February 1st, 2012
November 9, 2011. Time fell back three days ago, leaving me one less hour of daylight to enjoy on a gorgeous Indian summer Wednesday. I’m the attending physician on a busy family medicine inpatient service, and it’s been a long week of patient care and meetings. I rush out of the hospital somewhere near 5 pm, hoping to go for a short run before the season changes to winter.
Pulling out of the parking lot, the traffic slows to a crawl as both patients and pedestrians preoccupied with conversation meander through the crosswalk. I open my window to feel the warm fall breeze, reflecting on my day.
7:00 am. I attended morning report led by our family medicine residents, briefly discussing patients in the hospital and their plans of action. Oatmeal and raisins, faux egg mcmuffin sandwiches, caffeine and adrenaline fuel much of the conversation, which focuses on serious problems and crises in management, punctuated by frustrations dealing with care managers and insurance plan medical directors who constantly remind the residents that they need to discharge patients home as soon as possible.
In recent years, the Length of Stay (LOS) patients experience when hospitalized for medical and surgical care has decreased due to better treatments and concerted efforts to avoid nosocomial complications associated with prolonged hospitalization. However, these shortened hospital stays have created new problems – patients are sent home with less resolution of their acute illness, forcing physicians and hospital staff to manage increased patient turnover and associated communication and cross-coverage issues. Have we reached a safety plateau where hospital LOS cannot be cut any shorter?
The residents wrap up their morning report rounds with a thank-you to the departing night coverage team, and a plan to reconvene in a couple hours to further review patient care as a team.
7:30 am. On to an administrative meeting, learning about imminent plans by Medicare to dramatically cut reimbursements to hospitals and physicians for patients re-admitted to the hospital within 30 days for certain diagnoses, such as COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), asthma, and pneumonia. CMS (Centers for Medicare and Medicaid Services) had introduced these regulations to cut costs under the guise of improving “quality” of care. Although there is no evidence that such a reimbursement strategy actually improves medical outcomes, we were warned that there will be widespread adoption of this non-reimbursement strategy. I told the group of a recent study in the VA hospital system that demonstrated no improvement in 30 day readmissions despite the use of an integrated electronic information system and robust multidisciplinary discharge team follow up. Researchers had concluded that the reasons why patients with chronic illness were readmitted within 30 days were complicated and multifactorial, not simply the result of poor physician or hospital staff practice.
Gnashing of teeth followed shortly thereafter.
The cars in front of me begin to move slowly , the earthy aromas of fall mixed with automobile exhaust, directing my attention to a group of 3 people standing at the corner ahead. As the traffic halts again, I recall a few conversations of the day.
10:30 am. Our team spent the past 4 days taking care of a 53 year-old lady, Ms. M, suffering from schizophrenia, admitted to our hospital after a fall and syncopal episode. This was her 3rd admission to a third different hospital within the past 6 weeks. She had undergone extensive cardiac and neurological testing during the previous two hospitalizations, yet she was discharged back to her personal care home (PCH) with no follow up with a PCP (primary care physician), and had not been started on medications for her heart, cholesterol and diabetes as advised during the two admissions. One hospital note from a previous admission stated, “no PCP located, so no one contacted.” Ms M is well on her way toward joining the desperate statistic that the seriously mentally ill in our country die, on average, 25 years younger than their mentally “healthy” counterparts.
Despite the fact she could barely walk with her cane and walker, Ms. M lives on the second floor of the PCH, which has no elevator. Mrs. M felt isolated to the second floor, frequently falling when she tried to negotiate the steps. During this hospital stay, Ms. M worked with neurologists, physical and occupational therapists to optimize her ambulation. Our team contacted a community mental health organization to confirm guardianship arrangements and to ensure that care management services would be in place. We also notified Adult Protective Services to help monitor her care while new housing arrangements could be made. The resident and medical student spent several hours making phone calls and networking with these agencies, even locating a PCP (Primary Care Practitioner) who would assume responsibility for her care upon discharge.
After all these efforts to care for Ms. M and hopefully prevent another early readmission, we were informed later in the afternoon by her insurance company that the last two days of her 4 day admission would be “denied” and not reimbursed. Time consuming appeals processes would surely follow.
During our afternoon rounds, I reminded the team that today was the first day Ms M smiled. I told her I enjoyed her change in demeanor, and Ms. M told me in a flat affect, without a trace of irony, “I like to smile.”
The line of cars begins to move again. It’s so warm, I may be able to wear shorts one last time this fall if I can make it to the park in time for my run.
