Amy Faith Ho, MD MPH
@amyfaithho
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#emergencymed #millennial MD MPH | nat’l speaker & writer | 5x TEDx | #healthpolicy #socialmed #informatics #meded | 📚author
Dallas, TX
Joined March 2012
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This book is dedicated to our real-life
#superheros
, the
#Doctor
#Mommies
who both save lives and create lives💕
I hope I did you all justice👩🏻⚕️👩🏽⚕️👩🏼⚕️👩🏿⚕️ 📚
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Here’s the dirty secret of emergency medicine:
We don’t have to do prior auth. Like ever. We just order what the patient needs, and the patient gets it done in the ED.
But here’s why we care about prior auth anyways:
B/c not a shift goes by where a patient doesn’t land in the…
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Q: Why are waits at emergency rooms so long?
A: Because the rest of the healthcare system is failing.
The patient did everything right, but the healthcare system did them so so so wrong.
🧵…
They call their PCP, but can’t get an appointment. So they turn to the ER.
They…
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Why does this matter?
1. It’s terrible for patients
2. It stresses the healthcare system in ways it shouldn’t
3. It’s cumbersome and wasteful to insurers and clinicians both
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The first time I was assaulted, I was a 3rd year medical student, and a psych patient handcuffed to a gurney rail in the ER fought so hard, the entire metal rail (still cuffed to his arm) separated from the bed.
The 6ft piece of heavy steel would’ve gone flying into my skull…
Attacks at U.S. hospitals and medical centers have helped make health care one of the nation’s most violent fields.
Data shows American health care workers now suffer more nonfatal injuries from workplace violence than workers in any other profession.
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Need your gallbladder taken out electively? Too late (waiting for auth), now you’re in the ED with cholecystitis.
Had a “nodule” seen on a CT, but couldn’t get a repeat scan authorized…ever? Now it’s metastatic and you’re in the ED for crippling pain.
DVT? No problem, started…
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Me thinking about how middlemen in healthcare make billions profiting off of patients…meanwhile hardworking mom of two sweet kids is in tears in front of me sitting in an ER hallway bed because she couldn’t come up with the $800 UPFRONT that a specialist clinic required before…
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Dear America,
Happy Thanksgiving. Some pro-tips from the ER:
1. Do not drop a frozen turkey into a deep fryer. It is basically a bomb. Defrost…asap if you haven’t started already.
2. Don’t become carved meat. Avocados are the fingers’ nemesis…followed by mandolines. Use…
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So why does
#priorauth
exist?!
To “contain costs” by insurers…
Doesn’t sound terribly cost effective, does it? 😑
$58 million in labor cost alone of initial submission, not including the labor cost of denials/appeals and not including the cost of ED/hospital stays that…
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35million priorauths submitted to
@MedicareGov
#MedicareAdvantage
in a year - assuming 5 min/each and $20/hour of staff time (underestimated since this is physician/RN/admin blended time) that’s $58million of just labor cost.
Not including denials/appeals…
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If I ran a hospital, I would have brand-name graham crackers, pillows in the ER, thermostats that staff can adjust in workrooms, free parking, and no McDonald’s on-site.
Oh, and protected staff-to-patient ratios, an EMR that has clinician input, a transparent & reasonable…
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Citation:
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For those just now realizing insurers don’t care if you live or die—
🚨🚨🚨Insurers do not care if you live or die.
In fact, death is highly cost effective, especially if it is fast, and especially if you are chronically ill.
Up to 25% of all Medicare expenditures are spent on…
Here’s the dirty secret of emergency medicine:
We don’t have to do prior auth. Like ever. We just order what the patient needs, and the patient gets it done in the ED.
But here’s why we care about prior auth anyways:
B/c not a shift goes by where a patient doesn’t land in the…
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@sonodoc99
@TakeWeightOffMD
Physician: * prescribes medicine *
Insurance: * denies *
Physician: This patient needs the medicine, please don’t deny
Insurance: * denies *
Physician: Pretty please?
Insurance: * denies *
Physician: 🤬🤬🤬🤬🤬
Insurance: We need to verify medical necessity with the prescriber.…
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Dear house of medicine,
Happy (academic) new year.
