Wednesday, January 6, 2016

Checking Out?

As one who experienced this personally, the premature early release, summarily dismissal while still quite ill shows that it is not just an issue surrounding the elderly with regards to Medicare. It is towards anyone who falls through the cracks in the Medical Industrial Complex. You can be insured but the dance between the provider of your care and carrier often determines the care or lack thereof or simply the lack of an advocate to explain what your choices are, the idea of a second opinion and of course the actual state of your health that makes cognitive rational decisions impossible.

The comments with regards to the article  are in the 100s with regards to how the profit margins in hospitals determines care.   And I have reprinted one doctor who is challenged by another with regards to care and admission and another from a woman who discusses her care overseas.

I'm an emergency medicine physician at a large academic hospital and I can assure you that the decision to place a patient under "observation", while financially beneficial to the hospital, is also done with the best possible intention for the patient.

If you come to the ER, there are three possible outcomes - you get discharged, admitted, or placed in an "observation unit". These observation units are specifically designed for close monitoring and treatment of patients who are not ready to be discharged after a few hours in the ER but who likely won't require a full admission. These are typically asthmatics and congestive heart failure patients who need an extra day or so of treatments, low-risk chest pain patients awaiting further testing, acute infections requiring a few doses of IV antibiotics, and other similar conditions. Insurance, and medicaid and medicare in particular, won't pay for these as inpatient admissions, so without an observation unit, patients with these diagnoses were previously left lingering in the ER overnight - sometimes in a hallway stretcher - instead of a dedicated, monitored unit. In situations where the patient still isn't stable for discharge after 48 hours, they then get upgraded to a full admission. While not ideal, I have found this to be a great solution for conditions that fall into the "gray zone" of medical necessity.
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I am a cardiologist in private practice for 25 years and the son of 4 elderly parents. I disagree. The observation status is to the benefit of the hospital so that it is not coded as a re admission and to the detriment of the patients financially who are not told that insurance will not cover the cost of any meds supllied by the hospital during the observation period etc. Good luck expecting an elderly sick pt to understand the financial ramifications of observation status which is not explained to them any way. I have seen my inlaws get bills for medication ino observation status in the thousands of dollars due to the usual inflationary mark ups of hospital meds. TOTALLY UNFAIR. You are incorrect also to imply these pts were previously kept in the ER. They were admitted. As an academic ER physician who does not maintain long term patient relationships with patients as I do, and who is employed by the hospital system that benefits, your comments are clearly not advocating for patients, just the opposite. 
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If you move overseas legally (I have), you can generally get lifetime national health care from your new country for both emergency and non-emergency coverage for the cost of your residency application. After moving overseas, I had full access to national healthcare within only a matter of days. Amazing!   The American system is so bad, Americans convince themselves that healthcare simply can't be good elsewhere. This is patently untrue.   At the end of the day, a country can prove to provide quality not-for-profit healthcare for its citizens, or it can choose to not.

The 72 hour rule dictates most care regardless of how you were admitted, your diagnosis and your age. It is about money and of course insurance, but the reality is money and that those willing and able can have longer stays and better care (although I question that given the nature of the profession which veers on idiocy regardless).  But for the great unwashed you are out  and this in turn risks  health and recovery.   Ask new mothers about being shown the door within 48 hours after giving birth.  There is your post partum depression.

Then you have the bias, the level of incompetence, the push for turnover and the reality of the poor level of communication between staff with regards to the patient and their needs once released. If one can receive proper care are cheaper rates it seems plausible of course that means that interim care facilities are capable, and in the comments was another story about how that was so insufficient that it too lead to readmission and near fatality and the reality that for some seniors that burden cannot be met by the caregiver they are released to as they too are infirmed or delicate in health themselves. Or even verifying that said person exists and they are willing and able to do so.   It goes on and on the stories about the neglect and abuse at the hands of the Medical Industrial Complex. Hospitals are hotels with a 72 hour limit and then they need you to check out.

But in some cases you will be like the Terminator, you will be back.


The Hidden Financial Incentives Behind Your Shorter Hospital Stay

Austin Frakt
THE NEW YORK TIMES
THE NEW HEALTH CARE
JAN. 4, 2016

After one of her operations, my sister-in-law left the hospital so quickly that she couldn’t eat for days; after other stays, she wasn’t discharged until she felt physically and mentally prepared. Five days after his triple heart bypass surgery, my stepfather felt well enough to go home, but the hospital didn’t discharge him for several more days.

