I get to attend a lot of meetings in my current role, meetings that medical school nor residency nor fellowship prepared me for, meetings with people who don’t have a clue about medicine but either control the money, make the policies, or care solely about the hospitals image. Meetings about value based purchasing or outcome measures. Meetings where they are quick to tell you that everything is about providing care to the patient or about patient safety. Yeah, I roll my eyes to that.
I’ve been involved in discussions as to whether there is any evidence as to whether or not wearing blood stained shoe covers in the hospital cafeteria (or anywhere outside the operating room) is harmful to patients. What about some common sense?
Or meetings where the administrator du jour upset about his departments surgical site infection rate wants a bigger, broader, antibiotic for longer as “prophylaxis” in the name of “doing the best for our patients” and then gets upset when the theory of antibiotic surgical prophylaxis and risks associated with the haphazard use of the “baddest” antibiotic is discussed instead. I mean how about we start with the basics? How about we address the hand hygiene rates of your physicians for example? Hmmm?
Not too long ago, I went to a meeting where physicians were urged not to order too many esoteric tests. That’s fair enough because there is a lot of waste in medical tests. But the reason given was that we were not an academic institution, and couldn’t we just give the patient a prescription for the esoteric test in question so that it could be done as an outpatient…as an outpatient…for cost savings and better reimbursement for the hospital? That day, I looked at the administrator with my “are you kidding me eyes”.
I’m an infectious disease physician. I get called when physicians can’t figure out what’s going on with their patients. It’s my duty to think outside the box and if that means ordering an esoteric test to diagnose why a patient has had fevers for 3 weeks straight, I’m going to do that, academic center or not. This especially when we claim to be a tertiary referral center and we are told to accept all transfers. I mean what is the transfer center to say to the outlying hospital who wants to transfer a sick patient here. Oh, sorry, we are not an academic institution so we won’t be able to order esoteric tests in the workup of the patient? I can think of other laboratory related cost savings measures. How about tackling the complete blood counts (CBC) almost all patients in the hospital get drawn every day at 5 am? Better yet, what about the urinalysis with urine culture that almost everyone presenting to the emergency department gets just because they presented with a bladder. I suppose though that it is cost-effective to prove that a patient had a urinary tract infection (UTI) present on admission (POA) so that the hospital doesn’t get dinged a couple of days later for causing a preventable infection?
Anyway, I understand the reasoning behind administration requests at least simplistically. It’s bureaucracy, pure and simple. It’s the Centers for Medicare and Medicaid Services (CMS). Prior to sometime in the 1980s, hospitals were paid on the basis of the actual cost for providing care to Medicare beneficiaries. The hospitals made bank and the federal government saw things as wasteful. So now medical and surgical services are bundled into diagnosis-related groups (DRGs). CMS dictates how much it costs to provide inpatient care to a patient with a particular diagnosis.
Let’s use pneumonia for an example and let’s say that the bundled payment to the hospital for taking care of a patient with admitting diagnosis of pneumonia is $2000. So if patient A gets admitted to the hospital with admitting diagnosis pneumonia, and ends up having a simple pneumonia that responds nicely to antibiotics and is discharged in a day or so, great for the hospital. They didn’t spend more than the $2000 so they have made a profit. But if patient B gets admitted to the hospital with admitting diagnosis pneumonia but in the course of their two-week hospitalization gets diagnosed with leptospirosis (because the infectious disease physician came by and ordered an esoteric test), required mechanical ventilator support for their respiratory failure, and hemodialysis for their acute kidney injury, then the hospital is at a loss. Of course, this is rather simplistic and other diagnoses come into play that are determined at the point of patient discharge for which the hospital can get reimbursed.
My point is my little pigeon head physician brain understands some of all this administrator mumbo-jumbo. But still! Can’t I just be a physician and take care of my patients?
At another meeting we the medical staff were urged to order “lots of labs” on patients accepted as transfers from outlying hospitals so that the expected mortality on admission is accurately demonstrated. You see, physicians aren’t always that wasteful. If a patient is being transferred from another hospital, we have no qualms looking at the results of blood work drawn there, just a few hours earlier, to guide our medical decision-making. We don’t automatically duplicate all that blood work. Of course, we would repeat those that may be critical like a repeat potassium to see if any improvement has been made as a response to therapy received in the interim.
But from the viewpoint of hospital administrators when we don’t order a comprehensive lab panel for the patient on presentation to our hospital we do not prove that the patient is very ill at the time of admission. If we do not duplicate all the studies that show that the patient is critically ill within our hospital system and that patient later dies, a good likelihood because they were already on death’s door anyway when the outlying hospital asked us to take over “the care”, there is a mis-match between the hospital’s predicted mortality rate and the actual rate. This is a CMS definition and there is a time frame within which these labs need to be done thereby arguing for repetition of labs within hours. Within hours. I feel for the patient’s poor veins.
This matters because several years ago CMS decided to release mortality data on hospitals to show how they compare to other hospitals so that consumers can be better informed. The next trend of course is to penalize hospitals (financially) for poor data. So it’s all about the data. It’s all about massaging the data to make it look good. Incentives to order tests so there’s institution specific data so that actual mortality approximates predicted mortality rate. Incentives to transfer a patient out of your facility before he dies arguing that they need a tertiary level of care. CRAZINESS.
The US health care system needs such a major overhaul it’s not even funny.
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