On July 23, the New York Times ran a Judith Graham essay, "At Too Many Hospitals, a Revolving Door," dealing with what has been a wonky subject until health care costs got so out of hand -- patients coming back a second time for problems supposedly resolved with their original hospital stay.
Graham cites the New England Journal of Medicine for the overview. They studied data from 2004 and concluded that while 20 percent of Medicare beneficiaries returned with the same diagnosis within 30 days, alarmingly a full third came back within 90 days and half within the year. In between only half the patients saw their doctor. Costs to the taxpayer: $17.4 billion. The study cites "gaps in follow-up care" as the primary cause for returns.
Graham's anecdotal evidence reveals patients, when discharged from hospital care, still being confused by their medications, not being contacted by phone for follow up, and without a point person tracking their post hospital recovery. Result: most often, discharged patients and their families are in the dark about what comes next.
So, don't hospitals have "case managers"? Yes, they do, with nursing and social work backgrounds. And it was once their role, as their job title implies, to help recovering patients navigate through doctor's appointments, home health, questions about meds and treatments, and other anxieties of going home from the hospital. But these pros have been co-oped by Medicare to put together picture-perfect records of the patient's stay for audit and reimbursement. Case managers now spend their hours collating documentation from nurses, doctors, therapists, labs and radiology, to establish that everything possible has been done to heal the patient. They comb through the medical records dotting every i and crossing every t.
I used to wonder where case managers hung out, until one day in Santa Fe I opened the wrong door on the administrative hallway to a scene out of Man in the Gray Flannel Suit: rows upon rows of case managers diligently plowing through medical records at desks arranged with military precision.
They, like the doctors, may -- or may not -- pay a ritual visit to the patient and family before the patient leaves. Mostly, patients are handed off to their nurses for final instructions. Often the decision to discharge is made because the "expected disease pathway" has been met and the bed is urgently needed. (The hospital is paid for this, and results are not part of reimbursement calculations.) Driven by the time consuming demands of paperwork, my practice -- and the norm -- is to allot 10 minutes to get the patient in a wheelchair and headed to the elevator.
A "discharge" involves rounding up new prescriptions left in the patient's binder by the physician (racing to his next task) and a printout of condition-specific instructions, written in obtuse language decipherable only by post-graduates. The most important piece of paperwork by far is that single sheet of legalese with all of the instructions and medications. The heart of this chore is to persuade the patient to sign off on this, the document that will stand up in court.
Nurses are left with this assignment because they have established elements of trust with the patient at a vulnerable time in his or her life, and get to be the Judas goat who leads them out the door. Likely the nurse is well aware that the patient doesn't know what questions to ask or quite how to shift gears from dependency on professional staff to solo flight.
Predictably, as night follows day, patient returns are high. Readmissions are very profitable for the hospital. Essentially, they get paid twice for the same job. Moreover -- already knowing your susceptibility to antibiotics, your allergies, your baseline lab values and how you take your coffee -- the job is so much easier the second time around.
Distressed by the recent public discussion of this situation, the Center for Medicare Services has announced that they are going to tighten the noose on readmissions. They will start with a 1 percent penalty on the redo.
Whether that will send a shudder down the spines of hospital administrators is another matter.
Let's say you are an auto mechanic, and you don't get it right the first time. The fuel line still leaks or that noise in the front end comes back after a week. You kept a record of everything you did, though, and get your full payment of $100.
Huffy, the owner, then demands you take a lesser payment of $99 for your second try.
Tell me the truth, now, would you feel like you were getting screwed?
I doubt it.
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