12:30 pm. The medical student and I spent 20 minutes convincing Mr. G, a 42 year-old Cubs fan (obvious from the baseball hat constantly affixed to his head the previous 3 days) , that he should not smoke cigarettes prior to surgery the following day. Mr. G had been admitted with a partial bowel obstruction, and was understandably restless. He told us he wanted to go for a walk outside to enjoy the sun, and really just wanted a smoke to unwind. After complaining about the bowel preparation for surgery, too-soft mattress and incessant beeping noises that kept him awake the night before, he promised not to smoke if we would just let him go outside. We acquiesce.
I’m getting closer to the last stop sign before I leave the hospital campus and head home for my run. I guess there are 30 minutes of daylight left. As I approach the crosswalk, the 3 people standing on the corner are becoming familiar to me.
2:45 pm. The intern and I walk into the room to talk to Mr. B, a 62 year-old man admitted for the 4th time in the past 3 weeks, complaining of worsening abdominal pain due to chronic alcoholic pancreatitis. He was transferred to the medical floor from our emergency room, his 36th visit to his 4th hospital, in the past 9 weeks. As we enter the room, we are greeted by a shrouded figure moaning and lying motionless in a fetal position, a single scaly dry foot protruding from the bottom of the hospital bed. “Mr. B,” we call to him. His head emerges from the sheet, graying temples framing an angry scowl and half opened eyes. “I want my pain meds,” he announces. The intern explains that we are not going to give him narcotic pain medications, that his laboratory tests are unremarkable and his radiologic findings not too concerning. “I want my pain meds, I told you,” he repeats. The intern and I sit down, and talk to him for 25 minutes. We ask him about his past history of detox and rehab admissions, the revolving door of primary care physicians he has seen and not seen, and his willingness to receive treatment for his depression. Mr. B tells us that he is not suicidal, and names the various addiction specialists and AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) meetings he has frequented in the past. Then Mr. B asks if we are going to give him narcotics on this admission. We tell him we will not, that we would consult pain management specialists and work with him to address his pain and depression without narcotics.
Mr. B rolls his eyes, pulls the sheet back over his head, and swears as we walk out of the room. Shortly afterward, Mr. B signs himself out of the hospital AMA (Against Medical Advice).
I’m pumping the brakes, crawling to a rolling stop as I eye the 3 figures huddled in front of a bus shelter. One of our hospital security officers is sharing a laugh with Mr. G, sporting his Cubs hat and hospital gown. Mr G is pointing toward something in the distance past the rows of stop lights, and he is smoking.
3:35 pm. An infectious diseases specialist stops me in the hall to review a few of our complicated patients. In particular, Mr. K, a 43 year-old man who regularly uses cocaine, was being treated for a badly infected bite wound on his arm sustained while trying to “break up a fight between two dogs.” Though we speculated why he was being attacked by dogs so frequently (this was his 3rd dog bite in the past month), our team was worried about how he would care for his wound when he was discharged. We planned to send him home today, and become his new PCP (Primary Care Practitioner) in order to provide close outpatient follow-up of his wounds, but the infectious diseases specialist wanted to keep him just a few more days in the hospital, suspecting that the patient would “bounce back” quickly with worsening infection if he left today.
After our team agreed to keep Mr. K in the hospital, the infectious disease consultant told me with appropriate concern that he thinks our residents sometimes discharge patients out of the hospital too quickly. We talk about the immense pressures the residents and attending staff face from care managers and insurance companies to discharge paitents with less resolution of their acute illness, in an attempt to avoid denials of reimbursement. As a specialist, he admits that he doesn’t have to deal with these daily conversations defending and rationalizing the care we provide simply to avoid an insurance denial. We speculate with dread about the future of hospitals and our profession as reimbursement is squeezed, patient care acuity rises, and increasingly rapid turnover of patients escalates cross-coverage and communication problems.
A week later, I receive a letter from the insurance company telling me Mr. K’s last 3 days of his 6 day hospitalization, including intravenous antibiotics, wound care, and specialist follow-up, were “denied.”
3:50 pm. I am meeting with our senior resident to review team management strategy, when one of our pulmonary specialist colleagues walks in the staff lounge looking for a bagel. We talk about the upcoming CMS denials of reimbursement for readmissions for certain chronic illnesses and conditions. Of these “preventable” problems, COPD, DVT (deep vein thrombosis) and c.diff (clostridium difficile) colitis are especially meaningful since the pulmonologist co-manages our intensive care unit. “The bureaucrats who came up with this plan have forgotten this important fact: that despite our following all the best evidence-based guidelines for DVTprophylaxis, hand washing, gowning, gloving and alcohol wiping our stethoscopes, and compulsive central line care, there will always be a few patients who get clots, line infections, and c.diff infections. MRSA (methicillin resistant staphylococcus aureus) and c.diff are already widespread in the community, and they will happen here. Despite our best efforts to provide our COPD patients with necessary medications, education, immunizations and nutritional counseling, some patients will always smoke, get sick when the weather gets cold, and experience the unavoidable life stressors that get them in trouble with their breathing. We just don’t have complete control over our patients and their lives. The bureaucrats that impose these regulations forget that shit happens.”
