Category: Inpatient Practice

Suicide is the master thief. He steals from our family, from our friends, and from those that we admire. These are the faces of some of the lives that he has stolen. Although we have greater fear of his brother homicide, suicide takes more lives each year than homicide. Sometimes, suicide slips into our homes after we’ve feared him, after we thought we locked the doors and closed the windows to keep him out. Sometimes, he catches us off guard and we wake up in the morning and find that he’s stolen a life when we least expected it. He doesn’t discriminate by age or race or gender. He’ll strike the rich and the poor, the famous and the unknown, the strong and the weak. He has preyed on men and women for as long as humans have walked on the earth. Many people turn to him hoping that he can relieve their pain but all together too often, the pain goes on just as intensely in those who are left behind. Sometimes he whispers his intentions in our ears before he comes but all too often, we just don’t hear him or we don’t understand what he is saying to us. As physicians, whether we are primary care providers, emergency room physicians, specialists, or hospitalists, we are often in the best position to hear those whispers and to identify patients who are suicidal early on, when intervention can save lives.

Suicide is an enormous public health problem in the United States. It is the 10th leading cause of death in our country and the 2nd leading cause of death in persons age 10 – 34 years old. One American dies by suicide every 11 minutes. But this is not just a U.S. problem. In fact, the United States has just the 37th highest suicide rate in the world, led by Greenland which has the highest suicide rate at 83 per 100,000 population.

There is a gender paradox to suicide: in the United States, women are 3 times more likely to attempt suicide than men but men are 3.5 times more likely to die by suicide than women. Part of the reason is in the gender differences in method of suicide. Men most commonly use guns and women most commonly use poisoning – firearms are considerably more effective as a means of death than poisoning. Overall, guns account for 50% of all U.S. suicides followed by poisoning at 14%, suffocation at 28%, and miscellaneous other methods at 8%.

There are racial differences in suicide with caucasians having the highest suicide rate at 15.85 per 100,000 population followed by native Americans at 13.42, African Americans at 6.61, and Asian Americans at 6.59 per 100,000. Western states and Alaska have the highest suicide rate. Suicide is increasing – in 2001, the U.S. suicide rate was 10.7 per 100,000 population but by 2017, it was up to 14.0 per 100,000 population – a 30% increase in just a decade and a half.

45% of people who die by suicide saw their primary care physician within a month prior to their death. So what can we do in our office practices and our emergency rooms to identify those patients at risk for suicide and get them the psychiatric care that can save their lives? Fortunately, there are easy assessment tools that we can use that will help identify at-risk patients. There are many suicide screening questionnaires available – two that are commonly used in healthcare settings are the ED-SAFE and the Columbia screening tools.

The ED-SAFE tool (click on the attached images to enlarge) was originated as a National Institutes of Mental Health study performed at 8 emergency departments in the United States to determine the impact of suicide screening in emergency departments. It is available free of charge at the Suicide Prevention Resource Center website. It consists of two parts. The first part is the Patient Safety Screener (PSS-3) which consists of 3 questions and can be administer by nurses doing triage in the emergency department. Patients screening positive on the PSS-3 are then asked questions from the second part which is the ED-SAFE Patient Secondary Screener (ESS-3) which consists of 6 additional questions. The responses to the ESS-3 will stratify patients into (1) negligible risk, (2) low risk, (3) moderate risk, or (4) high risk. The risk categories then provide mitigation and recommended care for patients such as 1:1 observation and use of ligature-resistant rooms.

The Columbia Suicide Severity Rating Scale (click on the attached image to enlarge) was created by Columbia University, the University of Philadelphia, and the University of Pittsburgh with sponsorship by the National Institutes of Mental Health. It is available on-line free of charge at the CSSRS website. It was designed to identify those patients at risk of suicide in general settings and healthcare setting and has been endorsed by the CDC, FDA, NIH, Department of Defense, and other organizations. Based on patients responses to 6 different questions, there are recommendations for either (1) behavioral health referral at discharge, (2) behavioral health consult and consider patient safety precautions, or (3) psychiatric consultation and patient safety precautions.

These screening tools are the first step but frequently, a more detailed suicide assessment is necessary and this may require a more nuanced history from the patient. Major risk factors for completed suicide include:

1. Prior suicide attempts
2. Family history of suicidal behavior
3. Mental illness, especially mood disorders
4. Alcohol or drug abuse
5. Access to lethal means of suicide (especially firearms)

There are other risk factors to consider as well:

1. Caucasian
2. Male
3. Divorce or significant loss
4. Traumatic brain injury
5. Physicians
6. Prisoners
7. History of sexual abuse
8. Recent psychiatric hospitalization
9. Attention deficit hyperactivity disorder (ADHD)
10. Lesbian, gay, bisexual, or transgender
11. Self-injurious behavior

But in addition to risks, there are also protective factors that can sometimes offset suicide risks for individual patients. These protective factors can often make the difference between a patient being at moderate risk or high risk of suicide:

1. Family
2. Pets
3. The person’s individual morals
4. Religious faith

Suicide assessment is not just the purview of the psychiatrist. It is up to all of us: emergency medicine physicians, primary care physicians, hospitalists, and specialists. In an era when a hip replacement surgery costs $32,000 and immunotherapy for lung cancer with the drug nivolumab costs $150,000/year, we could save thousands of lives at the cost of just asking a few questions.