Here’s your annual paycut.
This one will bring you to a total 23% decrease since that whole “pandemic” thing.
Love,
The US Government
PS: We have shortage of healthcare workers and deep health access issues in this country.…
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@DrWutt
@tim_maliyil
Sad, but true.
Meanwhile, America be like: McDonald’s on every corner, prolific tobacco/alcohol lobbies, and no gun control.
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How do you tell a medical doctor?
Real doctors: *reluctant to state they are doctors in public/social forums*
Non-MD/DOs: *take every opportunity to say they are a doctor…* (chiropractors, naturopaths, pharmacists, apothecaries, charlatans…)
Doctors in public:
Stranger: “What do you do for a living?”
Me: I work down town.
“Where?”
At the hospital.
“What do you do there?”
I work in the operating room.
“Doing what?”
I take care of people.
“Are you a doctor or a nurse?”
Fine. Yes. I’m a doctor.
#MedTwitter
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“Patient is a poor historian”
🙄🙄🙄
IT IS NOT THE PATIENT’S JOB TO BE A TALENTED HISTORIAN.
It is your (our) job to be a talented history taker.
Whether that means coaxing out details, teasing out sensitive facts, explicitly asking relevant points, collecting collateral…
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Ortho-bound MS4: 275 Step 1, 280 Step 2, memorized Harrison’s Internal Medicine textbook while studying for their IM shelf, and can recite the Krebs cycle backwards
Ortho PGY1: asks Medicine to admit patient for femur fracture because the patient takes 2.5mg of amlodipine……
Ortho asking for the patient to be admitted to medicine because they have a blood pressure of 146/93.
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Responsibility with no authority is the most demeaning thing…and it’s the story of healthcare.
Clinicians have responsibility to answer their patients’ questions…but no authority to book patients for more than 10-minute visit lengths. That’s the time squeeze set by…
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One of my attendings in residency used to say “EM is a kid’s game” and chuckle while we (residents) ran around and he sat in his chair, sipping his tea.
He was one of those older docs that wore those shiny leather loafers with the tassels, knowing he’d never get close enough to…
Constantly walking the mental tightrope between “Im getting too old to do this gig” vs “I just need a nap”…
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I’m not a surgeon, but I may have been had
#gensurg
looked like this 10 years ago when I was matching. I rotated on surgery in a department almost all older white men. Toxic culture was prolific. Male attendings would prey on female med students & residents…
@TheNRMP
#match2023
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EM: One of the least happy specialties OUTSIDE of work.
Why?
I think this is a simple case of we-know-too-much.
I can name a million ways to die, many ways I’d rather not live, but only a handful of ways I want to live.
An aneurysm that decided today was the day, that…
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Explain this to me: why do hospitals have the absolute worst tissues?
Everyone has flu, covid and RSV right now, and here we are offering awkward half-size single-ply cardboard…
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There is no simple solution, just like there is no simple solution to violence as a whole.
Police officers, metal detectors, panic buttons, “de-escalation training”, “zero tolerance” signs…I’ve worked at places that do them all.
And there is still violence.
And people are…
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@CenterRotation
It’s not on the PCP.
You guys are overbooked, forced to cram complicated patients into 10 minute visit slots, then expected to document after hours for hours, fill out endless paperwork (ahem, prior auth), answer patient messages and review results, and then somehow maintain…
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Let’s not forget, the
@cmsgov
$/RVU conversion has decreased reimbursement universally every year since 2020. 6% cut in reimbursement through a pandemic…in an economic setting of 4.5% inflation. How does that make sense to have over a 10% pay cut for our “healthcare heroes”?…
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All I see here is:
incidentaloma, incidentaloma, incidentaloma…
What’s an incidentaloma?