You undoubtedly have similar stories. Patients are often left wondering whether they have been discharged from the hospital too soon or too late. They also wonder what criteria doctors use to assess whether a patient is ready to leave.

“It’s complicated and depends on more than clinical factors,” said Dr. Ashish Jha, a Harvard physician who sees patients at a Boston Veterans Affairs hospital. “Sometimes doctors overestimate how much support is available at home and discharge a patient too soon; sometimes we underestimate and discharge too late.”

Changing economic incentives — which are not always evident in individual cases — have also played a role in how long patients tend to stay. Recent changes to how hospitals are paid appear to be affecting which patients are admitted and how frequently they are readmitted.

What is clear is that hospital stays used to be a lot longer. In 1980, the average in the United States was 7.3 days. Today it’s closer to 4.5. The difference isn’t because hospitalized patients are becoming younger and healthier; by and large, today’s patients are older and sicker. Yet they’re being discharged earlier.

One big reason for the change came in the early 1980s. Medicare stopped paying hospitals whatever they claimed their costs were and phased in a payment system that paid them a predetermined rate tied to each patient’s diagnosis. This “prospective payment system,” as it is called, shifted the financial risk of patients’ hospitalization from Medicare to the hospital, encouraging the institutions to economize.

One way to economize is to get patients out of the hospital sooner. The prospective payment system pays a hospital the same amount whether a Medicare patient stays five days or four. But that extra day adds costs that hit the hospital’s bottom line.

So it’s in a hospital’s financial interest to encourage doctors to discharge patients sooner. A physician who practices at a Boston-area teaching hospital told me that hospital administrators exert social pressure on doctors by informing them that their patients’ stays are longer than that of their peers. It’s now easier for doctors to discharge patients sooner to a skilled nursing facility — where they’ll be monitored and professionally cared for — because so many more of them have been built in recent years.

Almost since the prospective payment system started, experts have raised concerns that it would lead to higher rates of readmissions. After all, patients discharged more quickly may tend to be sicker, more prone to complications or require a level of care that’s harder to provide outside the hospital. It seems logical, therefore, that more of them would need to return to the hospital. Evidence backs this logic. In the United States and other nations, when lengths of stay decline, readmissions rise.

Until recently, hospitals did not suffer financially when a patient was readmitted, so long as it was more than 24 hours after discharge. Indeed, readmission represented only additional revenue. If reducing lengths of stay increased readmissions while decreasing costs of each stay, hospitals benefited financially on both ends of the equation.

Medicare Recovery Auditors have reclaimer over $3 billion from hospitals in the last 5 years because Medicare patients were

But Medicare and private insurance companies picking up the tab lose money when a patient is readmitted. In some cases, a longer initial hospital stay that avoids a readmission is worth the additional upfront investment.

The federal government has created several new programs that penalize hospitals for readmissions. Under Medicare’s Hospital Readmissions Reduction Program, hospitals now lose up to 3 percent of their total Medicare payments for high rates of patients readmitted within 30 days of discharge. This fiscal year — the fourth one of the program — Medicare will collect $420 million from 2,592 hospitals that had readmission rates higher than deemed appropriate.

Since 2010, when almost one in five Medicare hospital patients returned within 30 days, hospital readmissions have fallen considerably. Though this fact was highlighted by the Obama administration, some people are seeing evidence that hospitals are gaming the metric. For instance, patients who are placed under “observation status” are not counted in the readmissions metric even though they may receive the same care as patients formally admitted to the hospital. Likewise, patients treated in the emergency room and not admitted to the hospital do not affect the readmissions metric either. As readmissions have fallen, observation status stays and returns to the emergency department after a discharge have risen.

“When asked by hospital administrators to keep patients in observation status, many physicians comply,” Dr. Jha told me. “Some hospitals’ electronic medical systems will alert emergency physicians when a patient has been recently discharged, and they’re encouraged to keep them in the emergency department and not readmit them.”

The influence of hospital financing is hardly perceptible to an individual patient. But the record is clear: Financing matters, and it affects both hospital admission and discharge decisions.

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