November 9, 2019

Recently, one of our primary care physicians was telling me about one of his patients, an 85 year-old woman who had a knee replacement at a different hospital here in Columbus. She was in the hospital for 4 days after her surgery but was very slow to recover and was determined to be unsafe for discharge home without additional rehabilitation so she was discharged to a SNF (subacute nursing facility). She spent a week getting rehab at the SNF and then returned home only to find that she had a bill for the entire stay the nursing facility; Medicare covered none of it. She paid her bills but in doing so, wiped out most of her savings.

 She was a victim of the Medicare 3-day rule.

The 3-day rule is Medicare’s requirement that a patient has to be admitted to the hospital for at least 3 days in order for Medicare to cover the cost of a SNF after the hospitalization. If the patient is admitted for less than 3 days, then the patient pays the cost of the SNF and Medicare pays nothing. So, if this patient was in the hospital for 4 days, why didn’t Medicare cover the cost of the SNF?

It all has to do with when the inpatient stay clock starts and that has nothing to do with when the patient first comes into the hospital for a surgery or a medical condition. It solely depends on when the attending physician entered an order for that patient to be in “inpatient status” as opposed to “observation status”. Medicare considers a patient to be in inpatient status if that patient is anticipated to need to be in the hospital for 2 midnights and in observation status if the patient is anticipated to be in the hospital for less than 2 midnights. Observation status was originally intended to be used to observe the patient to determine whether the patient is sick enough to warrant being admitted to the hospital.

But observation status has evolved into a monster that no longer resembles its original intended form. It no longer matters whether or not the patient needs to be in the hospital, it is now interpreted as the duration of that hospitalization – less than 2 midnights and you are an outpatient and more than 2 midnights you are an inpatient, no matter how sick you really are.

The problem that physicians face is that it is often difficult to predict how long a patient will need to be in the hospital when they first show up in the emergency department for their acute medical illness or in the operating room for their elective surgery. That is why observation status was invented in the first place. However, when it comes to covering the cost of a SNF, since Medicare only counts those hospital days after the physician decides that the patient really does need to be an inpatient. Many patients end up having to pay the cost of the SNF if they spend fewer than 3 midnights after that inpatient order was written, even if they additionally spent several days in the hospital under observation status. Medicare will not count those observation days towards the 3 inpatient days necessary to qualify for a SNF.

Part of the confusion is that even though Medicare won’t count those initial observation status days toward the SNF days, Medicare will pay for the observation status days just like they were inpatient days when it comes to the initial hospitalization. That is because for the purposes of hospital payment, Medicare will pay for up to 3 days in the hospital prior to when an inpatient admission order was placed. In other words, Medicare uses a different 3-day rule in defining inpatient hospital coverage as opposed to defining inpatient qualifying days for SNF coverage.

If a patient is in inpatient status, then Medicare part A covers the entire hospitalization plus all of the medications administered during the hospitalization. However, if a patient is in observation status, then the hospital stay is not covered by Medicare part A but instead is covered by Medicare part B which requires the patient to pay a 20% co-pay for all of the charges plus pay for any medications administered during the hospitalization. Lets take some examples to see how this works for a patient admitted through the emergency department with pneumonia:

