problem is that Alabama has shortages of health professionals in 62 of its 67 counties.

Niko Corley of the Alabama Medical Association says that “for Medicaid to be as efficient as possible, you’ve got to have physicians managing that care.”

The federal pay hike was supposed to increase doctor participation in Medicaid. But Kaiser Health News has reported that most states say they’ve seen no evidence that it did so — mostly because it was a temporary measure.

“The Medicaid pay boost was never meant to be a silver bullet,” Leonardo Cuello, director of health policy at the National Health Law Program, an advocacy group for low-income Americans, told KHN. Still, he worries about the provider fee cuts. “It won’t sink the ship but . . . I’m concerned it will contribute to access problems.”

Statesboro pediatrician Zeanah notes that many physicians have limited their numbers of Medicaid patients. That’s why her pediatric practice continues to see more patients.

Having the pay hike meant that the practice stopped losing money on delivering vaccines to kids on Medicaid. “We made a tiny profit,’’ Zeanah says.

Not having the pay hike, though, means more hours and less reimbursement. It means Zeanah and her pediatrician partners can’t build an office building to accommodate the growing practice.

Medicaid patients require more work, and are more often late or no-shows due to reasons such as lack of transportation, she says. “We have no social worker available to us. I am the social worker.”

Georgia desperately wants to recruit new physicians, Zeanah notes. “When you don’t have Medicaid payment parity, it makes it hard.”


Narrow networks: Many upset as insurers exclude favorite providers

Dr. Sean Lynch, an Augusta family physician, says dozens of his patients have been notified that he is no longer part of United's Medicare network.

Dr. Sean Lynch (left), an Augusta family physician, says dozens of his patients have been notified that he is no longer part of United’s Medicare network.


Months after she first read it, Vera Brown of Augusta is still upset about a letter she received from her health insurer.

UnitedHealthcare wrote to notify her that it was dropping Dr. Sean Lynch, her physician, from its Medicare Advantage doctor network.

“I’ve been with Dr. Lynch for years,’’ says Brown, 67, a registered nurse. “He treats me like his mother.”

Lynch, an Augusta family physician, says dozens of his patients got similar letters. “For many reasons, it has been a disaster, for us and our patients,” says Lynch.

Brown and Lynch both say they have not received an adequate reason from United as to why the change took place.

UnitedHealthcare’s action in Georgia came after it dropped physicians in several other states from its private Medicare Advantage plans. Overall, thousands of members were affected.

The insurer tells GHN that the Georgia markets affected by the Medicare action are Atlanta, Augusta and Columbus, and that only about 10 percent of doctors in its Medicare network were dropped.

“We do regret any inconvenience to our members,” says Gregg Kunemund, regional vice president for United’s Medicare business in Georgia.

The United move is part of an accelerating trend of health insurers offering consumers more limited choices of medical providers. The resulting health plans have become known generally as “narrow networks.”

Complaints about limited choice of doctors and hospitals in health plans — in Georgia and across the nation — arose during the rollout of the Affordable Care Act exchanges a year ago.

Healthcare CostThe Washington Post recently reported that about 70 percent of health plans sold on the ACA’s marketplaces this past year had narrow or ultra-narrow networks, according to McKinsey and Co. The consulting firm defined “narrow” as excluding at least 30 percent of an area’s largest hospitals.

Narrow networks were increasingly being used before the ACA was enacted, but they’ve become more prevalent under the health reform law, the Post added.

Industry officials say the changes are partly about holding down costs, a prime consideration for consumers who are concerned about affordability (and a major goal of the ACA itself).

“We’re trying to build networks that balance quality and cost,’’ says Graham Thompson, executive director of the Georgia Association of Health Plans, an industry group.

Kim Holland, executive director of state affairs at the Blue Cross Blue Shield Association, told Politico earlier this year that “every indication that we’ve received . . . from think tanks, physicians and consumer advocacy groups, is that the most important factor for individuals purchasing coverage through the exchange is price.”


