The Reality of Skilled Nursing Home Stays

The online journal Medscape published a Reuter’s article on Skilled Nursing Facilities and post hospital stays.  They discussed the often-lengthy time span between hospital discharge and the patient being seen by a physician or “an advanced care practitioner”.

Older, more infirm and cognitively impaired patients tend to be seen later than other patients. Apparently the later you are seen, the more likely it is that you will be sent back to the acute care hospital and be readmitted.  The study was conducted by Kira Ryskina of the Perlman School of Medicine at the University of Pennsylvania in Philadelphia. The researchers looked at Medicare claims from nearly 2.4 million patients discharged from acute care hospitals. Her data indicated that when patients were seen by doctors at the facility soon after discharge they tended to recover more often not requiring acute readmission to the hospital for the same problem.

The author went on to say that most families confronted with a family member requiring post hospital rehabilitation at a skilled nursing home do not know what to expect from a skilled nursing facility (SNF).  The truth is, most doctors who practice in the inpatient setting or in surgical and medical specialties have no idea what to expect. They have never gone into one, unless it is for their own recovering family member, and they have never cared for a patient on a daily basis in one.

My first month as a private physician in 1979, my employer took me to the local facilities to meet the administrators, charge nurses and social workers at the facilities. The medical director was a young internist who had no private outpatient office or practices just a nursing home practice at five institutions he called on.  I was told that the law required me to see new patients within 24 hours of arrival, examine them and write a note and review all orders and either approve or change them.  I was surprised that facilities were staffed with only one registered nurse per 40 patients. The RN was required to pass the medications each shift, with most patients being on multiple medications so that most RNs had little time per shift to do much else but pass the medications.

When a patient had a complication or problem the nursing staff called the family member and the doctor. The volume of calls was so immense that the young facility medical director could not find any physicians who would agree to cross-cover with him on the weekends so he could get some time off.  In most cases, even if I decided the phone call related medical problem could be dealt with at the facility, the family decided otherwise and wanted their loved one transported to the ER. Those of us who cared for patients at these SNF’s joked that the protocol for caring for a problem was to call 911 and copy the chart for transfer.

It used to disturb me that EMS services were being diverted to these facilities for non-critical issues taking them away from true emergencies, and delaying response times, but they seemed to like it.  The more trips they were called on, the more evidence they could present for a larger share of the city or county budget.

At some SNFs there was always an EMS bus or ambulance sitting in the parking lot outside.  The patients were insured by Medicare guaranteeing bill payment so the receiving Emergency Department and staff were happy as well.

We were required to see the patient monthly and write a note. I saw sicker and less stable patients more often than monthly.  Progress in rehabilitation was discussed at mid-day care planning conferences that the physicians were rarely made aware of.  My goal for discharge was when the patient could safely transfer from the bed to a walker or wheel chair, get to the bathroom and on and off the toilet safely and; get in and out of a car. If the family could convert their home into a “skilled nursing facility” the patient could go home as well.  Often the patient was sent home by the facility “magically cured” when their insurance benefits ran out.

Most of the work at the facilities is performed by lower paid aides. In my area of practice most of the aides are men and women of color from the Caribbean who have little in common with the mostly Caucasian elderly population they care for. The work is hard and the pay low with the employee turnover rate extraordinarily high annually at most institutions. The patients are elderly, chronically ill, often with impaired cognition, hearing, and vision. Their family’s vision of what should be done is vastly different from what can be accomplished.  I believe most of the staff are caring and well-meaning just under staffed and under trained.  Administrations concerns about liability from medical malpractice, elder abuse and other issues is well founded based on the plethora of ads on prime time TV, newspapers and the sides of travelling public buses touting law firms seeking elder care cases.

It is now harder and harder to actually see patients at these facilities even if you wish to.  While community- based physicians with local hospital privileges were once welcomed and encouraged to attend to their patients at the facility, now the facilities require doctors to go through a lengthy credentialing process – as if you were applying for hospital staff privileges.   When you actually show up and care for your patients you rarely see a physician colleague. Most of the care is assessed and provided by nurse practitioners and physician assistants working for physicians who rarely, if ever, venture into the facilities. They may supervise the care plan on paper but rarely lay eyes or hands on the patient.

