Categories
Epidemiology Medical Economics

Should You Mandate Employee COVID-19 Vaccination?

“Individual freedom!” has been the rallying cry of a highly vocal but increasingly small minority of Americans who oppose COVID-19 vaccines. Most of these anti-vaxxers represent the intersection of ignorance, arrogance, and obstinance. But should you require them to get vaccinated if they are your employees? In a free market economy, businesses with vaccinated employees have a competitive advantage over businesses with unvaccinated employees.

COVID infection is costly

A study from the City University of New York found that the average direct medical cost of a symptomatic COVID-19 infection is $3,045. Infections that require hospitalization are considerably more expensive than those that can be managed as an outpatient. A report from CMS found that the Medicare payments for a COVID-19 hospitalization was $24,033 (this does not include co-pays that the individual is responsible for). A study in JAMA Open Network this week found that the average out-of-pocket co-pay for a COVID-19 hospitalization was $3,804. A report from the Kaiser Family Foundation found that the average cost of COVID-19 hospitalization for commercially-insured patients with pre-existing medical conditions is estimated to be $20,292 (commercially-insured patients are younger than Medicare patients, have fewer medical co-morbidities, and tend to have shorter hospital stays – all resulting in lower cost per hospitalization than Medicare patients).

In addition to direct medical costs, there is a cost of lost worker productivity during their infection. Recommendations by the CDC are persons infected with COVID-19 should not return to the workplace for at least 10 days from the onset of symptoms. Those persons who are immunocompromised or who require hospitalization for more severe COVID-19 infections should not return for 20 days. Asymptomatic persons who test positive for COVID-19 should not return to the workplace for 10 days from the date of the COVID-19 test. In total, COVID-19 absenteeism is quite costly to employers.

Unvaccinated employees cost more

Vaccines are effective in preventing COVID-19 infection. Overall, unvaccinated persons are 6.1 times more likely to test positive for COVID-19 than vaccinated persons. That means that unvaccinated persons are 6.1 times more likely to be absent from work for at least 10 days. They are 6.1 times more likely to incur the $3,045 direct medical cost of the average COVID-19 infection. The graph below shows the COVID-19 case rate per 100,000 for vaccinated and unvaccinated Americans of working age.

Vaccines are even more effective in preventing severe infection; most of the people hospitalized for COVID-19 infection are now unvaccinated. The CDC reports that unvaccinated COVID-infected persons are 12 times more likely to require hospitalization than unvaccinated persons. Preliminary data suggest that unvaccinated persons are 20-30 times more likely to require ICU admission for COVID-19 infection than vaccinated persons. The graph below shows hospitalization rates per 100,000 for vaccinated versus unvaccinated persons.

Older unvaccinated workers are even more likely to require hospitalization. The CDC reports that in August 2021, persons age 50-64 were 30 times more likely to require hospitalization if they are unvaccinated versus being vaccinated. Currently, the cost of those hospitalizations is being borne by commercial insurance companies and by Medicare. However, in the future, this will translate to higher health insurance costs and higher Medicare costs. These costs will then be transferred to employees by higher health insurance premiums and higher Medicare payroll taxes

Not only are vaccinated employees more likely to be hospitalized with COVID-19, but they are also more likely to die if they get COVID-19. In August, the overall death rate was 11.3 times higher in unvaccinated than vaccinated persons. Dead employees not only result in the cost of replacing them but they also generate life insurance payouts that then result in higher life insurance premiums for the business. The graph below shows the number of COVID-19 deaths per 100,000 in vaccinated versus unvaccinated people of working age. One implication of this graph is that it is safer for a company to hire a 70-year-old vaccinated employee than to hire a 30-year-old unvaccinated employee from a COVID-19 death risk standpoint.

 

Unvaccinated workers who are exposed to COVID-19 also incur higher lost productivity costs than vaccinated workers. Recommendations by the CDC are that unvaccinated employees exposed to COVID-19 quarantine at home for 14 days from the date of exposure. However, vaccinated employees do not need to quarantine and can continue to work as long as they wear a mask. These worker absences can be very costly to the employer who continues to pay the worker who is off work (“sick time”) and has to additionally pay someone else to do that worker’s job (often requiring expensive overtime pay). Because of the different quarantine requirements, it is far more costly to the employer if an unvaccinated employee is exposed to COVID-19 than if a vaccinated employee is exposed, even if the employee has no symptoms.

If vaccines save so much money, why don’t we just mandate them?