A ditzle / wart / spot that may or may not be concerning, but ends up triggering a path of follow up scans ($), invasive/procedural diagnostics like biopsies and surgeries ($$$$$),…
Kim Kardashian shares new photos after getting a Prenuvo full-body scan:
“[It] has the ability to detect cancer and diseases such as aneurysms in its earliest stages, before symptoms arise. It was like getting a MRI for an hour with no radiation. It has really saved some of my…
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@DrWaym
Versed and Ativan are also on shortage…
I wonder if patients are angry for the same reasons we are: because the healthcare system failed us when we thought it would be there for us…
Staffing shortages, drug shortages, insurance “networks”, prior auth, long waits, high prices,…
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@EdGainesIII
“BRB, let me get prior auth for this here heart attack I’m having now….📞yes, I’ll hold…”
😑🤯😑🤯😑
Crazy how perverse the US healthcare system is.
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Before we get ahead of ourselves…little known fact:
The ACA severely limited physician-owned hospitals (banning creation of new ones that accept Medicare and limiting expansion of existing ones).
The justification was because physician-owners may have conflicts of interests…
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Happy
#DoctorsDay
! Thanks for the 🍕🌮🍪🍩, but next year could you:
-Help us not get bullied by insurance companies
@uhc
-Stop slashing
@CMSGov
reimbursement rates
-Make drastic social reform so
#healthcare
isn’t the dumping grounds for lack of food, shelter, transportation…
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We’re a 1-stop shop where you can get a physician, labs, imaging, medicines, specialists/consults, referrals, work notes, DME, and more all in one go…and we’re open 24/7/365.
ER crowding is not about making the ER more efficient, it’s about making the rest of healthcare less…
Here’s the dirty secret of emergency medicine:
We don’t have to do prior auth. Like ever. We just order what the patient needs, and the patient gets it done in the ED.
But here’s why we care about prior auth anyways:
B/c not a shift goes by where a patient doesn’t land in the…
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We shouldn’t need a viral video of the husband of a sexually harassed trainee fighting the (male) presenter/perpetrator at an
@acog
meeting to remind us that sexual harassment is a HUGE problem in medicine.
We may not talk about it, but there are exactly 0 women in medicine…
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You can’t understand modern medical training without understanding who birthed it: Sir William Halsted.
The “Halstedian Model” believed in graded responsibility with the strict hierarchy we still know today: Chief resident, Assistant residents, and Interns.
In the quest for…
What’s most important to remember about being a doctor is that if YOU suffered through a training experience constructed by a surgeon in 1900, out of his mind on cocaine, well then, everyone should.
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Apparently today is
#WomenEqualityDay
…
Here’s how
#healthcare
is doing:
💵74 cents on the dollar for female physician compensation compared to that of male physicians
👩🏻⚕️Only 37% of the US physician workforce are women
🤰🏻Female physicians have a higher infertility and…
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@Ambcare_pharmer
@sonodoc99
@TakeWeightOffMD
💯 Every layer reveals another strategy of trickery and limiting access…
🤬🤬🤬
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I was today-years-old when I learned that BLUE CROSS BLUE SHIELD IS A NON-PROFIT…
The deets:
#BCBS
is actually a federation of independently owned/operated BCBS companies, the overarching entity of which is BCBS Association
@BCBSAssociation
, which is a nonprofit. A nonprofit…
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If you want to understand WHY certain specialities are falling, yes it’s probably a difference in lifestyle and compensation. But compensation is a result of reimbursement and LOBBYING…
@AmerMedicalAssn
@MedicareGov
@CMSGov
@aapcstaff
@EmergencyDocs
@ACEPNow
@ACEPAdvocacy
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When I was a brand new assistant medical director, I showed up to a hospital committee meeting for the first time, and was immediately met with, “oh, you must be from the ER!”
I asked them how they knew, and they said, “you’re wearing a backpack…”
🫠…
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@shycollie
Yup. Patients don’t like it, nor do the referring doctors. It’s kind of a desperate times, desperate measures sort of thing…and US healthcare is beyond desperate, sadly.
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How to be hyper-efficient in
#Epic
#EHR
— from a physician
#informaticist
who loves to flyyy on shift🧵
1️⃣ Smartphrases are the
#1
documentation efficiency. Use a standard naming convention so you can find it quickly. I use:
.dc*** for discharge instructions (ie .dcviral,…
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Call me a pessimist, but I don’t think
#telehealth
is the magic solution people want it to be.