1. A patient comes to the emergency department with pneumonia and the physician writes an order for inpatient status when first coming into the hospital. The patient stays in the hospital for 5 days (all 5 in inpatient status) and gets discharged to a SNF.
   • Medicare part A pays for the entire hospital stay plus any related outpatient charges for the 3 days prior to the inpatient order being written (i.e., the ER visit)
   • The patient has no hospital co-pay
   • Medicare part A pays for the SNF
2. A patient comes to the emergency department with fever and cough but the physician is not sure if it is pneumonia at first so the physician writes an order for the patient to be in observation status when first coming into the hospital. Two days later, the physician determines that it really is pneumonia and changes the order from observation status to inpatient status. The patient stays in the hospital for 5 days in total (3 days in inpatient status) and gets discharged to a SNF.
   • Medicare part A pays for the entire hospital stay plus the ER visit and the 2 days in observation status.
   • The patient has no co-pay for the hospitalization
   • Medicare part A pays for the SNF
3. A patient comes to the emergency department with fever and cough but the physician is not sure if it is pneumonia at first so the physician writes an order for the patient to be in observation status when first coming into the hospital. The physician later determines that the patient has pneumonia but does not change the order from observation status to inpatient status until 4 days later. The patient stays in the hospital for 5 days in total (1 day in inpatient status) and gets discharged to a SNF.
   • Medicare part A pays for the last 3 of the 4 days the patient was in observation status plus the day that the patient was in inpatient status.
   • Medicare part B pays pays 80% of the first of the 4 days the patient was in observation status and 80% of the ER visit.
   • The patient pays for 20% of all of the hospital charges for the first observation status day and 20% of the ER visit
   • The patient pays for all of the medication charges for the ER visit and the first hospital observation status day
   • The patient pays for the SNF (Medicare will not cover the SNF since there were fewer than 3 inpatient days)
4. A patient comes to the emergency department with fever and cough but the physician is not sure if it is pneumonia at first so the physician writes an order for the patient to be in observation status when first coming into the hospital. The physician later determines that the patient has pneumonia but forgets to change the observation status order to an inpatient status order. The patient stays in the hospital for 5 days in total (all in observation status).
   • Medicare part B pays for 80% of the entire hospital stay plus the ER visit.
   • The patient pays 20% of the entire hospital charges plus 20% of the ER visit charge
   • The patient pays for all medications received in the ER and during the hospitalization.
   • The patient pays for the SNF (Medicare will not cover the SNF since there were fewer than 3 inpatient days)

Next, let’s see how Medicare applies the 3-day rule for an elective knee replacement surgery:

1. A patient comes into the hospital for knee replacement. The patient has no significant co-morbid medical conditions.  The surgeon writes an order for the patient to be in observation status at the time of the surgery. The patient spends 1 night in the hospital and is discharged home the next day.
   • Medicare part A pays for nothing
   • Medicare part B pays for 80% of the surgery and hospital charges
   • The patient pays 20% of the surgery and hospital charges
   • The patent pays for all medications received in the hospital
2. A patient comes into the hospital for knee replacement. The patient has difficult-to-control diabetes, heart failure, sleep apnea, and kidney failure so the surgeon anticipates that the patient will need to stay in the hospital for more than 2 midnights after the surgery to care for the medical conditions. The surgeon writes an order for the patient to be in inpatient status at the time of the surgery. The patient spends 4 nights in the hospital and is discharged home.
   • Medicare part A pays for the entire surgery and hospital stay
   • The patient pays nothing
3. A patient comes into the hospital for knee replacement. The patient has difficult-to-control diabetes, heart failure, sleep apnea, and kidney failure so the surgeon anticipates that the patient will need to stay in the hospital for more than 2 midnights after the surgery to attend to the medical conditions. The surgeon writes an order for the patient to be in inpatient status at the time of the surgery. The patient spends 4 nights in the hospital but still need more rehabilitation so the patient is discharged to a SNF.
   • Medicare part A covers the entire surgery and hospital stay
   • The patient pays nothing
   • Medicare pays for the SNF
4. A patient comes into the hospital for knee replacement. The patient has difficult-to-control diabetes, heart failure, sleep apnea, and kidney failure but the surgeon thinks that the patient will only require one night in the hospital post-operatively. The surgeon writes an order for the patient to be in observation status at the time of the surgery. After 2 days, the surgeon changes the order to inpatient status. The patient spends 4 nights in the hospital and is discharged home.
   • Medicare part A pays for the entire surgery and hospital stay
   • The patient pays nothing
5. A patient comes into the hospital for knee replacement. The patient has difficult-to-control diabetes, heart failure, sleep apnea, and kidney failure but the surgeon thinks that the patient will only require one night in the hospital post-operatively. The surgeon writes an order for the patient to be in observation status at the time of the surgery. After 2 days, the surgeon changes the order to inpatient status. The patient spends 4 nights in the hospital but still need more rehabilitation so the patient is discharged to a SNF.
   • Medicare part A pays for the entire surgery and hospital stay
   • The patient pays nothing for the surgery and hospital stay
   • The patient pays for the SNF (Medicare will not pay for the SNF)

Confused? You are not alone. It is because Medicare actually has two 3-day rules and they work totally differently. When an observation status order is changed to an inpatient status order, Medicare will consider the 3 days prior to the inpatient order being written as being inpatient for the purposes of covering hospital charges. However, for SNF coverage decisions, Medicare will not count the 3 days prior to the inpatient order toward the 3 inpatient days that Medicare requires in order for Medicare to pay for SNF charges.