Traditional trade-off: Choice vs. cost


The interplay between access to providers and costs has existed for years in the health insurance market.

“People have to recognize it’s a trade-off, and I’m not sure they do yet,” Matt Eyles, an insurance expert at the Avalere Health consulting firm, told Politico. “Broader access comes at a cost, and what’s the right balance between access and cost is an age-old question in health care.”

UnitedHealthcare, meanwhile, disputes the characterization of its Medicare Advantage physician network in Georgia as narrow. “We feel we have an adequate network,’’ United’s Kunemund says. “We want to make sure our members get great care.”

Geography, quality and efficiency are among factors that have influenced the company’s decisions, he adds.

The decision has no impact on the retiree members of the State Health Benefit Plan who will be moving to United’s Medicare Advantage plan next year, Kunemund says.

Still, the dislocation for current patients can be jarring, says Lynch, the Augusta physician.

“Most of my patients were assigned to an 82-year-old doctor,’’ says Lynch, who is 44. “No offense to this doctor, but how does it help my patients who have been sent to an 82-year-old doctor who’s about to retire?”


Lack of transparency


It’s difficult to determine how many Georgians have been affected by narrow networks.

But problems with Georgia’s ACA exchange networks became apparent last fall, during the exchange’s first open enrollment period.

Cindy Zeldin

Cindy Zeldin

“Provider directories were inaccurate or not up to date, or people were having problems finding a provider,’’ says Cindy Zeldin of the consumer group Georgians for a Healthy Future, which has supported the ACA.

If limited networks are done right, she says, ‘they’re not necessarily harmful to consumers.” And insurers have a legitimate argument about keeping costs down, Zeldin says.

Health insurers may be looking to drop what they perceive as high-cost doctors or hospitals, or they may be trying to negotiate the paying of lower fees to medical providers, she says.

“It’s not transparent,’’ Zeldin says. “It’s hard to get a handle on how these strategies are designed.”

Patients are often left confused over who’s in and who’s out of a network, says Dr. James Barber, an orthopedic surgeon in Coffee County. “There’s a lack of transparency for consumers.”

“Eventually, narrow networks will get so narrow that patients will revolt, just like they did with the HMOs in the 1990s.”

Barber says he’s concerned that the fear of being excluded from a narrow network may force physicians to accept lower reimbursements.

Plan options will increase for 2015


The state department of insurance has been tracking the issue of how adequate the exchange health plans’ medical provider networks are.

“We’ve been getting complaints from many Georgians,’’ spokesman Glenn Allen told GHN in June. Those consumers have either lost a longtime physician or a trusted hospital by enrolling in an exchange plan, or have not found enough physicians in their network, he said.

Thompson, of the Association of Health Plans, points out that Georgians will have more choices of insurers in the ACA exchange for the upcoming year, both in metro Atlanta and other areas of the state.

Georgia’s largest physician organization, though, says narrow networks “threaten the individual and trust-based relationship that physicians have with their patients.”

Donald J. Palmisano Jr.

Donald J. Palmisano Jr.

“Narrow networks also undermine the economic viability of the medical profession, which employs a lot of Georgians and which makes a significant contribution to the state’s economy,’’ says Donald J. Palmisano Jr., executive director of the Medical Association of Georgia. He adds that the increase of these networks “will exacerbate the shortage of physicians in Georgia.”

“MAG believes that patients should have the freedom to see the physician of their choice as long as the physician is willing to participate in the patient’s health insurance network,’’ Palmisano adds.

John Crew of Strategic Healthcare Partners, which consults for more than 30 hospitals, 600 physicians, and 26 behavioral health centers in Georgia, says he fears that all insurance companies are using this tactic to drive down reimbursement to medical providers.

He says narrow networks may favor those physicians who are employed by hospital systems. They also could exclude rural physicians, Crew says.

Zeldin, meanwhile, says that consumers should shop around as they review health plans, and ask for up-to-date provider directories from insurers.