The importance of the physical exam is an art that is lost in the allure of “high tech” solutions. Peritonitis, pulseless limbs, a pulsatile mass — these are just a few of the things…
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@george1_morgan
Some of the “Big Pharma” hate is actually part and parcel to PBMs (but they enjoy being a hidden, opaque, not often known middleman that drives up drug pricing and limits access…)
Not to say Big Pharma is completely innocent, but PBMs are definitely completely guilty.…
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There is some movement to eliminate the ban on physician-owned hospitals (
@AmerMedicalAssn
@SenatorLankford
@JackResneckMD
@FTC
@DOJPH
), though (good news!):
“by removing the POH ban, Congress would free physicians to invest and innovate in the hospitals where they apply their…
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Private equity: spends ~$1 trillion on
#healthcare
.
Healthcare: Still uses pagers 📟📟📟
Where’s the $$$ going?
Hint: it’s not to the patients or clinicians.
Middlemen, insurers, hospitals and executives…💰💰💰
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@BethKinn1
I’m very conservatively estimating $58million/year for Medicare Advantage patients alone…
But probably easily 10x that given that I intentionally underestimated the time it takes and also likely the labor cost…
35million priorauths submitted to
@MedicareGov
#MedicareAdvantage
in a year - assuming 5 min/each and $20/hour of staff time (underestimated since this is physician/RN/admin blended time) that’s $58million of just labor cost.
Not including denials/appeals…
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Who are the racketeers of healthcare?
Let me name thee one by one…
1. Healthcare Insurers - denials, delays, prior auth, the list is endless…
2. Pharmacy Benefit Managers (PBMs) - rely on kickbacks to get paid off in exchange for “tier”-ing what drugs are and aren’t…
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I’ve been told this in every Patient Experience lecture/course/workshop ever…
“Sit when you’re talking to patients so they know you’re on their level.”
In reality…this means I’m the doctor sitting on the trash can, at least 85% of the time…🗑️☣️
Luckily, the lid only breaks…
My simplest tip on improving patient interactions is sitting.
Sometimes there’s no chair. You should still attempt to get on the patient’s level. Kneel. Squat against the wall. Sit on the edge of their bed.
It’s simple and a proven method to increase patient satisfaction.
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Let's be explicit: "nonprofit" is a TAX STATUS, not a mission statement.
The majority of hospitals in the US are "nonprofit", but "nonprofit" doesn't mean not $ motivated. 🧵
Here’s how the model works: nonprofit status means tax cuts. Huge tax cuts. On the order of $28…
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A history of
@theNRMP
match: 🧵
The Match was established in 1952 when available resident positions vastly exceeded the number of graduating medical students. As a way to secure top students as residents, hospitals were:
1. Offering positions earlier and earlier, sometimes…
This weekend, the AMA House of Delegates adopted a resolution citing antitrust concerns with the NRMP Match, and calling upon the AMA to study alternatives to the residency match that would be less restrictive on free market competition.
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How is it a single tornado at a single manufacturing plant of a single pharmaceutical (
@pfizer
) wipes out the supply of 8% of hospital injectables?!
Answer: GPOs.
What are GPOs…?
Another mafia of healthcare…🧵
Group purchasing organizations are analogous to PBMs, but for…
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True confession:
When I get home late from the ER and the baby’s already been asleep for 6 hours, I turn on the baby monitor to look at him in his crib and say goodnight.
Sometimes he wiggles a little, still asleep, as if he knows I’m there — and immediately any residual…
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Things worth less than the US health insurance market ($1.6 TRILLION):
🇪🇸The entire GDP of Spain ($1.49T)
🇸🇦The entire GDP of Saudi Arabia ($1.06T)
🇨🇭The entire GDP of Switzerland ($870B)
🪖The US defense budget ($886B)
💊The global pharmaceutical industry ($1.48T)
📚The US…
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The
#privateequity
#healthcare
playbook:
Step 1: Woo groups with promises of efficiency, innovation, cash injection, growth, and the negotiating power of consolidation (against insurers, etc.)
Step 2: Laden group with massive, expensive debt as part of the “cash injection” to…
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Nearly 50% of pregnancies in the US are unintended, especially in young, low-income minorities, so this is a HUGE step in health access that the
@US_FDA
just approved the first over-the-counter (OTC)
#birthcontrol
.