Medicare’s coverage rules are byzantine and indecipherable for the average patient. Even physicians often do not fully understand the nuances of the two 3-day rules. But if you want to make a patient unhappy with their hospital stay and with their surgeon, there is no better way than to slap that patient with an unexpected $20,000 co-pay and SNF charge after their elective knee surgery. It is incumbent on all physicians to get the inpatient status order correct as early in the hospitalization as possible to ensure that Medicare appropriately covers inpatient charges and SNF charges. If there is any chance that the patient will need to go to a SNF after hospitalization for a medical illness or a surgery, then the initial order should always be for inpatient status and not observation status.

July 13, 2019

A small article about trauma in the journal JAMA last week has big implications about the business of hospital finances. In short, it shows that the U.S. spends more on trauma than any other group of diseases… and the implication is that in the future, financially healthy hospitals will need to be trauma centers.

The study looked at a random sample of 20% of all Medicare claims between 2008 – 2014 for patients over age 65 years. During this time, there were 11.8 million hospital admissions. The authors then looked at the ICD-9 diagnostic codes submitted to Medicare for these hospitalizations. Not surprisingly, heart failure accounted for the most hospitalizations at 692,031 (5.9% of total admissions) but trauma ICD-9 diagnoses were the second most common reason for hospitalization at 653,413 (5.6% of total admissions). Extrapolating this to the full 100% of Medicare admissions during that time, it works out to 3.46 million admissions for heart failure and 3.27 million admissions for trauma during the 7-year period.

Next, the study examined the total amount of Medicare payments for each of these conditions for the 90 days after the initial date of admission. Looking at the total cost of care for those 90 days, trauma was overwhelmingly the most expensive condition, costing $2.76 billion. Of that amount, the index hospitalization for trauma cost $1.11 billion, or 40% of the total cost.

This analysis was done using ICD-9 CPT codes. In 2015, the United States changed to ICD-10 codes but that is unlikely to have any impact on the implications of the study. The ICD-9 trauma codes are 800 – 959.9 and includes various fractures. Although the study’s authors did not break down the cost by specific CPT code, it is likely that geriatric fractures accounted for the largest portion of the trauma costs.

Patients with traumatic injuries are preferentially directed to hospitals that are designated trauma centers. Many hospitals undergo verification (accreditation) by the American College of Surgeons  as level 1 (highest level of trauma care capability) to a level 3 center (lowest level of trauma care capability). Currently, there are 517 hospitals that are verified as level 1, 2, or 3 trauma hospitals by the American College of Surgeons. However, the requirements for designation of hospitals as being trauma centers is state-specific and not all states require American College of Surgeons verification. A study in 2003 reported that there were 1,154 trauma centers nationwide when including hospitals that were designated by their state as being a trauma hospital but did not undergo American College of Surgeons verification. In that study, 16.5% were level 1 hospitals, 22.8% level 2 hospitals, 21.7% level 3 hospitals, and 39.0% level 4/5 hospitals.

Trauma in Medicare patients is expensive because it involves older patients who frequently have medical co-morbidities and because a geriatric fracture is extremely expensive. For example, in the United States, there are more than 300,000 hip fracture hospitalizations each year with each fracture resulting in average direct medical costs of $51,000 per fracture. DRG 430 (fracture of hip and pelvis with major complications or comorbidity) results in hospital payments of $9,192 where as DRG 390 (hip and femur procedures with major complications or comorbidity) is $20,928, and DRG 379 (hip replacement with major complication or comorbidity) is $21,987. Following a hip fracture, there are the additional costs of rehabilitation, nursing homes, and medications.

As the U.S. population continues to age, the Medicare population will also age. The U.S. Census Bureau projects that the percentage of Americans over age 65 years old will increase from 15.2% of the total population currently to 23.5% of the current population in 2060. In 2035, for the first time in our country’s history, the percentage of the population over age 65 will exceed the population under age 18. It is projected that those over age 65 will increase from 49 million in 2016 to 78 million in 2035. This population growth has enormous implications for trauma care. By 2035, we will need more hospitals that are capable of managing trauma in the Medicare population. Since most of these trauma patients will likely be geriatric falls and fractures, hospitals will need a robust orthopedic surgery program, a strong physical therapy department, and close ties to post-hospital rehabilitation care. Under current U.S. healthcare financing, inpatient surgery admissions for hip and leg fractures are some of the most lucrative admissions for U.S. hospitals and are a major contribution to maintaining a positive financial margin at the end of the year. Based on the projected increase in the U.S. population over age 65, the total amount of Medicare payments to hospitals for trauma care, particularly geriatric falls and fractures, is going to increase significantly.

The bottom line is that in order to remain financially viable in the future, hospitals with more than 150 beds should be starting plans to become at least a level 3 trauma center today – that is where the money is going to be flowing in the future.

