Medicare, if you only knew…

The following guest post was written by Aimee Seidman, M.D., FACP.  Dr. Seidman is an award winning internal medicine physician in Rockville, MD, a suburb of Washington, D.C.

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If I could have a penny for every dollar I saved Medicare, I’d be rich. As a concierge physician, my patients can expect advocacy that stretches from the office to the home, hospital, rehab facility, long term care setting, and to the hospice. When I work with a patient, they can expect me to intervene between the various subspecialty physicians or hospitalists involved in their care, spread out my arms in front of them as if ready to take a bullet for them, and defiantly yell “get your paws off my patient until we hear what the plan is”.

How often are x-rays, ultrasounds, MRI’s, cardiac caths, and yada, yada, yada done in patients with a shortened life expectancy, poor quality of life, or clear living will instructions? How often is patient autonomy ignored in the rush to ‘complete work-ups’? Why do we have to work everything up? We need to stop what we’re doing (and stop the cowboys who are shooting from the hip) and think about the patient’s status and whether or not the proposed intervention is appropriate.

The last time I asked one of my 80-101 year olds how aggressively they wanted their medical treatment to be, they said “no way…leave me the hell alone! When my time comes, it comes. Just make a nice party!“  I shudder to think of the feeding tubes inserted and other interventions done in clear violation of a living will, even if that living will is right there with the patient or family members present.

I believe we scare the daylights out of people by telling them all the horrible things that will happen if they don’t consent to treatment plans. But it’s all defensive medicine. “I’ve got to be able to document that I warned them about this horrible death so I don’t get sued”. I suspect non-intervention, comfort measures, and hospice care are rarely offered to families in a way they can hear it. ER doctors and hospital physicians are just doing their jobs-they want to ‘save lives’ (or at least keep them alive until the next shift) and the primary care doctor is never consulted.

What do people think we do, order mammograms all day? Those of us in concierge medicine who have close relationships with our patients know them and their families well enough to expedite decision-making in a way that is medically and ethically appropriate. The whole point of my concierge practice is to first, do no harm (remember that?), allow my late stage Alzheimers disease patient to have a dignified death, and not spend millions of dollars on unnecessary procedures.

Not only that (I’m almost done), if all primary care physicians and the health care community made a conscious effort to inquire about living wills, explain the subtleties, and respect the choices made, fewer people would use ambulances, go to the ER, stay in the hospital, etc.

The other piece to this is the education of families regarding end of life issues, preparation, ethics, and closure. As it is, families deal with guilt, sadness, confusion, and anger when called upon to make these tough decisions or to respect an established living will. Most of us have seen families reluctant to honor a living will because they can’t bear the thought of letting grandpa starve to death.

If consulted about these decisions ahead of time, much of the combat will not occur. So how much have I saved Medicare by avoiding all this unnecessary stuff? Tens of thousands of patients, times a fortune of money, equals a boatload of bucks.

So, do you want to know ways to fix health care?

1.      Tort reform so docs aren’t so paranoid and aren’t playing “cover-your-butt medicine”;

2.      Docs, shut up and listen to your patients;

3.      Stop insulting the community of doctors who want to practice medicine in a particular model labeling them elitist and focus on things that will work (and by the way, most of us have scholarship patients, indigent patients and perform community service);

4.      A national campaign to educate consumers about the importance of living wills and have discussions over details, including family members in the discussion;

5.      Make it clear to the medical community that honoring a patient’s autonomy in the form of an advance directive is their obligation under the law

6.      Do no harm.

Just listen to me and give me a penny for every dollar I save Medicare, then I’ll really be rich.

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Please note, the opinions expressed in this guest blog post are those of Dr. Aimee Seidman, founder of Rockville Concierge Doctors.

Hospital Administration: Spending Your Tax Payer Dollars / Shorting You on Benefits

Last summer my 86 year old father awoke in the middle of the evening with profuse rectal bleeding. He felt weak and dizzy and called 911. The paramedics transported him to the local emergency room at a hospital close to his home – about one hour south of my home.