Things to remember:
👩🏻⚕️Take it the SAME TIME OF DAY, EVERY DAY.…
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I don’t understand why there is a “is healthcare a privilege or right” debate in America.
#EMTALA
has made healthcare a right, period. This 1986 federal statute mandates EVERYONE gets medically screened for an emergency and given emergency treatment if needed, regardless of…
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Now this doesn’t all have to be negative.
Every day I don’t wake up with stage 4 ovarian cancer is a happy day to me. I have a peace with what I think the meaning of life is. Natural light, the smell of a fresh-toasted sandwich (non-turkey, of course), a still room…all things…
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@DrAlexUrology
Haha ya, he never liked to tell us about those days though…as if he popped out of the womb grey haired, wise, and in leather loafers!
I agree though — this is why the hours of training matters…it’s the acumen that comes with the actual hands in training. Datasets can get you…
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One of the greatest myths as a
#doctor
about
#healthcare
#business
is that it’s all about RVUs.
We talk in RVUs & we measure ourselves in RVUs, but this is a distraction, because the translation of RVU to actual $ is where the healthcare complex has won.
Denials, appeals,…
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@BellevueDoc
Good call. I will add therapy ponies (in addition to baseline therapy dogs) to the plans!🐴🐶
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@plasticolicious
True confession: I am one of those people who hold the avocado in my hand while pitting/slicing it…yes, even though I know better 😳😳😳
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Talking a little more about medical loss ratio (MLR), the ACA actually required that insurers keep to at least a 80% MLR, though there are liberal rules on what can quality as “medical loss” (aka paying for healthcare) beyond just paying for healthcare.
Even with those liberal…
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@A_Wetstone
Actually, they’re requiring it for DIAGNOSTIC colonoscopies too…as in the patient is SYMPTOMATIC with signs of colon cancer, and the c-scope has to go through prior auth…
what?!
@AmerGastroAssn
@AmCollegeGastro
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@MananShahmd
I’d be remiss if I didn’t mention HR2584 (Safety from Violence for Healthcare Employees (SAVE) Act) which federally criminalizes intentional intimidation or assault to hospital employees.
This is helpful…but it only penalizes (and arguably deters)…
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Same for white coats…chances are, if someone is wearing a white coat, they are a chaplain/pharmacist/therapist/food services/etc…
If they are wearing a fleece or soft shell, probably a doctor, and probably have their name and credentials embroidered on said clothing 🤣…
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As an
#ERDoc
, I often see patients at the end of their lives, sometimes delivering the news to next of kin.
Probably the most profound part of my job, and here’s my takeaway:
Your family, your friends, your relationships — they are your legacy. And if you’ve done a good job,…
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Before you say this is “just” a
@MedicareGov
issue: the RVU conversion rate does “only” set the reimbursement for
#Medicare
…but that’s 21% of total national health spending.
Not to mention, our older, vulnerable population only continues to grow…AND commercial insurers…
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Reminds me of a July 4th mattress sale at Macy’s ad…but that’s probably bc they’re focusing $ on meds, not advertising.👏
This should be the standard in US healthcare.
Albuterol $15
Augmentin $10
Budesonide $16
Clopidogrel $5
Truvada $15
Estradiol cream $20
Imatinib $12…
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So let’s talk this through:
@change_hc
, the largest healthcare payment system in the US (owned by United
@UHC
) has a ransomware attack that shuts them down for 4 weeks and counting.
Meanwhile, this means physician practices aren’t getting any payments, losing millions of…
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This is the definition of a toxic culture, one that perpetuates and insulates itself as women self-select away…to change this, you need to disrupt. Heavily female surgical residency classes aren’t bias, they are progress. They are changing the field and culture of surgery.
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@_____LR____
I mean, I understand the temptation…but that’s kind of sad, isn’t it? It’s literally taking the best part of medicine (connecting with people, figuring out subtleties, piecing together puzzles) and being like “can’t someone/something else do that part and digest it for me so I…
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When you’re doing a big nat’l talk at
#FIX17
but your lil one won’t hold on to anyone else...you
#momboss
the stage with her
@feminemtweets
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I worked last night, on the eve of July 1.
