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.

Whatever Happened To Nursing Care and Communication?

When I completed my training and joined the staff of our local community hospital to practice General Internal Medicine, every floor was run by a charge nurse. I had learned in medical school and during residency that if you wanted to get things done in a timely manner and get nights sleep while on call, you learned the rules and regulations on Mr. or Mrs. Jones floor and followed them.

In the late 1970’s and early 1980’s when you arrived to make patient rounds, the floor nurse would gather the medication list, the patient vital signs and go with you to the bedside. You would greet the patient, take a brief history, perform an exam and discuss the problems of the previous night with the patient and the nurse. You would receive a direct verbal report from the day shift nurse or departing night shift nurse of the patient’s concerns and the nursing staffs’ insights, thoughts and concerns. By the time you moved on to the next patient you had answered all questions, reviewed all medications, discussed the plans and goals for the day and reviewed the lines of communication .  These nurses had graduated high school and gone on to a two year nursing school. They received on the job training and supervision from senior staff who had been working at that hospital on that floor for decades. These nurses could change a sheet and bedding on a patient immobilized in bed in traction. They took vital signs by holding the patient’s hand and looking into the patient’s eyes and feeling if the pulse was healthy and brisk and if the hand temperature was warm and dry. The therapeutic nature of the hand holding and human touch was grossly underestimated by administrators and economists

In the mid nineteen eighties, as health insurance companies began to rule the care of patients at a discounted rate, things changed. At the local corporate hospital nurses stopped coming to the bedside. In fact they stopped getting a direct verbal report from the outgoing nursing shift.  The outgoing shift left their report on tape recorders for the incoming shift to listen to when they had a chance. Gone was the stability of tenured and experienced nurses replaced by per diem nurses from temporary agencies who could be practicing in one hospital on Monday and four others the rest of the week.  These nurses might be seasonal employees flown in from Scandinavia or Canada to service the increased winter seasonal volume in South Florida. They were no longer great care givers. Most of them were now going from high school to four year colleges to study nursing. Many were then encouraged to go on and get graduate nursing degrees.  Nurses with a four year degree were not looking to empty bed pans, change bedding or even change bandages unless wound care was their designated specialty. Outside the critical care units, they were primarily administrative, directing “aides” with little or no formal school training and no nursing school training. BP cuffs were replaced at the bedside by robots. No longer were hands held to check vital signs. No longer did the nurse have time to go to the bedside with the doctor to review the patient’s progress and identify the problems and goals for the day.

They became so well educated that nursing couldn’t keep them in the profession. They wanted more. They became physician assistants and nurse practitioners so that with their advanced degrees they could be given more clinical responsibility and allowed more clinical decision making. The problem is that they were not given the formal training one need to have to make these decisions. They were not given the arduous clinical oversight of a large volume of cases one needs over a prolonged training period to become a trained clinician.  They were supposed to assist primary care doctors and generalists and expand the ability of our small primary care population to see patients. Unfortunately, these PA’s and NP’s soon realized that there was no money in primary care and most generalists could not afford to employ them anyway. It was much nicer to work for a plastic surgeon and orthopedist and do their entire pre op and post op care so they could stay in the OR and generate more revenue. It was much easier to leave the bedside and go work for hospital administration or a medical equipment manufacturer in sales then become a supervisor of under educated aides while filling out paper work all day long.

I miss the days of going to the bedside with the nurse and the medication sheets. We made fewer errors. The communication and rapport were better. The nurses were our eyes and ears watching and caring for our patients while we were in the office. The technology and training was supposed to improve communication not make it more difficult. I would love to see the two year nursing program for care givers return. We need doctors and nurses going back to the bedside. We need nurses who are allowed to care for patients rather than supervise others and fill out checklists.