I call my parents daily to check up on them and learned of the trip to the hospital during one of these calls.  Mom is 84 and wheelchair bound with multiple structural and cardiovascular issues. Dad is 86, a WWII decorated paratrooper with dementia and orthopedic issues that dwarf his other chronic problems. They have an aide for several hours a day that is the glue that holds their lives together in their own home.

No one was home when I called and of course my folks had their Jitterbug senior special cell phone turned off so they were unreachable.   I left several messages and finally about 8:00 p.m. my mom answered the phone, denied that the cell phone was turned off, denied that I had left any messages on her answering machine and told me that dad was in the ER at Memorial Hospital. Her description was quite vague as to what was going on but I did learn that their long-time physician was unavailable and the hospitalist service was caring for him.

I phoned the ER and spoke to a nurse who was nice enough to tell me that he was stable and they were holding him for observation. He had not yet required blood transfusions and they did not know the exact source of the bleeding but he was still in the emergency department and comfortable.  I drove down that evening and saw dad in the ER. The next evening, unable to find his doctor, I drove down as well and saw dad in his hospital room on the medical floor.  He was weak but in good spirits.  I left a note with his nurse to please ask his physician to call me at his convenience and left my office and cell phone numbers.

Two days later I received a phone call from his long-time physician, who had returned from visiting her family to explain what was going on. She said that his gastroenterologist had been in to see him and he was doing well. The next day after some “tests”, dad’s liquid diet was advanced to a soft diet.

At 5:00 p.m. I received a harried phone call from my mother. She told me that dad was being discharged immediately and that if they stayed longer Medicare would not pay for it and my folks would be totally responsible for the bill. Dad had been in bed for four days, had not walked the halls, had not showered or washed himself and had not yet had a bowel movement since admission.

As a board certified geriatrician I realize the importance of these benchmark pre-discharge steps being achieved BEFORE you send a patient home.  It was too late for dad who was out the door and home.   His aide was upset because she leaves at 7:00 p.m. and she felt dad was too weak to get out of bed and walk to the bathroom without falling. I hired a night nurse and put in a call to his doctor.  I demanded that he be evaluated for a stay in a rehab facility until he was able to ambulate or at least send in a physical therapist to help him regain his strength and ability to walk. A few days of bed rest completely de-conditions most senior citizens and the complications of falls, and their prevention, must be addressed to prevent a bad situation from becoming worse.

His physician told me that “he did not meet criteria for home health assistance or rehabilitation stay” because he had been in the hospital for less than three full days.  I was astonished. He had been in the hospital for five to six days by my count.  She told me his first two days in the hospital were not as an admitted inpatient but as an outpatient observation.   By discharging him at 5:00 p.m. he had missed being an inpatient and qualifying for benefits by several hours.

Outpatient observation status is a game hospital case managers and administrators play to bill more money. When a Medicare senior citizen is admitted as an inpatient the hospital receives a bundled total payment based on the diagnosis or DRG.  If the patient is kept in observational status the hospital is no longer limited to receiving a flat rate but can unbundle the charges and bill ala carte for each service rendered.

The Center for Medicare and Medicaid Services (CMS) in its 12/03/2009 bulletin on page 3 defines outpatient observation services as “the use of a bed and possible monitoring by nursing or other ancillary staff, which are reasonable and necessary to evaluate the patient’s condition for possible inpatient admission.”   The decision as to inpatient admission status or observational status is supposed to be made by the patient’s doctor.  The problem is that is as far as it goes. No one at the CMS level has actually delineated criteria for an inpatient or traditional admission or for outpatient observation.

At the hospital level, administration now places a document on each patient chart requiring the physician to defer that decision to the hospital employed case manager who is not a physician. Over the years, hospital administration has diminished the political power of the individual physicians and medical staff to be advocates for their patients by destroying the medical staff bylaws and infiltrating medical staff governing bodies with physicians loyal to, and employed entirely by, the hospital.

The result is a tremendous conflict of interest with no one watching out for the patient.  The hospital then controls the rules and regulations and can even bully staff members into relinquishing decisions on admission status to the hospital employees rather than the patient’s physician.  One of the reasons hospitalist medicine has become so popular is that hospital administrators love the idea of controlling the physician side of care, something that acted like a “check and balance” in favor of patient advocacy when physicians were independent.