Vaccine misinformation has permeated the American public and has spilled over into American politics. Intuitively, one would have thought that Republicans would have been more pro-vaccine than Democrats given that Republicans historically were aligned with business and were in favor of policies that reduce business costs. Furthermore, Republicans historically opposed legislation that places constraints on the free market. Paradoxically, during the COVID-19 pandemic, Republicans have fought against vaccinations that could have lowered costs to businesses. Republicans have also introduced legislation that would prevent individual businesses from requiring employee vaccinations – even when businesses believe that having 100% employee vaccination can give them a free market competitive advantage over other businesses. As a consequence, when it comes to COVID-19 legislation, Chambers of Commerce have been aligning themselves with Democrats rather than their normal alignment with Republicans.

Most Americans are already vaccinated. As of this week, 66% of us have received at least one dose of a COVID-19 vaccine. Because many children are not eligible to be vaccinated, a better metric is the percent of adults who are vaccinated – currently 79% of Americans over age 18 have received a vaccine and 96% of Americans over age 65 have received a vaccine. The people who are vaccinated are not the ones who are vocally protesting against vaccine mandates – it is the minority of Americans who are not vaccinated that are making all of the noise. They are also the ones who are filling up our hospitals, increasing costs to employers, and increasing costs to Medicare and insurance companies. Getting these Americans vaccinated is not just good for our country’s health but it is good for our nation’s businesses. So, how to best get them vaccinated?

The mandate versus the nudge

A mandate is a directive requiring an employee to do something. A nudge is a more subtle means of influencing employee behavior without imposing a mandate. An example of a nudge applied to COVID-19 would be to make it easy for employees to get vaccinated by giving them paid time off work to get vaccinated. A nudge can be as simple as providing education about COVID-19 and vaccines in the workplace. Some employers use the nudge of paying their employees to get vaccinated and in Ohio, we have a free tuition lottery that vaccinated teenagers are automatically enrolled in. Public shaming can be a powerful nudge, for example requiring unvaccinated employees to wear masks at work but allowing vaccinated employees to work mask-free, making it clear to all who is and is not vaccinated. But perhaps one of the most effective nudges is to transfer the costs of COVID-19 to unvaccinated employees.

This was the approach taken by Delta Airlines which increased insurance premiums by $200 for unvaccinated employees. So far, 90% of Delta employees are now vaccinated and Delta projects that 95% will be vaccinated within the next month. On the other hand, United Airlines mandated vaccination and currently has 96% of its employees vaccinated with 3% having a medical/religious exemption to vaccination and only 1% of employees refusing vaccination. American Airlines and Southwest Airlines are also mandating vaccinations but their company policies are being stymied by a Texas law prohibiting businesses with headquarters in Texas from requiring vaccinations. This represents a fascinating social experiment: whether the mandate is more effective than the nudge. Over the next year, we will have an answer to this question and future economic analysis will show us which is the most cost-effective: the Delta Airlines strategy or the United Airlines strategy.

The difference between a mandate and a nudge is that a mandate eliminates choice but choice is inherent in a nudge. As a species, Americans rebel when being told what to do and are passionate about having the freedom of choice. In the song Growing Up, Bruce Springsteen said this better than anyone when he sang: When they said “sit down”, I stood up. The nudge can influence us to change our behavior without requiring us to change our behavior. But there are situations when the mandate is essential, for example, in the military on the battlefield.

When is the mandate better?

The danger of a vaccine nudge is that it may not be effective and if the business needs all of its employees to be vaccinated in order to be competitive, relying on the nudge could put the business at a competitive disadvantage. As an example, elective orthopedic hip replacement surgeries are very lucrative and are mostly performed in people over age 65. These older people have COVID phobia (which is why 96% of them have received a vaccine). The hospital that boasts that all front-line employees are vaccinated will be at a competitive advantage to attract people needing a hip replacement surgery compared to a hospital with unvaccinated nurses and doctors.

Many, if not most, businesses actually welcome legislated vaccine mandates. When the mandates come from the government, then the employer does not have to take responsibility for the mandate and can tell employees “Hey, this requirement is from the government, I’m just the messenger…”. Furthermore, with government mandates, a business does not need to worry about losing employees to its competition over vaccine requirements. If only one restaurant in town mandates vaccinations, there is a danger that the serving staff may quit and go work for a different restaurant rather than get vaccinated but if the State Health Department mandates that all restaurant employees in the state get vaccinated, then those serving staff will be unable to get a job anywhere if they remain unvaccinated.

