Author: Ann Marie Marciarille

Or so my local "Emergency Room of Brookside" bleats from its website  but, even more oddly, from the pop up advertising that is dodging my web browsing these days.  Yes, many are haunted by targeted impulse buy purchase opportunity pop ups during their web browsing.  It is called behavioral targeting. I get it. And, I am looking at lots of hospital service sites and articles as part of research on a manuscript.  But, generalizing from that, is there really behavioral targeting for using ER services?

And what an ER add it is, telling me the current waiting time at this local ER in minutes.   Of course, when you click through they offer a list of all the conditions that may be ER worthy, stressing the danger of ambiguous symptoms. To be fair, they also post an equally ambiguous list of what may not be ER worthy but only Urgent Care worthy.  Overall, I do think the pitch is that what you don't know may kill you and better be safe than sorry when parsing urgent from emergent.

The curious thing about this is how at odds it is with current health insurance plan design that is trying to  move the "prudent lay person" standard on current covered ER services more than a bit by structuring plans or Medicaid coverage to include  financial disincentives for ER use that is not, retrospectively, deemed to be life threatening.  Of course, 20-20 hindsight is not the  current legal standard and so the law stands at the crossroads of insurance plan design hoping to lower non-emergent ER use and hospital systems constrained by EMTALA's screen all bias and  incentives to seek higher reimbursement rates for certain procedures delivered in the ER. Consumers, of course, are caught in the cross-fire. I won't call it friendly fire because I don't think either polarized position serves consumers well.

Anthem is making a name for itself as it rolls out these "non-emergency clauses" on a state by state basis. Missouri is on those states, though there has been surprisingly little push back — except by hospitals and Senator McCaskill — over the re-making of the standard.  This may be, in part, because hospitals have been incrementally declining to cover ER services for years or it may be that health insurance plan enrollees may not fully appreciate the non-emergency clause until it bites.

Interestingly, in coaching its plan enrollees on how to self-screen for appropriateness of ER use, Anthem sends them to a web page not unlike the Emergency Room of Brookside page linked above, minus the fear-inducing warnings that life-threatening conditions may masquerade as merely urgent conditions. So, there it is, two sets of troubling symptoms and the layperson responsible for sorting through them and deciding whether a fear-inducing or fear-rationalizing reading is appropriate. Of course, I 'm still trying to figure out how the auto accident victim who was transported  by ambulance on back board and later released with a diagnosis of not ER covered bruises and scrapes was supposed to have stopped all the clocks to complete their self-diagnosis while in the ambulance. 

I can't help but think that this is really another battle in the epic war between hospitals and insurers over who will determine cost and control of  coverage.  Clearly, Anthem contemplates that hospitals will screen more stringently for ER care in light of the distinct possibility that they may be treating an individual who is going to be uninsured for the ER encounter. And ERs are riding into battle under the banner of consumer protection and EMTALA enforcement fears.

When public discussion turns to surprise medical bills, I sometimes wonder if this misnomer — for they are health care bills whose price often could not be determined in advance and whose insurance status often could not be determined in advance — helps to screen the roles that providers and insurers combine to play in this phenomenon.  

 

 

 

https://vimeo.com/170503830

 

 

K.U.'s David Slusky gave an interesting talk on The Impact of the Flint Water Crisis on Fertility.  A 4.9% decrease in birth weight is hard to ignore.

What made me really sad was the undeserved optimism expressed by some in the audience about the potential for a litigation strategy for the fix.  Yes, there has been criminal side activity.  But, on the civil side, people should know that while the Safe Drinking Water Act does allow for private citizen suits, it does not allow for private plaintiff damages. Any funds recovered are payable to the government alone.  That may be part of why the case has been filed under federal civil rights law, which allows both private plaintiff damages and has a fee shifting provision. This theory of the case has had its own challenges, of course, with the Supreme Court only recently reviving two consolidated putative class actions against government authorities from the rocky shoals of dismissal on the grounds of preemption.