I bring this up because at my community hospital, where I care for my patient’s administration, is now attempting to influence doctors to give up the decision-making on admission and cede it to their case managers as well. A note was sent to the entire staff instructing us to not admit patients who do not meet “interqual” criteria for admission but to let their case managers assign them to observational status.

When I inquired about what interqual criteria were, and where “interqual” criteria were listed in the CMS bulletins or Federal Register, I was told they did not exist there.  Once again the fox is watching the hen house.

In these times of deficit spending and economic crisis hospitals are using our tax dollars to bill ala carte at a higher level and limiting senior citizens right to qualify for necessary post-hospital rehabilitative care by making much of their hospital stay “ observational” as opposed to traditional inpatient status.

I wrote a letter to Memorial Hospital about my dad’s stay and asked to see their criteria for inpatient admission.  Just like my local hospital could not produce criteria, neither could Memorial Hospital. I wondered how a frail 86 year old, dizzy, bleeding rectally and on anti-platelet agents to prevent clotting did not meet criteria for hospital admission?  I received a phone call from the Chief Medical Officer at Memorial Hospital months later saying he had reviewed my dad’s case and he was comfortable with their decision-making.

The issue needs to be addressed by patients, family members, legislators and concerned physicians. Hospital administrations are bullying physicians into relinquishing their advocacy and decision making so that they can charge more using the observational status rather than the inpatient admission status. By using this technique the patient does not meet the three day minimum hospital stay to provide post hospital care and treatment paid for by Medicare and the patients supplemental insurance policies. Once the patient’s personal physician relinquishes decision-making power to the hospital employees, they have created a conflict of interest which, if left unaddressed, will raise health care costs and affect quality of the patient’s care.

Hospitalists and Community Physicians- It’s All About the Handoffs

I referred my second patient to a specialty surgery department at a local university center last month. The patient is a practicing physician with severe lower back disc disease and structural abnormalities. He saw a highly acclaimed surgeon who won the patient’s confidence.

I performed the required preoperative evaluation requested by the surgical team, called the surgeon to make sure we were on the same page, and made sure all the appropriate records and labs arrived at the center prior to the patient’s surgical date. Three days after the scheduled procedure I received a phone call after-hours from a nurse at a local rehabilitation facility telling me my referred patient had been transferred from the university center after discharge and requesting confirmation of  admitting orders to their facility for postoperative rehabilitation.

I had not received a phone call from the surgeon or his staff to discuss how the surgery had turned out. I had received no phone call, fax or email telling me when they planned to discharge the patient. I received no communication discussing discharge instructions and medications.  The surgeon is a chief of a department responsible for teaching fellows, residents and students how it should be done. He fumbled the handoff and sent a patient on his way with a bunch of handwritten chicken scratches on a form filled out by a case worker. In the era of cell phones , smart phones , email , faxes , instant messages and tweets it seems like communication between practitioners has gotten worse not better due to lack of effort and failure of practitioners to acknowledge that it is their job to take the time to make the transition smooth and seamless.

The hospitalist program at my community hospital is no better. Physicians employed by the hospital were supposed to “move “patients and facilitate discharges helping the hospital’s financial “bottom line.”  Hospital administration contracted with non-fellowship trained hospitalists to admit patients who arrive through the ER and have no doctor. The hospitalists are only too happy to admit patients of staff members who do not wish to attend their patients in the hospital.

The problem is that the hospitalist do not enjoy coming in at night. When a patient with a hip fracture shows up at our ER, the orthopedic surgeons on call for the ER now believe they are consultants not doctors. They will not admit a surgical case. They want the PCP or hospitalist to do it for them. If a broken hip case arrives after 7:00 p.m. “the hospitalist “admits the patient sight unseen over the phone and then comes in by 7:00 a.m. to see the patient.

Our hospital has some patient unfriendly bylaws. If the ER doctor calls you and says your patient requires admission you have 30 minutes to provide admitting orders over the phone or in person but you have 12 hours to arrive and actually see the patient.  Showing up 12 hours later often pushes the surgery back a day negating the main reason hospitalists were hired. When the patient is ready to leave the hospital it is rare that the facility has introduced the patient to an outpatient physician for follow-up care.  If the patient actually has an outpatient physician it is even rarer that the hospitalist contacts them to discuss the hospital course and discharge medications and instructions.