These facilities serve a vital role in the post-acute hospital care of patients. According to this study and article, Medicare spent $60 billion dollars in 2015 on this care. When a hospitalized patient has a frail spouse or no spouse at home, with no local nuclear family able to provide home care, the SNF is the only real option.

I suggest families visit the potential choices first. Speak to patients and their families about the care and services.  Review online state inspection and violations records. Ask about the transition from the hospital to the SNF. Who will be responsible for caring for them at the facility?  Meet them and talk to them. Make sure you are on the same page. If you can find a facility that has an onsite physician team with a geriatrician as the chief medical provider.  It may be the best option.

For these transitions to work and save money by stopping the revolving door form hospital to SNF to emergency room for every medical question, the SNF’s need some form of sovereign immunity from frivolous lawsuits if their services and care meet the legally required standards. The recent post- hurricane heat-related tragedy at a Hollywood, Florida nursing home underscores the need for vigilant inspection and regulation of this industry. The good homes need to be identified and need to be given the support and latitude required to care for this ever increasing portion of our American society.

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Why the Medicare System Can Not Stay Solvent

My spry 90 year old patient decided she had a urinary tract infection two weeks ago. She had difficulty urinating and the constant urge to void with no fever, no chills, no back pain, no bloody urine. She was advised to come in for an appointment the same morning but this didn’t suit her. The alternative choice was to see her urologist who made time available that same day. She decided this was not convenient either. I called her and took a history and attempted to negotiate a visit but she declined strongly. She chose to void into a sterile container she had at home, put it into the refrigerator for storage and start to take some ampicillin that had been prescribed for her last urinary tract infection weeks before. One day into the ampicillin therapy she had her full time aide drop the urine off at the office for a culture and analysis (It came back negative for an infection several days later). That night she could not void. She called the urologist and the covering doctor suggested she drink more water. She complied even after she developed nausea and vomiting which continued into the early morning hours. Her aide called 911 and EMS brought her to the emergency department.

This frail elderly woman has not been eating well for months. As her total protein drops and her activity diminishes decreasing her leg muscle tone, her lower extremity peripheral edema or swelling increases. Her veins drain less efficiently than in the past contributing to the swelling. She suffers from a chemical electrolyte regulatory abnormality with chronic low serum sodium. Vomiting electrolyte rich material and replacing it with electrolyte free water further diluted and lowered her serum sodium. Upon arrival in the Emergency Department, the ED physician noticed the swelling in her legs and reflex ordered a Congestive Heart Failure (CHF) lab panel. The government (CMS) has made such a big deal about recognizing CHF that physicians and hospitals are afraid to not recognize it and not treat it. If you don’t treat it there are financial penalties for the docs and the institutions. The CHF panel consists of expensive and sensitive heart muscle enzymes that elevate in a heart attack, a lipid profile and a BNP which elevates in CHF. The problem is that the heart enzymes and BNP elevate in a host of chronic conditions seen in the elderly unrelated to heart failure.

I was called into the hospital to evaluate and admit the patient in the middle of the night. A Foley Catheter was now inserted into her bladder and draining fluid. Steps had been taken to slowly correct her sodium abnormality. A urine culture was sent with the initial catheterized urine and the evaluation of her heart based on “indeterminate” heart enzymes was completed. She did not have a heart attack. She was not in heart failure. Her serum sodium rebounded slowly with a treatment called fluid restriction. Three days later she was voiding without the catheter, ambulating with her walker and aides assistance and ready to go home under the care of her aide and two daughters. She was scheduled to see me in 72 hours with the urologist to follow.