Meanwhile, in Augusta, Vera Brown is changing her Medicare coverage so that she can keep Dr. Lynch as her physician.

“I’m going to stay with Dr. Lynch, whatever plan I go on,’’ Brown says. “When you get older, you don’t want to do all this flip-flopping. It’s not good for older folks.”

The PA pipeline: More trained to fill Georgia’s growing need

Members of the PA program at Georgia Regents University wear blue to raise awareness of diabetes

Members of the PA program at Georgia Regents University, including Timber Wages, wear blue to raise awareness of diabetes

Her 27 months at physician assistant school was an intense experience, says Timber Wages.

“It’s like trying to drink water from a fire hydrant,’’ says Wages, 31, who attended the PA program at Georgia Regents University in Augusta.

A fire hydrant?

“The volume of information is overwhelming,’’ she explains, adding with a chuckle, “but not impossible.’’

Timber Wages

Timber Wages

Wages, originally from Calhoun in northwest Georgia, weighed several job opportunities when she graduated about a year ago. She joined an Augusta urgent care center as a PA in primary care, and also works at a Columbia County detention center.

Over the past decade, both Georgia and the nation have seen a surge of PAs. The higher demand comes from several factors: the growth in outpatient clinics; the shortage of primary care physicians; and the added emphasis on cost-effective, team-based medical care.

A physician assistant is a health care professional who has the training to perform many of the duties that doctors routinely handle. PAs must be licensed and each must work under the direction of a physician.

About 95,000 PAs are practicing across the country, up from 43, 500 in 2003.

The number of PAs in Georgia has increased by 67 percent over the past 10 years, now surpassing 3,000. Still, experts say there’s a shortage of them in the state.

Though she and other PAs are not allowed to prescribe certain medications, Wages says she can do most things a primary care physician can do. That’s why PAs are so valuable in primary care: They can relieve much of the workload of doctors.

A large majority of Georgia PAs, more than 75 percent, are currently practicing in metropolitan areas, according to a state workforce survey.

Wages says an attractive feature of being a PA is lateral career mobility, where she can work in primary care for a while, then transfer into a specialty, such as dermatology or orthopedics.

nccpaMost physician assistants end up going into a specialty, says James Cannon, board chairman for the National Commission on Certification of Physician Assistants.

All are trained in primary care, which can help a PA who moves into specialty medicine, says Cannon. He’s a PA who works in psychiatry, and while he treats substance abuse patients, he also can address their primary care needs.

The NCCPA organization, based in Johns Creek in the northern Atlanta suburbs, is the only certification and licensing exam entity for the PA profession. NCCPA certification (passing a PANCE exam) is required for initial licensure in every state.


A calling that’s relatively new


The PA profession arose in the 1960s, when physicians and educators recognized there was a shortage of primary care physicians.

To help address the need, Dr. Eugene A. Stead Jr. of the Duke Medical Center, formed the first class of physician assistants in 1965. He selected four Navy corpsmen – military medics who treat sailors and Marines – to be the first students.

Now, PAs and nurse practitioners (who also can handle many of the duties frequently left up to doctors), are considered part of the solution to primary care shortages, especially with the coverage expansions from the Affordable Care Act.

Chris Parker, associate project director at the Georgia Health Policy Center, adds that under the ACA, “as more individuals find coverage, an even greater demand will be placed on our primary care system, especially in rural and underserved communities.

A Rand Corp. study published in November said new roles for PAs and nurse practitioners may cut a predicted shortage of physicians by about 50 percent.

“Growing use of new models of care that depend more on non-physicians as primary care providers could do much to reduce the nation’s looming physician shortage,” said David Auerbach, the study’s lead author. “But achieving this goal may require changes in policy, such as laws to expand the scope of practice for nurse practitioners and physician assistants, and changes in acceptance, on the part of providers and patients, of new models of care.”