I come to a complete stop at the crosswalk. Mr. G smiles and taps an ash onto the sidewalk. I then realize the third man standing in the group is Mr. B. He is barely recognizable now as he stands there wearing rumpled slacks and a blue overstuffed sweater, throwing his head back laughing with Mr. G and the security officer, slapping his thigh with one hand and holding a cigarette with his other. That salt and pepper hair and scraggly beard confirms his identity. I wonder what they are laughing at, but then again, I don’t want to know.
4:20 pm. One of my family medicine faculty partners and I are talking about our grant-funded, evidence-based integrated behavioral and physical health care initiative, which will help our patients access the mental health services they need on-site in our primary care office. We are excited at the prospect of strengthening our Medical Home and improving the quality of life for our patients and their families, yet we worry that this model of care may not be financially sustainable because there are, at present, no consistently reliable plans to reimburse us for this care among our multiple third party payers.
The “hotspotting” work done by Dr. Jeff Brenner (Camden Health Coalition) in caring for the medically underserved, especially those patients who are “high service utilizers,” demonstrates that patient-centered care not only improves outcomes but dramatically decreases costs. Brenner had identified the 1 percent of patients who account for over 30 percent of health care costs in his community, finding them localized in “hotspots” within public housing and other poverty-stricken locales. One particularly “hot” patient Brenner identified utilized more than3.5 million dollars of heath care services in five years. Brenner and his team of visiting nurses, social workers and community health workers used creative outreach methods to provide care for these patients, preventing unnecessary ER (emergency room) visits and hospitalizations. In spite of this innovative work, Dr. Brenner has also met many obstacles in getting reimbursed from the third party payers who are saving money from his work providing cost-effective, high quality, patient-centered care.
My partner and I discuss the paradox of the public health perspective on Brenner’s “hotspotting” work – that throwing so many resources at the few most costly users goes against the directive of caring for the greatest number of patients with the limited resources that are available. Today, however, our efforts to “bend the cost curve” require not only creative solutions, but new rationalizations of how we care for others, and where our responsibilities for patient care begin and end. Mr. B is clearly one of these “hot” patients racking up immense health care costs unchecked. Could Mr. B benefit from more intense outreach? What team can facilitate change in his lack of insight, his lack of motivation for self-care? And what incentive does any primary care physician have to assume his care? Mr. B would certainly drag down any Pay For Performance (P4P) or quality measure score any physician would hope to attain to demonstrate her worthiness to payors or potential patients. And who would reimburse that doctor for the immense time and effort it would take to help Mr. B change his behavior?
Today, I am only too happy to pass this torch to someone else. But who will take it from me?
I look at my watch. Its 5:03 pm. I have just enough time to throw on my shorts and go for that run. Laying in my hammock is a worthy option also. I drive away from the hospital campus, leaving Mr. G and Mr. B behind, laughing and smoking in my rearview mirror.
We are not health care providers. We are, in fact, health care enablers – the healthy and worried well, motivated to optimize their health, come to us for advice and encouragement. The fortunate insured come to our offices and we enable them access to quality illness care, “health maintenance,” and support. The uninsured, unmotivated or unreachable behind societal and institutional barriers remain hidden and out of touch, meeting us transiently and expensively in crisis, in our hospitals because our present models of care delivery rely on patients to meet us where we are, not where they are. Within our broken system, we enable them to stay expensively out of sight. Health care policymakers and administrators continue to move the responsibility for increasing costs on the physicians and hospitals themselves, implicitly placing the “blame” for illness and bad outcomes on physicians. Meanwhile primary care physicians enable the bureaucracy to continue this expensive shell game as we continue our unheralded and significantly under-reimbursed work in the trenches — too busy to speak out against these injustices, too burdened by administrative obligations, and unable to afford the money or time to implement more creative ways to care for patients where they live.
When physicians and hospitals are “graded” on easy-to-measure outcomes that may or may not be clinically relevant, and are reimbursed only when complicated, often unpreventable bad outcomes don’t occur, the incentive for health care enablers will be to weed out patients with any complicated illness or chronic condition, and to care for only the young and healthy. Many physicians now limit their Medicare and Medicaid patient panels, sometimes refusing to see these patients at all. The sickest and most complicated patients will ultimately end up in safety net practices, like our residency program health centers, as increasingly hospital- and health system-employed practitioners compete for the healthiest and most compliant patients. When will the moral and financial incentives to provide high quality, patient-centered care align meaningfully among physicans, hospitals, payers, and the public we serve?
I arrive at home at 5:17 pm. The sun is just sneaking down past the trees, throwing shadows and reflections across the leaf litter. It’s the glowing end of an Indian summer day. There’s enough time to run.Email This Post Print This Post