As physicians, we learn about the Starling curve in the first year of medical school. It expresses the relationship between left ventricular end-diastolic volume and cardiac output. The same can...
Hospital and physician performance is measured by a lot of different quality metrics and everyone wants to look good. Sometimes, there are ways to make yourself look good without actually being good – by gaming the metrics. Nobody actually talks about these gaming strategies but a lot of people think about them. I’m not recommending that anyone actually do these strategies but you should be aware of them so that when a physician or hospital reports fantastic quality metrics, you can be sure that the quality is real. Here are some of the ways to game the metrics:
- Never write an admission order in the emergency department between 9:00 PM and midnight. Hospitals calculate length of hospital stay based on the number of days that a patient is an inpatient. But… most hospitals count those numbers of days by the midnight census. So, a 4-day length of stay means the the patient was an inpatient for 4 midnights in a row. An easy way to cut a day off of the length of stay is to wait until after midnight to admit patients who show up in the ER in the evening. With electronic medical records, the determination of when a patient gets admitted is usually based on when the admission order is placed. Therefore, the sly hospitalist who wants to keep his/her length of stay low will do all of the work of admitting patients in the evening but not actually sign the admission order until 12:01 AM.
- Transfer long-length of stay patients to another service just before discharge. Outliers (those patients who are in the hospital for many more days than would be normally expected for their medical condition) are like hot potatoes – no one wants to be holding them when the get discharged. This is because the hospital length of stay is generally credited to the discharging physician and not necessarily the physician who cared for the patient during the rest of the hospital stay. So, the surgeon with a patient with catastrophic post-operative complications who has been in the hospital for 3 months would want to transfer that patient to the endocrinologist for “diabetic care optimization” a day or two before discharge – that way the endocrinologist gets credited with the 3 month length of stay.
- Keep unhappy patients in observation status. Hospitals have to report their patient satisfaction scores and internally, hospitals track patient satisfaction by physician – these scores are often used as part of bonus incentives for hospital-employed physicians. Patient satisfaction is measured by the HCAHPS surveys that are sent to patients after discharge. However, Medicare only requires patients who are in inpatient status to get the HCAHPS surveys and so patients in observation status do not get sent HCAHPS surveys. So, if a physician has an angry patient who they know is going to give them a terrible HCAHPS score, by keeping that patient in observation status, even if it is for 4 or 5 days, then the physician can keep the HCAHPS survey out of their hands.
- Give all of the hospital staff buttons that say “I’m a 10”. The HCAHPS survey boils down the results to those responses that are “top box” which means that they are rated either a 9 or a 10 on the 10-point rating scale. Medicare doesn’t allow hospitals to try to directly influence how a patient answers on the surveys (for example, a nurse discharging a patient cannot tell the patient “We’ll be sending you a survey about your hospital stay and I hope that you will rate us a 10”). However, every advertising executive knows the importance of subliminal messages. So by putting the number “10” at the top of the patient’s menu, on the inpatient walls, and on signs in the hospital lobby, subliminal messaging can work its wonders.
- Keep patients who are admitted near death in observation status. Inpatient mortality rate is also a metric that physicians (and hospitals) are measured by. However, if a patient dies in observation status, then that patient does not count toward the hospital’s reported mortality rate. Observation status is used for patients who are anticipated to be in the hospital for less than “2 midnights” and means that the patient remained an outpatient without being formally admitted to the hospital. So, no matter how sick a patient is, if the physician anticipates that the patient is going to die before two midnights pass, then by keeping that patient in observation status, that patient never counts toward the physician’s (or the hospital’s) reported mortality.
“Gaming the system” is defined as using the rules and procedures meant to protect a system in order, instead, to manipulate the system for a desired outcome. It is a law of nature to attempt to gain advantage within one’s environment in order to succeed and there will always be those who interpret the rules to their advantage. Awareness of how the rules can be manipulated can prevent us from being the ones who are taken advantage of.
June 23, 2018