June 16, 2019

When the average person thinks of donating blood, the first words that come to mind are “Red Cross”. However, the American Red Cross only supplies about 40% of transfused blood in the United States. What most people don’t realize is that the U.S. uses a free-market approach to maintain its blood supply with the result that there are dozens of different blood suppliers for our nation’s hospitals and they compete with each other.

Every day, 35,000 units of packed red blood cells, 7,000 units of platelets, and 10,000 units of plasma are transfused in the United States. In order to meet the needs, there has to be a continuous flow of donated blood into the country’s blood banking system because blood has a short self-life: 42 days for red blood cells and 5 days for platelets. However, red blood cells can be frozen for up to 10 years.

Most countries use a single, government-directed supplier for the blood supply but the U.S. utilizes a network of non-profit blood services that are overseen by federal regulations. As of 2016, there were 786 registered blood establishments that collect blood plus 725 hospital and non-hospital blood banks. Blood centers account for 93% of all collected blood and hospital blood banks account for 7% of collected blood.

We do not transfuse as much blood as we used to. Lower transfusion thresholds (from previous thresholds of 8-9 g/dL hemoglobin to current thresholds of 7 g/dL), a trend toward less-invasive surgeries, the increased use of erythropoietin, hospital blood management programs, and improved medical technology have led to a reduced utilization of blood; the number of units transfused has dropped by 25% since 2008. As the demand for blood has fallen, there has been more competition between the various blood suppliers and many suppliers have gone out of business. So, who are all of these blood suppliers?

• The American Red Cross. This is the most visible and publicly recognizable blood supplier and accounts for about 40% of the nation’s blood.
• America’s Blood Centers. This is a network of more than 50 independent, local blood suppliers that supply about 50% of the nation’s blood. Its member organizations manage more than 600 donation sites in 45 states. Two of the largest members are Vitalant (western United States) and Versiti (midwestern United States).
• The Armed Services Blood Program. This supports the military and their beneficiaries.

Blood is a unique commodity in that it is almost entirely donated for free by volunteers. The cost of blood is therefore primarily due to the expense of processing, storage, and distribution. Hospitals will typically contract with a particularly blood supplier based on (1) per-unit cost to the hospital and (2) quality of service from the blood supplier. Because of the declining demand for blood and because the U.S. has experienced a period of hospital consolidation into large hospital systems that can compete aggressively for blood pricing, the financial margin for most blood centers are razor thin and many operate at an annual financial loss.

Because 92-95% of blood is transfused into hospital inpatients, the cost of blood is absorbed into the hospital’s general expenses rather than being passed directly to the consumer (i.e., the patient). This is because hospitals are paid by a DRG price that is fixed based on an inpatient’s diagnosis and the hospital gets paid the same whether 1 unit of blood is transfused or 20 units of blood is transfused. Most blood is sold on a consignment model – the hospital stores blood but only charges the blood centers for the units actually transfused; therefore, the blood centers bear the cost of outdated units. The net result is that the blood suppliers are happy when more blood is transfused and the hospitals are happy when less blood is transfused. The average price paid from hospitals to blood centers in 2013 was $225 per unit.

About 38% of the U.S. population is eligible to donate blood but only a fraction of eligible persons actually donate. All blood is subject to testing for communicable diseases including:

• Hepatitis B surface antigen (HBsAg)
• Hepatitis B core antibody (anti-HBc)
• Hepatitis C virus antibody (anti-HCV)
• HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2)
• HTLV-I and HTLV-II antibody (anti-HTLV-I and anti-HTLV-II)
• Serologic test for syphilis
• Nucleic acid amplification testing (NAT) for HIV-1 ribonucleic acid (RNA), HCV RNA and WNV RNA
• Nucleic acid amplification testing (NAT) for HBV deoxyribonucleic acid
• Antibody test for Trypanosoma cruzi, the agent of Chagas disease

The most common blood type is O+ followed by A+. People with type O- blood are known as universal donors because anyone can received type O- red blood cells. Persons with type AB+ are known as universal recipients because they can receive blood of any type. Like 9% of Americans, I’m B+ so I can receive blood from people with blood types B+, B-, O+, and O- (in other words, 59% of of the population); I can donate blood to people with blood types B+ and AB+ (in other words, 13% of the population). There are differences in blood types between countries and between racial/ethnic groups. For example, 11% of South Koreans are AB+ (universal recipients) whereas only 0.5% of Ecuadorians are AB+. On the other hand, only 0.1% of South Koreans are O- (universal donors) whereas 11% of people in the United Kingdom are O-.

On my 16th birthday, the first thing I did the day I got my driver’s license was to drive to the American Red Cross blood donation center to give blood. Except for a few years during residency and fellowship (when I was regularly exposed to HIV secretions and blood in the ICU), I gave blood every 2-4 months for the next 40 years. About 3 years ago, the Red Cross raised the minimum hemoglobin necessary to donate blood and I found myself too anemic to donate. After anemia tests showed iron deficiency and a work-up for GI bleeding was negative, the conclusion was that I donated too frequently and didn’t eat enough meat. So, I started taking iron supplements for a week before and after blood donations, cut back my donation frequency to every 4 months, and learned to love grilled ribeyes again.