I called her the next day and she was doing fine. The next morning when I called she was constipated so we instituted a program which using over the counter medications corrected the problem. At 3 PM the next day she called my office and left a message that she wanted to speak to me. My nurse asked her if she was sick and she just repeated the need to talk to me. I called her when I finished with patients and she told me, “I am dying. I am very sick. I feel like I have to pee and I cannot. I have called 911 and I am on my way to the hospital.” When I tried to determine what the definition of “very sick” meant she couldn’t elaborate. She was not febrile. She had no chest discomfort or shortness of breath, she just couldn’t void. I called the ED and spoke to the head nurse and physician and reviewed her recent clinical course and findings. One hour later they called me to tell me she was in urinary retention and her bladder was overloaded. They placed a Foley Catheter in her bladder and ¾ of a liter of urine emptied relieving her discomfort and very sick feeling. The problem was that the ED physician saw her leg edema and sent off the CHF Lab Protocol again. This was a different ED physician than the week before. This time the Troponin I cardiac enzyme marker was in a higher in determinant range. “Steve,” he said, “her EKG is abnormal. I think she is evolving a myocardial infarction and needs to be readmitted.” I reminded him that we had completed this exercise last week with her long time cardiologist and her heart was fine. He told me he didn’t care. The risk medical legally was too high to send her home. The costs and hospital stay now start again.

This patient had daily 24 hour care by an experienced aide. Both her college educated adult children were with her. She had my office phone and cell phone as well as access to the very flexible urologist. She still chose to do it her way relying on EMS and Emergency Departments due to fear, anxiety and having no financial skin in the game. The urologist wondered why she didn’t just call him and he would have reinserted the catheter in his office. I wondered why she just didn’t call earlier so we could see her before my staff left for the evening. It didn’t matter if we were capitated, being paid for quality metrics or if the fee for service system was abolished. This strong willed independent complicated ancient senior citizen was determined to do it her way. The system runs on algorithms and protocols and generates information routinely that requires a common sense interpretation based on the clinical setting and issues. The risk of medical malpractice despite government funding this care plus the risk of government sanctions based on chronic disease protocols makes intelligent and compassionate care which is affordable almost impossible.

MRI Use in the Detection of Prostate Cancer

As men live longer the likelihood of them developing prostate cancer increases. Some experts estimate that if we biopsied the prostate of every male 80 years old or older, we probably would find prostate cancer present in almost all of them.

The PSA test has been shown to be less valuable than previously thought when discovered because it does not distinguish between an elevated level due to normal prostatic enlargement, infection or the presence of cancer.  When it is elevated due to cancer it cannot predict which tumors are aggressive and require aggressive treatment and which tumors are non-aggressive or indolent and can just be watched.  For this reason, CMS or Medicare and the United States Preventive Task Force are opposed to PSA use as a screening test.

To deal with these issues, Robert K. Nam MD, MSc, chairperson of genitourinary oncology and professor of surgery at Sunnybrook-Health Sciences Centre in Toronto, Canada has published a small preliminary study in the Journal of Urology on the use of MRI (magnetic resonance imaging) to predict the presence of and the aggressive status of prostate cancer disease.

They recruited men who knew they would be undergoing a PSA test, a MRI of the prostate and a prostate biopsy. Their preliminary results show that the MRI was a better predictor of the presence of prostate cancer than the PSA.  It was also felt to identify how aggressive the disease was which influenced treatment options offered. It was additionally felt to be very accurate in identifying when no prostate cancer was present.

Small numbers of patients were entered in this pilot study. A larger randomized controlled study is now in the planning stages to further clarify these initial findings.  At the same time in our community some of the urologists are now ordering MRI scans to elucidate what is causing an elevated PSA in individuals who have a non-diagnostic digital rectal exam and an elevating PSA.

Antibiotic Associated Colitis Increases Risk

At least a half dozen times per week patient’s call with symptoms of a viral upper respiratory tract infection or present to the office for a visit with symptoms and signs of a cold.  These illnesses are caused by small viral particles which do not respond to antibiotic treatment.   Your body’s defense system attacks these viral particles and over a period of hours to days defeats them.   Despite years of ongoing public health announcements and handouts by doctors and nurses and attempts at patient education you find yourself negotiating with strong willed patients who want a “Z Pack” or some other antibiotic which they do not need.  “I know my body,” they argue.  “My northern or previous physician knew to always give me an antibiotic, why won’t you?”