The system in the Intensive Care Unit is no better. After years of debate and disagreement based primarily on economic issues and turf and privilege battles, administration contracted with a pulmonary group on staff to provide fulltime intensive care physicians. They went out and hired a bunch of young ICU specialists and salaried them.  These physicians run the critical care areas.

I have always favored fulltime ICU physicians in our community hospital because with no interns or residents there are no physicians in the facility after hours. I was a bit surprised when the contract allowed the ICU doctors to go home at 11:00 p.m. leaving no one in the units until the next morning. My first contact with the intensivists came after a weekend away during which my associate covered for me.  He admitted a patient to the hospital with a raging pneumonia.  Since the patient was taking an anticoagulant Coumadin he had to specifically choose an antibiotic that didn’t alter the affects of the blood thinner. Later that first night the patient had some respiratory distress so my associate came in and transferred the patient to the ICU. He called the intensivist and discussed the case in detail.  He made rounds the next day and reviewed the chart and pointed out to the ICU specialist that the antibiotic he had switched the patient to potentiated the Coumadin effect. He suggested checking the clotting study and adjusting the dose of the Coumadin.

When I came in on Monday I found the patient lying in a pool of blood from the rectum. His PT/INR had been elevated the day before and required lowering the Coumadin dose. No action had been taken. His PT/INR on Monday was even higher.  I called the charge nurse and barked out some orders. She reminded me that the intensivist was in charge. The intensivist that morning was a young woman in her early thirties. When I asked her why the monitoring of his Coumadin dose was left unattended she took great offense and answered, “I wasn’t on call this weekend, why don’t you take it up with the doctor on call.  He’s asleep now so I would give it a few hours before you call him.” I gather she wasn’t willing to “take one for the team.”

Within the last six months an editorial in the Journal of the American College of Physicians was critical of hospitalist programs for the poor communication when a patient leaves the hospital and returns to his doctor in the community without communication occurring.  A recent research article in the same journal revealed that patients treated by hospitalists require re-admission to the hospital for some complication of the original problem far more often than if their personal physician cared for them. The ultimate cost to the system was higher. The problem is the communication and handoffs.

Part of the problem is that physicians no longer feel it is their responsibility to contact their peers. In the past, physicians had close knit referral circles and patterns using physicians they trusted and worked well with. Insurance company managed care programs destroyed those referral patterns forcing physicians to use the doctor on the panel or else they would not pay the bill. Often the consulting doctor on the panel was resentful of receiving a consult from a doctor who had never used his services but would now use them at the panels discounted rate. They felt no strong compulsion to contact the referring physician and discuss the case. T

The referring physicians are not without blame either, often sending patients to physicians they have little contact with accompanied by little if any information as to why they were being consulted. A culture of communication and sharing of information professionally became a culture of “I am too busy to make a call.” The one that suffers is the patient and the people paying more for care because of communication breakdowns.

The American Medical Association and the American College of Physicians have supported the development of the specialty of hospital medicine long before I believe they should have. These organizations are heavily dominated and supported by specialty physicians who are paid handsomely to stay in the operating room and perform procedures rather than care for the patients.  Having hospital employed physicians to be their “scut “workers and take care of the patients with their nurse practitioners and PAs makes sense to them. It breaks the link of good continuity of care and just isn’t very good for patients or overall costs.

Legislators, politicians, employers, insurers, medical school faculty keep looking for ways to overcome the shortage of primary care physicians and the large gap in payment between cognitive services and procedural services. The solution to the problem is to pay the primary care physicians well for their evaluation and management services, train them thoroughly and completely and allow them to care for their patients in all our health care venues.

There Is A Malaise Among Us

In my professional life, and on this blog, I have complained bitterly about the orthopedic surgery department in my community changing from physicians to technicians to “consultants” as they now prefer to be called.  These same physicians once aggressively sought out hip replacement patients to admit to their surgical service where they would provide admission, discharge oversight and care.  Now, these “consultants” see the patient before surgery, operate and then turn their patients’ post operative care over to their nurse practitioners, physician assistants and technicians as well as hospital based and employed internists or, the patient’s own medical doctor.