Princeton's Sam Wang was the Bartlett Lecturer this year at the Linda Hall Science Library in Kansas City.  I have been turning over in my mind, since attending his April 17, 2018 talk, the idea of Austism as both aloneness and sameness, the craving for repetition and the inward turning focus.  Sam Wang's most interesting observation was a sort of parlor trick where members of the audience plugged their own mental responses into a formula  tracking both the prevalence of autism and major mental illness in their families along with correlation of certain end scores with certain college majors. Afterwards, I believe I located the article he was tracking with his observations.  The relationship between certain brain characteristics and academic interests is a fascinating one. 

U.S. District Court Judge R. David Proctor's summary judgment ruling on the applicable standard of review for plaintiffs' Sherman Section One claims on territorial allocation between and among the Blues is worth a read.  Defendant Blues are being sued under Sherman for aggregation of a market allocation scheme as well as output restrictions that Judge Proctor determined should be subject to "per se" analysis under Sherman One.  This means that the court does not plan to  evaluate pro-competitive justifications for the market allocation and output restrictions referenced in the ruling.

There are so many interesting angles to this opinion but today I wlll note just one: Judge Proctor's strong statement that the court sits not to anticipate where antitrust law might go or be going on certain kinds of restraints and restrictions but to apply the law as it is.  That trying to get out ahead of the law is actually inimical to what antitrust law is about, despite its being a continuously evolving field of law.  "The Supreme Court jealously guards the precedential effect of its opinions."  Reading the tea leaves to identify now-disfavored precedent is to be discouraged.

This is a very thoughtful opinion. But, such an approach, does fly in the face of one strand of antitrust analysis that prides itself on advancing economic analysis first and arguing legal precedent inconsistent with new economic thinking now be considered disfavored as a result. 

 

 

Trevor Noah's Monday night  observation that budgetary restraint seems to have fallen out of fashion in Washington was punctuated by the observation that the current administration is spending money" like Lil Wayne at an out-of-network dentist."  This was a great laugh in a long series of Lil Wayne jokes but also a piece of  rarely seen health insurance humor.  Quite the image — Lil Wayne does seem to have a penchant for dental sartorial splendor.  And, whether he's sporting implants, a grill, or both,  it is  unlikely decorative implants were covered by something like Delta Dental. 

The New York Times has an article on the hard-to-look-away-from indictment in the Verruckt water slide decapitation case. The article, however, is mostly about how Schlitterbahn did not comply with engineering standards in the construction of the waterslide. Not a word about how  neither the Kansas Legislature nor the Kansas City, Kansas government cared to make inquiry into the safety of  the design or, even,  failure to design what was, at the time, the world's tallest waterslide/roller coaster.

Verruckt means insane. Read the indictment itself. It will make you crazy, no waterslide/roller coaster required, to watch ten year old Caleb Schwab march to his death.

But absolutely nothing posted on what to do in the case of a tornado.

 

The blogosphere has taken note that Amazon has hired a geriatrician.  ChenMed's take on this is that Amazon may see the value in targeting an older chronically ill demographic as its place to make a disruptive entry into health care. I'm still stunned Amazon was able to find a geriatrician to hire. After all, in some markets, a credentialed geriatrician is paid less than an ordinary primary care provider. Yes, advanced training as a geriatrician can be an income reducer for someone interested in primary care.

 

 

I am pleased  to report my research assistant, Sarah Lynch (UMKC JD Candidate, 2019), has already presented at the Children's Mercy Hospital Pediatric Sleep Disorders Clinic narcolepsy family day on different approaches to legal and regulatory restrictions on drowsy driving.  One big takeaway, so far, neither Kansas nor Missouri specifically target drowsy driving in licensure  restrictions though there does seem to be some accident reporting tracking of driver fatigue as a contributing factor to traffic incidents. This is in stark contrast to states like New York with substantial targeting of licensure restrictions for drowsy or potentially drowsy drivers.  Given the default is self-monitoring for individuals with narcolepsy who wish to drive in Kansas and Missouri, we are wondering what value, if any, narcolepsy-specific restrictions add to public safety.