It might be a good time to circle back to John's original question, which is, what are the ethics of not treating an injured diver when a facility has the staff and training to do so?
First, I think that there are some misconceptions about hyperbaric facilities, in that some believe that any hyperbaric facility has the capability and equipment to treat injured divers. This is definitely not the case. The overwhelming majority of hyperbaric chambers in this country are monoplaces (i.e. only one patient at a time can be treated in the chamber) associated with wound care clinics, and are used as an adjunct to wound healing. The medical professionals who staff these clinics are by and large excellent at what they do, which is, heal wounds. However, many of the physicians are not fellowship-trained in hyperbaric medicine; rather, they attend a week-long introductory course. This course does not prepare them to diagnose and treat diving injuries. Also, monoplace chambers are pressurized with 100% oxygen and many do not have the ability to provide a patient with air breaks as required by the U.S. Navy treatment tables. Would it be ethical for one of these facilities to agree to treat a diver? Arguably not.
The second, more fuzzy situation is the one mentioned in the article that Reku linked, in which a hyperbaric facility that used to operate 24/7 and treat emergencies stops doing so. There are a few reasons that this could happen: first, I can tell you from years of first-hand experience that it's difficult to staff this. I wish I had a dime for every minute I spent on the phone trying to get a PRN critical care nurse to come in and dive with an intubated patient. Often I'd end up going in myself, relying on my hyperbaric fellow and attending physician for outside chamber support, and catching up on the charting when the treatment was finished. Some facilities have staffing challenges that force them to give up treating 24/7 emergencies.
Another consideration that's already been mentioned is financial. Divers make up a vanishingly small fraction of the income for most hyperbaric facilities, and DCS isn't the most common emergent indication treated. It also costs money to pay staff to be on call 24/7, and the overtime adds up quickly in 24/7 facilities, our own included. The present environment of diminishing reimbursement from Medicare and private insurance carriers makes it increasingly difficult for hospitals to operate, and quite frankly, every health care facility in the U.S. is looking for ways to streamline care, operate more efficiently, and yes, cut costs. It's only going to get worse in the years to come. Reimbursement decisions are algorithm-based and are made by people with very limited knowledge of hyperbaric medicine. Here's an example (with back story): hyperbaric patients being treated for chronic conditions may require up to 60 treatments in order for the therapy to be effective. At Duke, we offer patients two treatments per day because we have the physical capacity to do so. This allows them to complete their treatment course much more quickly. Medicare refuses to reimburse for twice-daily treatments. It doesn't cost them any more, but some under-informed bureaucrat decided that only one treatment per day is reimbursable. Who's on Medicare? Retired people, many of whom are on a fixed income, and many of whom (in our case) come from a long distance away. Getting their treatments twice daily would let them go back to their daily routines faster, maximize their quality of life and minimize their expenses (many of them stay in hotels). This case has been made to Medicare numerous times, without success.
Here's another example: if we treat an emergency, some private insurers require us to inform them within 24 hours. If you've ever tried to navigate a phone menu for a health insurance company, you know what we're up against. We have to punch the same buttons that patients do and wade through endless automatic phone menus that don't have what we need. However, if we don't call within 24 hours the patient gets stuck with the entire bill. Our administrative coordinator fights this every day.
Here's another example: many state subsidiaries of a certain well-known private payor now operate under the Milliman Care Guidelines (MCG) for reimbursement. The MCG for hyperbaric oxygen therapy include only three of the fourteen UHMS-approved indications, and these state subsidiaries will not reimburse for things like late effects of radiation (the best-studied indication for hyperbaric oxygen) or carbon monoxide poisoning. MCG is a private company that ostensibly looks at all the available evidence on which treatments are effective and then sells the results of that research to insurance companies. What kind of research do you think insurance companies are going to lean toward: that which requires them to reimburse more, or reimburse less? In the interest of fairness, the North Carolina branch of this payor has been very reasonable and, upon our request, agreed to change its policy to reflect all of the current UHMS-approved indications.
In other words, another reason that emergency hyperbaric facilities are closing is that hospitals are being forced to significantly alter the way they do business as a result of tighter and tighter reimbursement criteria from both government and private payors. Some health care administrators come to the conclusion that the return on investment of keeping a chamber crew on call 24/7 is insufficient because the volume (and therefore the reimbursement) is relatively low. The case could be made that it is neither ethical nor in the best interest of patient care to further limit access to a treatment modality that can preserve life or function.
Best regards,
DDM