The “consultants” will no longer admit the patient to their surgical service, insisting that the patient be placed on the medical service and, they have taken steps to relinquish their skills in post operative and post surgical wound and general care. They see the patient before surgery, in the OR and several weeks later in the office to check on bone and appliance alignment and to remove the surgical sutures.   I am told the impetus for this change in the orthopedic role is cost and liability and based on specialty specific recommendations of consultants.

Over time, I have seen the post surgical stay reduced from 10 days down to less than four days. Patients no longer go directly home from the hospital.  In most cases, they are sent to skilled nursing homes for rehabilitation and strengthening. I have written about how these overregulated and inspected homes are spending so much money on personnel to keep them in compliance that they can’t afford to staff the facilities to provide skill, nursing and care.

With nighttime patient-to-nursing ratios of 40 residents to one nurse; how can anything get done each shift?   I have written about the conveyor belt / revolving door between recently discharged post hospital patients and the hospital Emergency Department using the 911 system and diverting emergency EMTs from true emergent issues to being a transportation corp.

An article in the Journal of the American Medical Association finally added some credence to my observations. Researchers looked at the subject of Medicare age patients receiving primary hip replacements and hip replacement revisions between 1991 and 2008.  They looked at over 1.4 million primary hip replacements and 348,000 hip replacement revisions. When looking at first time hip replacements they found that mean length of stay dropped from 9.1 days in 1991 and 1992 to 3.7 days in 2008.  This resulted in 20% fewer patients going directly home from the hospital and a 17% increase in patients going to skilled or intermediate care nursing facilities by 2007 and 2008.

The good news is that the overall death rate at 30 days declined from 0.7% in 1991 to 0.4% in 2008.  The bad news is that the rate of readmissions rate for complications of the surgery within the first 30 days rose to 8.5% in 2007 and 2008.

When we look at look at hip replacement revisions, the length of stay declined from an average of 12.3 days to 6 days. In hospital mortality declined from 1.8% to 1.2% but 30 day mortality increased from 2% to2.4% and 90 day mortality from 4% to 5.2%.  Fewer patients were discharged to home in 2008 than 1991 with a resulting increase in transfer to skilled and intermediate nursing facilities by about 17% at the end of the study dates.  When hospital readmission rate was looked at for revision of hips the readmission rate increased by 2007 and 2008 significantly

This data is about real human beings. It means we have not figured out the correct length of hospital stay for this procedure. It may mean that we have reduced the expense for the hospital stay while increasing the expense to the system, patients and family in other areas of health care accounting.

With regard to revisions of hips, more people are dying and more people are coming back to the hospital for readmission than in the past.  Maybe the orthopedic surgeons need to spend more post operative time attending to their patients directly for a longer hospital stay before transferring them to the care of others at a nursing home?

The topic is intensely personal to me especially as we approach Mothers’ Day. During the time of the study my Medicare age mother dislocated her hip repair repeatedly. Each time she was brought back to the operating room, given a whiff of anesthesia and the artificial ball joint was forcibly pushed back into the socket. She would awaken, be given a day or so of rehabilitation and oversight by the surgical assistants and mid level providers and then sent back to the skilled nursing facility for strengthening and rehabilitation before returning home. After each episode her orthopedist would tell me how much force and pressure and strength were required to push that hip back into the socket.

On one of those admissions the hospital physical therapist became alarmed by the fact that the involved leg appeared to be two inches shorter and externally rotated on the last day of therapy. She was having difficulty walking and bearing weight.  She called the surgeon who sent one of his staff to see her in her room prior to transfer. That staff member had never met her. He told her that our hospital physical therapy department was “notoriously inaccurate in measuring limbs.”  He didn’t examine the limb or order an x-ray but transferred her to the nursing facility immediately.

Upon arrival she could not stand up and bear weight. The receiving facility physical therapist requested a hip x-ray. The x-ray showed that she had been discharged from the hospital with the hip still dislocated. The ball could not stay in the socket because the pelvic bone had been fractured during one of the attempts to push the ball back in place.

My mom refused to go back to the same hospital or surgical group and was transferred to another center of excellence for extensive reconstructive surgery.  She has never ever walked independently again.