In states with a high percentage of the population vaccinated, it is easier for employers to mandate vaccination because the pool of unvaccinated employees is relatively small to begin with. The implication is that if you have employees who quit rather than getting vaccinated, there will be ample other workers out there who are vaccinated and who you can hire to replace them. Thus, it is safer for a business owner in California to mandate vaccinations than for a business owner in West Virginia. The graphic below shows the geographic variation in vaccination status.

Similarly, within each state, there are regional variations in vaccination rates that can affect the worker pool and thus the willingness of a business to invoke a vaccine mandate. For example, in Ohio, it is more feasible for a restaurant owner in Delaware County, where 68% of the population has received a vaccine, to mandate employee vaccinations than in Holmes County, where only 15% of the population has received a vaccine. The restaurant owner in Holmes County will have a difficult time finding vaccinated applicants to replace unvaccinated workers who quit because of a vaccine mandate. In the graphic below, Delaware County is the darkest shade county in the middle of the state whereas Holmes County is the lightest shade county.

Another situation where vaccine mandates may be preferable is when mandates can mitigate personal injury litigation. Ever since COVID-19 vaccines have been available to all adults, there is a risk of getting sued if a customer becomes ill or dies from a COVID infection acquired at a business. In many situations, causality can be hard to prove. For example, it can be hard for a customer to conclusively prove that he acquired COVID-19 from an infected bartender at the pub that the customer was in for 45 minutes one evening. However, hospitals may be uniquely vulnerable since patients hospitalized for several days with non-COVID-19 conditions are as a group more susceptible to having severe COVID infections and hospitals have robust epidemiology measures in place that can effectively trace disease contacts. In the future, a hospital will likely be held responsible in civil court for patients who become infected from an exposure to an unvaccinated nurse with COVID-19.

When is the nudge better?

The danger of a vaccine mandate is that some recalcitrant anti-vaxxer employees may decide to quit. For many businesses, this may actually be a good thing if those individuals have a history of being disruptive or otherwise being problem employees in the past. But in other businesses, a large number of employees quitting because of a vaccine mandate can lead to worker shortages, reduced business production, and unfavorable public relations. The wise employer will find out which employees are unlikely to get vaccinated before the employer roles out a vaccine mandate. Strategically timing a vaccine mandate after researching employee vaccination status may provide the company with a rare opportunity to eliminate undesirable employees without having to deal with a protracted human resources battle over alleged unlawful job termination.

In some businesses, particularly those with a small number of employees, relentless education will eventually sway all but the most rabid anti-vaxxers. Once all of the existing employees are vaccinated, then the business can adopt a proof of vaccination requirement for all new employees, thus getting the benefits of the mandate without losing any employees.

Sometimes, the incremental nudge can be highly effective. With the incremental nudge, employee choice is preserved but over time, the consequences of choosing to be unvaccinated become incrementally more onerous for the employee. An example is as follows:

  • Step 1: Education about COVID-19 vaccination in the workplace
  • Step 2: Paid time off to get vaccinated and recover from any vaccine-related side effects
  • Step 3: Pay an incentive of $100 to every vaccinated employee
  • Step 4: Requirement that unvaccinated employees wear masks at work but vaccinated employees are not required to wear masks
  • Step 5: Requirement that unvaccinated employees get weekly COVID-19 nasopharyngeal swab tests
  • Step 6: Requirement that unvaccinated employees get daily COVID-19 nasopharyngeal swab tests
  • Step 7: Increase health insurance premiums for unvaccinated employees by $500 per year
  • Step 8: Increase life insurance premiums for unvaccinated employees by $500 per year
  • Step 9: Mandate vaccination

By the time the employer reaches step 8, only the most hardened anti-vaxxers will remain unvaccinated. This will be a relatively small percentage of employees and will mostly be disruptive employees that the employer would like to have an excuse to get rid of anyway. Therefore, step 9 could be mandating vaccinations and then terminating those few remaining unvaccinated employees. This allows the employer to time the mandate strategically in order to selectively cull the employment roster.