The average donor is male, married, college-educated, with an above-average income, white, and between the ages of 30-50. However, 45% of donors are over age 50. So there is a great need to recruit younger people into the donation pool as the current donor pool ages out. In addition, given the ethnic and racial differences in blood types, there is a need to ensure that our nation’s blood donor demographics more closely represents the nation’s ethnic and racial demographics  so that tomorrow’s blood supply optimally meets tomorrow’s blood demands. We need to eliminate the current disparities that exist in blood donation.

Our nation’s blood supply is a business but a business that is a unique hybrid of volunteers and commercial enterprises that is like no other business in the world. The dynamics of our blood supply is changing based on changes in healthcare financing and some healthcare experts believe that the blood supply system as we currently know it is in peril. But regardless of the changes in economics, patients will still need blood and volunteer donors will still be the ultimate suppliers of that blood. So what am I going to do about it? I do what I’ve always done. I’ll take iron supplements for the next few days and then donate a pint.

May 8, 2019

As an intern, the one specialty I was sure I did not want to go into was pulmonary. The inpatients all had either COPD or lung cancer brought on by the bad life choice of smoking, the sputum they brought up was gross, and there didn’t seem like there was anything we could do for them. So, back in 1987, I decided to do a critical care fellowship and pulmonary was just the necessary appendage to a critical care fellowship. I was a bit surprised when I read the 2018 Medscape Physician Compensation Report that reported that pulmonologists appear to be among the most satisfied of physicians. The report is the compilation of 20,239 physicians in 29 specialties who responded to the annual Medscape survey.

Although the main focus of the report is about monetary compensation, there are several other questions that to me are more interesting than salary One question asked is “If you were to do it all over, would you choose medicine again?” Pulmonologists were more likely than any other speciality to respond that yes, they would choose medicine again at 88% of respondents, with cardiologists a very close second. In a previous blog post, I have commented on the fact that fewer physicians are choosing infectious disease and nephrology and this is reflected by the the low percentage of nephrologists (66%) and infectious disease specialists (68%) who would choose medicine again.

So, could it be salary that makes pulmonologists so happy? Probably not. All physicians make an extraordinary income compare to the rest of Americans. But pulmonologists are in the middle of the pack when it comes to earnings and earnings do not correlate very well with whether or not a respondent would choose medicine again. In fact, physicians in the highest earning specialties were just about as likely as the lowest earning specialties to report that they would go into medicine again. Plastic surgeons at 80% choosing to go into medicine as a career and orthopedic surgeons at 75% are the highest earners (note that neurosurgeons were not reported in the Medscape survey) where as pediatricians (79%) and endocrinologists (78%) are the lowest earners. So, it does not appear that income determines career satisfaction. However, in the Medscape survey, a separate question asked “If you had to do it over again and went into medicine, would you pick the same specialty?” In this case, earnings correlated with whether the physician would choose the same specialty with 98% of orthopedic surgeons and 97% of plastic surgeons choosing the same specialty again.

What about how the physicians feel about their compensation? The pediatrician knows that he or she is going to make a lot less than an orthopedic surgeon before starting residency. But does career satisfaction correlate to how appropriately the doctor believes that he or she is compensated for the work he or she does? Maybe so. The Medscape survey indicated that 70% of pulmonologists reported that they felt fairly compensated. The only specialists who reported feeing more fairly compensated were emergency medicine physicians at 74%. Interestingly, some of the specialists who were least likely to feel that they were fairly compensated were also the specialists who had the highest incomes. Only 50% of plastic surgeons and 51% of orthopedic surgeons felt fairly compensated.

So why are pulmonologists so happy and willing to go into medicine again? No one knows for sure but I have my own opinions.