Our new interns were in the ED, orienting, and I kind of forget how their presence brings such an air of excitement every year.
It reminds me of all the “firsts” that have that special spark (but quickly become dulled by routine in…
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Doctor shortage? Follow the money: 22% decrease in compensation, 86% feel overworked, 67% thinking employment change.
@doximity
@AmerMedicalAssn
@FierceHealth
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Healthcare is a complex system, upheld only by the dedication and service of a team of exceptionally hardworking and compassionate individuals.
I've been privileged to be a part of that team, not only for the privilege of treating patients, but also for the opportunity to work…
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Great 🧵- my takeaway since having a 👶🏻myself: if a patient comes to the ER postpartum, DO NOT BLOW THEM OFF. The barrier to leave the house is so high, that if they put on pants to come to the ER, they NEED something. HELP.
NEW! Our work on postpartum disparities in NY 2014-16
@JAMANetworkOpen
:
🤱 6% of births w ED visit in 6 wks
Black pts had ⬆️ ED visit rates across all hospital types 9% (range 7-13) AND more likely to give birth at hospitals w highest ED visit rates
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The math: Year over year, the $/RVU conversion rate set by CMS has decreased.
We are set to be almost 10% less since 2020 with CMS’ most recently announced proposal for 2024. With the ~17% inflation since then, this puts us at total 23% decrease.😡
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Violence in healthcare: why are people so angry?
Because the healthcare system failed us when we needed it the most…
Staffing shortages, drug shortages, prior authorization, extortionist middlemen, long wait times, high prices, rampant health disparities and inequities,…
Violence in Healthcare: Why Are People So Angry?Because the healthcare system has failed us all when we needed it most, by
@amyfaithho
via
@MedPageToday
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Sexual harassment is PROLIFIC.
In formal studies, 30% to over 50% of female physicians report being sexually harassed in their careers.
This is in FORMAL studies — because of stigma, shame, fear of retribution, and a feeling that “nothing will change if I report”,…
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Why does this matter?
1. It’s a financial racket, pure and simple. 87.9% of these boards’ revenue come from exam fees…exams which are functionally mandatory since insurances, hospitals and other employers of physicians require it to practice.
2. MOC…
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@AshleyGWinter
But what if your baby’s foot was so sad from being put to sleep with no blanket, it decided to necrose from loneliness?
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To those who crossed paths with me during this recent whirlwind of an experience,
Thank you.
That may sound odd given the intensity of what occurred, but it sparked discussion and discourse – opportunities to learn and grow.
Hierarchy and abuse in healthcare is rampant, not…
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A story of
#specialities
, with dinosaur squirties 🦖🏥🦕👶🏻
#iykyk
#medtwitter
#rounding
#specialty
#emed
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Is
#emergencymedicine
doomed?
No.
Our future is certainly cloudy - private equity, bad actor insurers, rampant under-staffing, misguided bureaucracy, increased violence, worsening addiction/mental health, worsening health disparities…
Our "safety net" is more strained than…
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@WilliamCherniak
@doximity
@ACEPNow
@EmergencyDocs
Most definitely. I often see ER docs with teenage children bring their teens to shadow a shift…almost always weekend nights. Amazing life lessons.
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Citation:
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@T_Fus
💯
If you recall, pre-ACA, insurers actually would completely deny coverage to people with pre-existing conditions…
Literally, they are interested in you as a premium-paying healthy person with little to no healthcare expenditures, and not interested in you if you are anything…
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Also, my PhD hubs:
Him: “I AM a real doctor!”
Also him: * passes out at the sight of blood *
Me: 🙄🙄🙄
Inevitably, our formal mail does generally say “Dr. & MRS. husbandsname”…
le sigh.
#womeninmedicine
@womeninmedchat
@WomenInMedicine
@AMWADoctors
@AAWEPSection
@AWAEM
…
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Next level…✅
🤣😎💻
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@averagemoneymd
This sounds like the promised land…do you have free parking and brand name Graham crackers too?!?! (And dare I ask…pillows in your ER?!?!)
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