The answer is quite simple. They do not work to shorten the course, intensity or duration of your illness. They do in fact put you at risk of developing complications of antibiotic use. When your infection requires the use of antibiotics to restore health, it is worth taking these risks. When you do not need the medication it definitely is not. This was confirmed by an article and research presented by E Erik Dubberke, MD of Washington University School of Medicine in Saint Louis, Missouri commenting on Medicare Data about the death rate associated with antibiotic related colitis infections due to Clostridia Difficile.  Bacteria normally reside in our large intestine and promote health and digestion.  When we prescribe an antibiotic it kills off the healthy and beneficial bacteria as well as the infection related bacteria. This destruction of healthy bacteria creates an environment conducive to “opportunistic “bacteria normally suppressed by the normal flora to invade and take over your gut. The resulting fever, cramping, diarrhea with blood occurs as the intestine become inflamed with colitis. One of the common opportunistic pathogens is Clostridia Difficile.

Dr. Dubberke looked at Medicare data and compared 175,000 patients older than 65 years of age and diagnosed with Clostridia difficile infection and compared them to 1.45 million control patients. He found that those with clostridia difficile infection had a 44% increased risk of death. When comparing admissions to nursing homes for treatment there was an 89% increased risk due to antibiotic related colitis care.

Antibiotics are wonderful when appropriate. They will always carry a risk of a side effect, adverse reaction or complication which is a risk worth taking in the correct setting.  It is clearly not worth the risk when your doctor tells you that it will not work.

How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?

There is No Hope for Ending Medicare Fraud

South Florida is apparently a hotbed for criminal Medicare fraud. It is easy theft with crime rings accessing Medicare numbers of the elderly in Dade County and Broward and setting up durable medical equipment companies that bill our local Medicare subsidiary for equipment that doesn’t exist. Having said that, yesterday I received a Medicare Summary of Benefits letter for my mother at my home. She is almost 90 years old and my brother and I are her legal guardians and handle all her financial affairs while she resides in a skilled nursing facility in northern Palm Beach County, Florida. We moved her to this excellent campus in May of 2015 from a facility in Broward County and by submitting a change of address notice to the US Post Office, all her mail now comes to me. The official Medicare Benefits Summary stated that on September 11, 2015 a claim had been received for a wheelchair for my mom for $280 from a durable medical equipment company in Miami, Florida. The ordering physician was her former physician at her former Broward County skilled nursing facility. I thought it was strange that a bill would be submitted for a wheelchair four months after she was gone from that facility so I tried to reach the doctor. I was told that he was no longer at that facility. I next called my mom and asked her if she had received a new wheelchair in the last few months and she just did not remember if she had or not. I had no knowledge of it but the move from one facility to another accompanied by closing down her apartment in the assisted living section had been tumultuous and disorderly.

I then called the Medicare Fraud number listed on the piece of mail, 1-800- Medicare. The call was answered by an automated attendant who did not list “Fraud Report” as one of the choices so I pressed 5 for “other.” I was placed on hold for five minutes and a pleasant gentleman asked me why I was calling. I explained and he politely asked me to please hold on. Another five minutes elapsed before he got back on the line and apologized for the delay. He started asking me personal questions about my mother for security purposes such as her address, phone number, date of birth, Medicare number. He then asked me to hold on while he prepared a report and another seven minutes elapsed. He told me he would be transferring my call to a supervisory claims officer and I held on again.