The future is right around the corner

In the very near future, there will be two kinds of people: those who are vaccinated against COVID-19 and those who either have had or will have COVID-19 infection. This pandemic is different than the SARS, MERS, and Ebola outbreaks – in those outbreaks, the virus was able to be contained locally until no new infections occurred. COVID-19 today is too widespread throughout the world and has long past the time when it could be locally contained. This pandemic is also different from the 1918 influenza pandemic and the 2009 H1N1 pandemic – in those pandemics, the inciting virus eventually disappeared and was replaced by other, less deadly strains of the virus. COVID-19 does not show any signs of going away or being replaced by a less deadly coronavirus.

Thus, it appears that COVID-19 is going to be with us for a long time and unless all nations can mount a universally successful vaccination campaign, as was done with polio, COVID-19 may be with us indefinitely. But it is clear that vaccination is the only way out of a perpetual pandemic. The good news is that the number of unvaccinated people is dwindling as the tolerance of the vaccinated for those who are unvaccinated also dwindles.

October 20, 2021

Categories
Procedure Areas

How To Create A Lung Cancer Screening Program

Imagine if a Boeing 777 jet crashed and killed all on board. And then imagine such a crash occurring every day for a year. That is how many Americans die of lung cancer, a disease that is not only preventable (if you don’t smoke) and curable (if found early). More people die of lung cancer than die of colon cancer, breast cancer, and prostate cancer combined.

This year, 235,760 Americans will be diagnosed with lung cancer which accounts for 12.4% of all cancer diagnoses. The 5-year survival rate is only 21.7% and an estimated 131,880 Americans will die of their lung cancer this year. The problem with lung cancer is that it is usually found late, after it has already spread and no longer surgically curable. As a consequence, the 5-year survival of lung cancer is much lower than any other common type of cancer. However, lung cancer screening programs can identify lung cancer at an early stage, when it can still be surgically cured.

Screening for colon cancer and breast cancer is relatively straight forward: at a certain age, everyone starts getting a colonoscopy every 10 years and all women start getting a mammogram every year. Screening for lung cancer is more complicated for two reasons. First, because the criteria for who should or should not undergo screening is more complex and second, because there has to be a process in place for managing all of the abnormalities that are identified on screening tests (most of which are not lung cancer).

It has long been known that screening with regular chest x-rays does not work; x-rays just do not identify lung cancers at an early enough stage. A landmark study in 2011 showed that low-dose chest CT scans not only identify more lung cancers than chest x-rays, but patients who got chest CT scans were 20% less likely to die of lung cancer in the subsequent 6.5 years than those who only got screening chest x-rays:

A more recent study from last year showed that patients who got lung cancer screening chest CTs had a 25% lower risk of dying of lung cancer in the subsequent 10 years:

Clearly we need to be screening patients for lung cancer but only 2-4% of eligible smokers are currently getting screened. So, why aren’t we screening more? The two major barriers are patients and healthcare providers. Patients are often unaware of screening programs, fear a cancer diagnosis, worried about the costs, or simply do not have access to screening. Physicians are often unfamiliar with the screening guidelines, unsure of insurance coverage, lack the time in the office to counsel patients about screening, don’t know what to do about abnormalities found on CT, are skeptical about the efficacy of screening, or are worried about the risks of false positive findings. In February 2015, CMS approved lung cancer screening for Medicare recipients if they met a group of specific criteria. In March 2021, the US Preventive Services Task Force revised the guidelines for screening to now include:

  1. Adults age 50 – 80 years old
  2. At least a 20 pack-year smoking history
  3. Currently smoking or quit within the past 15 years

People who meet all three of these criteria are recommended to undergo an annual low-dose chest CT scan. Screening should continue until the person has quit smoking > 15 years earlier, is no longer willing to undergo curative surgery if a cancer is found, or develops another medical condition that substantially reduces life expectancy. For Medicare coverage, the patient must additionally have no signs/symptoms of lung cancer and screening must include smoking cessation counseling.

One of the issues raised by lung cancer screening is that chest CT scans can pick up a lot of benign abnormalities. In fact, 97% of all abnormalities found on screening chest CTs are not cancer. For this reason, there has to be a process for managing these abnormalities – both for choosing the best way to biopsy those patients who have abnormalities that are more likely to be cancer and for arranging follow up testing for those patients who have abnormalities that are less likely to be cancer. This is where a carefully designed lung cancer screening program can be effective and efficient.