Using PAs and nurse practitioners in “medical homes” – teams of health professionals working together to coordinate care – can relieve the doctor shortage by serving larger numbers of patients than a single physician can treat, experts say.

Georgia now has four PA schools – at Emory in Atlanta, Mercer in Atlanta, Georgia Regents University in Augusta and South University in Savannah.

USA Today reported last year that according to the American Academy of Physician Assistants, 60 new physician assistant programs were waiting then for accreditation, and 10,000 new PAs were expected by 2020.

Jeff Chambers is one of five PAs on an  Air National Guard special medical team.

Jeff Chambers is one of five PAs on an Air National Guard special medical team.

“There are a lot of jobs available, especially in emergency medicine,’’ says Jeff Chambers, a physician assistant who works in orthopedics in Athens. “More primary care jobs are opening in rural areas.’’

As a PA in orthopedics, he says, “I can put bones and joints back in place,’’ plus assist in surgery.

It’s cheaper and quicker to train a PA than a doctor, says Chambers, a past president of the PA association.

Nationally, the median salary for a PA is about $97,000.

Wages says she wanted to practice in Georgia because it’s her home state.

“I’m very proud to be a PA,’’ she says. “And I enjoy general practice much more than I anticipated.”


Hospitalists: The specialists whose patients all have beds

Nurse practitioner George Mackel (right) is one of the first hospitalists at Morgan Memorial Hospital

Nurse practitioner George Mackel (right) is a member of the hospitalist team at Morgan Memorial.

Morgan Memorial Hospital in Madison got tired of having so many patients who were just passing through.

Too often in the past, the hospital has stabilized newly arrived patients, only to see them quickly bundled off to Athens for further treatment.

Ralph Castillo, the administrator for the 25-bed hospital in one of the most famously beautiful communities in Georgia, thinks he has the solution to this stopover problem.  He has launched a program that he says will save lives and keep more patients in Morgan County, closer to home and family.

Castillo introduced a team of hospitalists – mainly physicians who specialize in the care of patients who are admitted to a hospital.

Morgan Memorial has brought in a hospitalist group of nine physicians and five nurse practitioners/physician assistants who manage and coordinate all aspects of a hospitalized patients stay while working closely with a patient’s primary care physician– from admission until discharge.

The idea, Castillo says, is to increase patient and physician satisfaction. Every day, a hospitalist comes in very early, catches up with the nursing staff on any overnight developments, and tends to about 10 patients in an eight-hour shift.  That’s about 60 percent of Morgan Memorial’s inpatients on an average day.

Previously, all six of Madison’s primary care doctors came to the hospital to see patients who had been admitted.  Castillo said having hospitalists at Morgan Memorial enables doctors in the community to see more patients in their offices, while inpatients have a hospital-based doctor to respond quickly and expedite their recovery.

A new idea for a small town

Most people around Madison don’t even know what a hospitalist is.  But that’s probably true of most people around the country.

“Hospitalist” is a relatively new medical specialty, one rooted in a California experiment that began in 1992.  The term “hospitalist” was coined four years later in a New England Journal of Medicine study.

Morgan Memorial Hospital

Morgan Memorial Hospital

Studies conducted in Minneapolis, Long Island, N.Y., Los Angeles and other urban areas indicate that hospitalist programs can decrease the average length of hospital stays by up to 35 percent.  In Georgia, hospitalists have been around for a while in larger, regional hospitals.

But almost no data are available anywhere about hospitalist programs in small or rural facilities.

Because the service in Madison is only a few months old, its impact on patient care remains unclear.  And there are skeptics.  Not every local doctor has agreed to cooperate, and pharmacists are worried that working with hospitalists could make their job harder.

Morgan Memorial does not directly pay the salaries of hospitalists.  They are part of an Integrated Care Program (ICP), a bundle of inpatient and emergency department services that cost the hospital $800,000 to $900,000 annually.

Since the hospitalists went to work at Morgan Memorial about four months ago, the average number of  inpatients is higher by one to two per day.