It took five or more minutes before a woman got on the phone and repeated the same questions I had already been asked and answered. I tried to explain the purpose of the call and my relationship to my mother but she politely silenced me and told me that she had the original agent’s summary and knew the reason for the call. She asked me to hold on while she looked up the claim and another ten minutes elapsed. When she returned she told me that Medicare paid durable medical equipment claims monthly for up to twelve months and possibly this was a late claim for a 13th month. I then asked her what type of non-motorized wheelchair could possibly cost 12 X $280. I explained to her that all I was interested in was reporting a suspicious claim. She told me that without me forwarding her a copy of my Power of Attorney form she would not be able to reveal any claims history information to me. I told her I wasn’t asking for her to reveal any information but was just trying to report a suspicious Medicare claim. She responded that the claim had been denied and not paid so why was I making such a fuss in the first place. Having invested almost an hour trying to be a responsible citizen I gave up. If this is the type of system we as citizens put in place and tolerate then we deserve to be ripped off!

2015 Changes in Medicine for Medicare Patients

CMS, the parent organization for the Medicare program has decided to reduce health care costs. One method for reducing health care costs is to pay a flat bundled fee for services to one entity and let that entity worry about how to pay for all the services and equipment. CMS first venture into this practice in the State of Florida begins shortly with Medicare deciding to pay one flat fee for knee and hip replacements. In our local area they will pay Boca Raton Regional Hospital (BRRH) one time. The hospital is expected to provide physicians, nurses, pharmaceutical goods, the orthopedic appliance (the hip and knee) and all related costs including your postoperative stay in a rehabilitation facility and physical therapy. If a patient has a medical complication of the surgery, or the surgeon needs consultative physician assistance, that too is covered in the bundled fee.

This means that your orthopedic surgeon will either need to be an employee of Boca Raton Regional Hospital or a contracted physician at an agreed upon price for that service. For several years now, CMS has been encouraging hospitals and health care organizations to organize into Accountable Care Organizations (ACO’s) which would receive the bundled payments and distribute them according to a formula they devise internally. The ACO’s have formed in most parts of the country, but Florida remains as a stronghold of fiercely independent physicians primarily in the medical and surgical specialties that are procedure oriented and generate large revenue streams. They have seen hospital systems like Boca Raton Regional Hospital purchase physician practices and try to run them at least twice in the last 25 years. In each case the hospitals lost large sums of money, the practices ran inefficiently and were returned to the physician owners as a means of cutting their losses. Over the last few years, in addition to building many new facilities , BRRH has been buying up local physician practices and employing the doctors in primary care ( Boca Care), hematology oncology ( Lynn Regional Cancer Group), plus their hospitalist service, emergency department physicians ( who additionally staff their community Urgent Care Centers) pathologists , anesthesiologists and others. By accumulating so many of the formerly private physicians’ as employees or contracted help, they were able to change the structure and bylaws of the medical staff rules and regulations and bylaws allowing the hospital administration to effectively eliminate a checks and balances arm of decision making that protected patient and physician interests.

When you enter the hospital for a knee or hip replacement, it is unclear if your personal physician will be paid by Medicare for seeing you if that physician is not a member of the Accountable Care Organization or an employee of the hospital. A non-employed, non-contracted consulting doctor may possibly bill the patient privately for their services but it is unclear whether Medicare will pay the doctor if they accept assignment, or reimburse the patient if they pay privately and submit the receipt to their insurances for reimbursement. CMS plans to bundle payments for 30% of existing conditions by 2017 and over 70% by 2023. These changes are part of the Affordable Care Act or “ObamaCare”.

I will continue to see my patients who need a hip or knee replacement and develop a fair payment option for them. This will apply to any future bundled service CMS implements as well. My patients will continue to be cared for by me! Experienced local physicians have a healthy distrust of the hospital as an employer based on their past track record. Younger physicians coming out of training with large educational debt and a desire to balance their lives by working regular shifts are more willing to accept employment positions and work for the ACO’s. The goal of the Federal Government is to reduce health care spending by fiat rather than by natural market forces. As the Baby Boomers age and develop more chronic conditions and require more care It seems to me that physicians will need to spend more time with these complex patients rather than less time in short conveyor belt type visits being advocated CMS and current health care policy makers. Feel free to contact me if you wish to discuss any of this.