1. Variation in practice location. It is said that variety is the spice of life and few other specialists practice in such a variety of locations. On any given week, a pulmonologist will see patients in the outpatient clinic, the intensive care unit, the bronchoscopy suite, a hospital nursing unit, or a long-term acute care hospital. It is hard to get bored when you have contact with so many other doctors, nurses, and respiratory therapists.
2. Pulmonologists have a built-in mid-life crises solution. Very few physicians do a pure pulmonary or pure critical care medicine fellowship. Instead, most do a combined pulmonary-critical care fellowship. It takes about 14 years of college/medical school/residency/fellowship to finally become an attending pulmonary & critical care physician so most start their career about age 32 and then retire around age 66. Straight out of fellowship, most newly minted pulmonary/critical care physicians do mostly critical care. This is because in the ICU, the first day on the job, you have a full set of patients whereas it takes a few years to build up an outpatient pulmonary referral base. At the other end of one’s career, when a pulmonary/critical care physician gets closer to retirement, he or she has built up a nice outpatient practice and is tired of the emotional and physical demands of the ICU. For most, the pulmonary and the critical care curves cross at age 45; younger than that and they do mostly critical care, older than that and they do mostly pulmonary. So right when many professionals are getting tired of their job in their mid-40’s, the critical care physician is metamorphosing into a pulmonologist and gets to have a different job for the second half of his or her career. When I started my career, I identified mainly as a critical care physician. Now, I identify mainly as a pulmonologist. It was surprising to me that whereas 88% of pulmonologists would choose medicine again, only 75% of critical care physicians said they would choose medicine again as a career. This may relate more to age than career choice since self-identified pulmonologists are older than self-identified critical care physicians.
3. They do procedures… in moderation. In the past month, I have done (or supervised fellows doing) central lines, arterial lines, chest tubes, bronchoscopies, thoracenteses, ventilator management, endotracheal intubations, pulmonary exercise tests, and PFT interpretations. But procedures are only a minor part of the pulmonologist’s workday. Nevertheless, that mix of both procedures and E/M (evaluation and management) services gives variety to the workday and keeps one from being stuck in a career rut.
4. We are entering a golden era of pulmonary medicine. Pulmonary is about 20 years behind oncology and 30 years behind cardiology with regards to scientific breakthroughs. We as a society have invested enormous public and corporate research money into finding cures for cancer and cardiovascular disease in the past several decades and it has really paid off. Pulmonary diseases such as idiopathic pulmonary fibrosis, cystic fibrosis, and asthma are just now getting the major research breakthroughs that oncology and cardiology have already experienced and many of the previously untreatable pulmonary diseases are becoming not only treatable but sometimes even curable. That makes for it being a very exciting time to be a pulmonologist.

This is all just speculation of course. But it is comforting to know that the majority of doctors in all specialties would do it all over again if they could. Pulmonologists just want to do it all over again a little more.

April 28, 2019

Hospitals are under enormous pressure to reduce length of stay. Since the hospital is paid by the diagnosis and not by the number of days a patient spends in the hospital, the shorter the length of stay, the higher the financial margin. In addition, if the hospital is frequently full to capacity, it is far cheaper to reduce length of stay than to build additional hospital rooms and hire additional nurses. In a previous post, I listed ways that the hospital can decrease its length of stay (or length of stay index which is the length of stay adjusted for the severity of the patients’ medical conditions). One often overlooked contribution to an excessively long length of stay is an excessive number of patients in observation status.

Observation status is for patients who are anticipated to require less than “2 midnights” in the hospital. It was designed for those patients who present to the emergency department with uncertain symptoms and the doctors just need a day or so to determine if the symptoms are something serious or something that could have been treated as an outpatient. However, observation status has evolved into something altogether different. Now, insurance companies and Medicare increasingly look at observation status as patients with illnesses that you can fix in the hospital in less than 2 days. In other words, patients that absolutely need to be in the hospital but that can turn around quickly and be discharged in < 3 days.

The top 3 diagnoses of patients in observation status are chest pain, abdominal pain, and syncope. However, I have had insurance companies deny patients who are admitted to the ICU in respiratory failure requiring intubation and mechanical ventilation if the doctors were able to treat that patient and get them off of the ventilator in < 1 day and out of the hospital in 3 days.

The number of patients in observation status is increasing: in 2011, Medicare spent $690 million on observation status care but by 2016, that number had grown to $3.1 billion. CMS likes observation status because it saves Medicare money – patients are treated as outpatients, therefore they have to pay a 20% co-pay for the hospital stay and they have to pay for their pharmacy charges, thus saving Medicare from having to pay these charges. However, the net effect of this is to transfer much of the costs to the patients and to the hospitals. Therefore, hospitals can lose money on observation status patients, particularly those in the hospital for medical (as opposed to surgical) conditions.

Palmetto (a Medicare administration contractor) uses the following definition for determining observation time:

“Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physician’s order. Hospitals should round to the nearest hour. “

This is generally interpreted as the time the patient is placed in a bed in the emergency department. On the other hand, inpatient length of stay begins at the time that an admission order is written and this time can be considerably later than when the patient was first placed in an emergency department bed. Therefore, when thinking about observation versus regular admission:

1. Observation: the clock starts when a patient is placed in an emergency room bed
2. Inpatient admission: the clock starts when an admission order is written

The percentage of hospitalized patients in observation status has been steadily increasing over the past decade, to the point that now, many hospitals will have > 30% of hospitalized patients in observation status. But too high of a percentage of observation patients can adversely affect your inpatient length of stay index (as well as the hospital’s financial margin).