“There were more patients leaving our ER room than they needed to,” Castillo said, “and having a hospitalist here enabled us to keep more patients here for the routine medicine rather than automatically shipping them to Athens.’’

Castillo said the hospitalist program also makes life better for primary care doctors in the community, giving them more free time.  “I’ve got one physician in particular – he’s been able to travel outside the state of Georgia more often than he had in the past,” Castillo said, “and he’s also been able to actively participate in both of his children’s extracurricular activity.”

Benefits vs. drawbacks

Four of Madison’s six primary care doctors have agreed to hand off acute care patients to the new specialists at Morgan Memorial.

One is Dr. Dan Zant, a family practice physician who’s also chief of staff at the hospital.

“It helps me be free to tend to my patients in the office,’’ Zant says. “It’s helped me expand my hours to see more patients.’’ And after hours, he says, the hospitalist program allows him “to turn it off and enjoy some family time.’’

Dr. Miguel Cossio – known as “Dr. Mickey” to his patients – is one of two who have not.  He says he feels strongly obligated to continue seeing his patients when they are hospitalized.

“It’s like you have a friend,” he said of the patient-doctor relationship.  “When times are good, everyone’s your friend…but a true friend is there in the good times and the bad.”

Though Cossio says he has “no opinion one way or the other” about the hospitalist program, he made clear that has no intention of switching over to it.

Local pharmacist Elise Lang, who practices at Thrifty Mac, worries that the hospitalist program will make it harder for pharmacists to stay in the patient care loop.

The Affordable Care Act, she said, has already increased paperwork for folks in her profession, especially when ventilators or other medical equipment are needed.  In such situations, pharmacists need more information from the treating physician.

But hospitalists, who see only inpatients, don’t necessarily have every patient’s complete medical records on hand when the pharmacist calls, Lang said.

And sometimes these physicians are harder to reach than office-based doctors.  “They don’t keep regular business hours,” Lang said.

Other area pharmacists say they’ve faced the same issue when trying to fill orders for patients hospitalized at larger facilities with hospitalist practices, including Athens Regional Medical Center.

The full costs and benefits of Morgan Memorial’s hospitalist program remain to be seen.  Most hospitals don’t see the positive effects until at least a year of services, experts say.

“At the end of the day,” said Castillo, “we want the patient well and on their way, just like the primary care physician wants the patient well and on their way.”


Lee Adcock is a first-year health and medical journalism student at the University of Georgia. She is also a music critic for various media outlets.


A test is a useful tool, but can lead to ‘premature’ diagnosis

What happened to Alex Halstead demonstrates that sometimes a quick diagnosis isn't always correct.

Alex Halstead’s appendicitis wasn’t diagnosed during an initial ER visit.

It was finals week in December 2009 and Alex Halstead, a 19-year-old undergraduate at the University of Georgia, was doing some late-night studying for an exam the next day when she felt a stinging pain in her lower right abdomen.

The pain was severe, and she was worried that she might have appendicitis.

By midnight, thanks to her roommate, Halstead was at the emergency room of Athens Regional Medical Center. The doctor on duty felt the problem was serious enough to admit her.

“At this point, I’m pretty much keeled over in pain,” recalls Halstead today.

After recording her vital signs and hooking up an IV of painkillers, the doctor gave Halstead what she remembers as a “metal-flavored milkshake.” This was a contrast agent that makes it possible to view abdominal structures –- such as a swollen and inflamed appendix –- using a CT scan.

The CT scan, surprisingly, showed nothing out of the ordinary.

Based on that scan, the doctor ruled out appendicitis. He concluded instead that Halstead had an ovarian cyst, a much less threatening condition. She’d had one before, and women in her family were plagued by endometriosis, which can sometimes cause intense abdominal pain.

As it turned out, the doctor was wrong.

Looking back, the emergency room doctor appears to have made a type of medical error known as “premature closure,” said family practice expert Mark Ebell, a member of the U.S. Preventive Services Task Force and a professor in UGA’s College of Public Health. This type of mistake happens when a doctor reviews the patient’s symptoms and makes an initial diagnosis without adequately considering other possibilities.

In this case, the doctor jumped to a conclusion based on Halstead’s medical history and the CT scan results.

The doctor at Athens Regional sent Halstead home with pain medication and recommended that she contact her gynecologist in the morning. Her alarmed mother rushed to Athens that morning and drove her to the office of gynecologist Frank Lake, who practices in Gainesville at Northeast Georgia Physicians Group, which is affiliated with Northeast Georgia Medical Center (NGMC).

When Halstead described her symptoms to Lake, he said it sounded like “textbook appendicitis.” He didn’t put much stock in the CT scan, because such tests inevitably miss a certain percentage of appendicitis cases.

“The mistake that can be made is that we rely too much on our diagnostics,” said Lake.

Lake immediately called a colleague at NGMC for a surgical consultation. When Halstead arrived at the hospital, it didn’t take long for the surgeon to identify the cause of her pain.

YouTube Preview Image“He hit the bottom of my heel, and I started immediately vomiting and crying,” Halstead remembers. What she had was appendicitis, just as she had initially feared, and she was rushed into surgery.

Even a slight jolt can cause someone with acute appendicitis to vomit. Knowing that, the surgeon had used a simple physical maneuver –- not fancy equipment –- to identify a potentially life-threatening problem.

In this instance, one doctor’s educated guess and another’s basic exam technique yielded a better diagnosis than did a complex test. But in fairness, Lake readily acknowledges that he and the surgeon may have benefited from the passage of time in Halstead’s case. When they saw the young student, her condition was surely much worse and more obvious than when she was examined in the emergency room.


Thinking is a subtle thing


Many hospitals now use checklists and other protocols to prevent “procedural” errors, the kinds of mix-ups that can potentially cause a patient to get the wrong medicine or the wrong surgery. But systematic efforts to reduce errors in judgment –- such as misdiagnosing Halstead’s appendicitis –- have lagged behind, said Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens.

Diagnosis happens in the mind of the physician, not in a public, documented setting. This complicates the challenge of developing regulations or policies that prevent errors. But Richardson sees two areas that policy shifts can target.

The first is noise.

Emergency rooms and intensive care units are often noisy places, making it difficult for doctors to detect subtle clinical symptoms. For example, a quiet but dangerous heart murmur can be drowned out by the cacophonous environment of the ER.

Last November, CBS News reported that a hospital in the Canadian province of Ontario tackled noise pollution by installing sound-absorbing ceiling tiles, creating more private rooms and moving overhead loudspeakers to the hallways instead of over patients’ beds.

Richardson also believes the reimbursement system needs an overhaul.

Sometimes a doctor cannot make an accurate diagnosis after the first meeting with a patient. But under the current system, doctors can be reimbursed only for time and procedures linked to a specific billing code, which reflects a diagnosis. This puts pressure on physicians to label a condition before they really know what it is, Richardson said.

“Some label has to be applied,” said Richardson. “That label develops a kind of momentum, a life of its own, and that tends to narrow further thought.”

In the same way, relying solely on imperfect technology, as the initial doctor did in Halstead’s case, can prevent physicians from using their clinical skills and common sense to figure out what’s troubling their patients.

“If it walks like a duck, and it quacks like a duck, it’s probably a duck,” said Lake.

Nearly 7 percent of people are afflicted with appendicitis at some point in their lives, and the ailment is misdiagnosed between 20 percent and 40 percent of the time, according to the Agency for Healthcare Research and Quality.


Ian Branam is a second-year master’s student in health and medical journalism at the University of Georgia. He is interested in developing health and medical content for the web and spent the summer developing a social media campaign for smoke-free workplaces. He particularly enjoys writing about health policy, health disparities and chronic diseases. Follow him on twitter at @ianbranam or visit his website at

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