There are some clinical situations when it is very clear that a patient should be in observation status. For example, a patient who comes in with new chest pain and you are not sure if it is angina or just a strained chest muscle and so you put the patient in observation status for the night so you can do a stress test in the morning – if the stress test is negative, the patient remains in observation status and goes home and if the stress tests is positive, the patient is converted to inpatient status to get the heart worked up further. However, frequently it is not clear on the surface whether the patient should be in observation status or be an inpatient. So, hospitals frequently uses proprietary decision-making support tools such as the Milliman criteria. Additionally, hospitals will often employ “physician advisors” to help in the decision about whether or not a given patient should be in observation status, particularly when the admitting physician disagrees with the decision support tool recommendation.

Putting a patient in observation status is safe and does not expose the hospital to a risk of audit by Medicare. However, an excessively conservative approach to observation status could result in many patients who would have a low inpatient length of stay being classified as observation status and thus inflating the inpatient length of stay.

Therefore, to keep the inpatient length of stay down, the hospital must use observation status correctly. In other words, over use of observation status will result in an increase in the inpatient length of stay. If the hospital’s length of stay is high, then check the percentage of patients who are in observation status and determine if some of those observation patients could be more correctly classified as inpatients.

March 12, 2019

On Christmas Day, an article was published in JAMA that confirmed what many of us had suspected for a long time. When hospitals are penalized for high 30-day readmission rates, patients are more likely to die.

The background is that 30-day readmission rates in U.S. hospitals are disturbingly common and very expensive. In a 2009 article in the New England Journal of Medicine, Jencks and colleagues found that overall, 21% of patients admitted to American hospitals are readmitted within 30 days of being discharged. The total cost of these readmissions was estimated to be $17.4 billion. Ten years ago, this sent reverberations of horrification through the health financing community where it was immediately assumed that hospitals were gaming the system by discharging their patients too early and with insufficient outpatient transitional care. So, in 2010, CMS announced the Hospital Readmission Reduction Program that imposed financial penalties on hospitals that had higher than expected 30-day readmission rates for patients with heart failure, myocardial infarction, and pneumonia beginning in 2012. In subsequent years, COPD, coronary bypass surgery, and joint replacements were added. The result of this program was that hospitals developed many programs to keep patients from “bouncing back” to the hospital.

Many of these programs were (and still are) noble and effective, such as ensuring that there is good communication with the outpatient primary care physician, ensuring that discharge medication reconciliation occurs, and ensuring that there is adequate home healthcare pre-arranged before discharge. However, there was an unintended consequence of the program: creating “the wall”.

In the 1978 satirical novel, The House of God by Samuel Shem, an innocent new medical intern named Roy Basch learns strategies to survive his intern year from a senior resident named The Fat Man. In the book, one of the most respected physicians in the hospital was “The Wall”. This was a physician in the emergency room who refused to admit a patient (“Meet ’em and street ’em”). With the advent of the Hospital Readmission Reduction Program, all of a sudden, “being a wall” was seen as being very admirable. Not just the physicians in the ER but also the primary care physicians, transition clinics, and home health nurses who tried to do everything possible to keep patients from going back to the hospital. In other words, we created a culture of “a readmission is a sign of weakness”.

The recent JAMA article looked at 8.3 million hospital admissions for heart failure, myocardial infarction, and pneumonia before and after the Hospital Readmission Reduction Program was instituted. The result: after the program was begun, the outpatient mortality of heart failure and pneumonia increased significantly. However, there was no difference in the inpatient mortality for those patients who did get readmitted. The insinuation is that by keeping patients from coming back to the hospital who really needed to be in the hospital, patients were more likely to die.

There are dozens of reasons that patients get readmitted to the hospital within 30 days of discharge and some of them are truly preventable. But the overwhelmingly most common reason for readmission is that the patients are just sick. And when we create barriers for admitting patients who truly need inpatient care, patients get sicker and die. In this sense, the Hospital Readmission Reduction Program has been very effective: it has kept patients from coming back into the hospital, it is just that many of those patients really needed to be in the hospital.

So, where does this all leave us? Our hospitals do need to be good stewards of our country’s healthcare finances so we do need to put programs in place that promote continued recovery after patients are discharged. But by non-selectively penalizing our hospitals for readmitting patients who are not recovering, we are inadvertently promoting poor overall health outcomes. CMS policy makers are going to have to take a hard look at the Hospital Readmission Reduction Program to determine if the collateral damage that has resulted justifies continuing the program in its current form. But those of us who care for patients and who operate our country’s hospitals also have to take a hard look at our own practices to be sure that we consistently do the right thing for each patient, even when that thing may result in financial penalties by readmitting them when they need our services.

January 13, 2019