Components of a lung cancer screening program

To be successful, a lung cancer screening program should include a CT scan capable of low-dose chest imaging, a radiologist available to interpret that CT, a clinical provider, and a pulmonologist. Ideally, the screening should be able to be completed within an hour and a half with the patient going to just one location. The entire screening visit should be able to be ordered by the patient’s primary care provider using a single order set. The screening visit should consist of:

  1. An initial review of the patient for inclusion criteria
  2. An encounter with a clinical provider with experience in pulmonary nodule management and smoking cessation counseling
  3. The chest CT scan with radiologist interpretation
  4. A second encounter with the clinical provider after radiologist’s CT interpretation is available
  5. Ordering of appropriate follow-up testing

Let’s look at each of these steps in detail:

Initial review of patient for inclusion criteria. The US Preventive Services Task Force lung cancer screening criteria have not yet been adopted by all insurance companies. As a result, different insurance companies will have different requirements for screening eligibility. After the primary care provider places an order for lung cancer screening, the order should initially go to a nurse who can check the patient’s insurance and verify that the patient meets the age and smoking history requirements for that specific insurance company. Most insurance plans additionally require that the patient has not had a chest CT for any purpose within the past year. Once the patient’s eligibility is confirmed, then the order can be routed to the screening clinic for scheduling.

Initial encounter with clinical provider. This provider can be a physician or an advance care provider. Given the nature of this encounter, a nurse practitioner or physician assistant is an ideal choice. During this encounter, the screening process is discussed, the patient’s eligibility is confirmed, smoking cessation counseling is given (if the patient is an active smoker), and the CT scan is ordered. There should be “shared decision making” between the provider and the patient so that the patient understands that non-cancerous abnormalities are common but may require additional testing. It should also be confirmed that the patient is willing to undergo biopsy and/or surgery if warranted by the CT findings. Typically, 8-10 patients can be scheduled during a 4-hour clinic time.

The chest CT scan. Ideally, this should be done immediately following and at the same location as the encounter with the clinical provider. The CT machine should be capable of low-dose chest CT protocols. The procedure time for this type of CT scan is less than a minute. The radiation dose of a standard chest CT scan is 7.0 mSv whereas the low-dose chest CT is only 1.5 mSv. To put this in perspective, a chest x-ray is 0.1 mSv and a mammogram is 0.4 mSv. A normal person gets 3.0 mSv in background radiation every year. Ideally, the CT should be interpreted by the radiologist immediately with the results available to the clinical provider.

Second encounter with clinical provider. If the CT scan results are immediately available, then the patient should go directly from the CT scan back to see the clinical provider. If the results are not immediately available, then this second encounter can be done by telephone or telemedicine later that day or the following day. Because most electronic medical records are configured to release radiology reports the same day as the CT scan is performed, there is the potential for patients to see the results before the clinical provider if the second encounter does not happen immediately after the CT scan is performed. This can result in a great deal of anxiety if the patient does not understand the significance of abnormalities noted in the radiology report. For this reason, it is optimal for the clinical provider to be able to discuss and explain the findings as soon as possible following the CT scan. Depending on the radiologist’s report, the clinical provider has several options:

  • If the CT scan is normal, a follow up lung cancer screening visit in 1 year can be ordered.
  • If the radiologist identifies a nodule or other abnormality and the patient has had a previous chest CT elsewhere in the past, the provider can request those images and arrange a follow-up appointment to compare the findings and determine if they meet radiographic stability criteria.
  • If the radiologist identifies a nodule or other abnormality and the patient has NOT had a previous chest CT, then the clinical  provider can order a follow-up chest CT scan and office visit based on the 2017 Fleischner Society guidelines. These guidelines provide recommendations for how soon to perform follow-up CT scans based on whether nodules are solid or subsolid, whether nodules are solitary or multiple, the size of the nodule, and whether the patient has lung cancer risk factors.
  • If a finding suspicious for lung cancer is identified, then the provider should have access to a pulmonologist to determine the most appropriate next step. Because a PET scan is most commonly performed prior to biopsy or surgery, this will often entail the clinical provider ordering a PET scan to be followed by consultation with a pulmonologist. Sometimes, the pulmonologist may be able to advise the clinical provider regarding next steps via a telephone consultation. These next steps could include:
    • PET scan
    • Bronchoscopic biopsy
    • CT-guided needle biopsy
    • Surgical biopsy/resection
  • If the patient desires more extensive smoking cessation assistance, then the clinical provider can refer the patient to a formal smoking cessation clinic.

Lung cancer screening is more than just ordering a chest CT

Lung cancer screening is a lot more complex than screening for other cancers. To be successful, lung cancer screening requires interdisciplinary coordination, incorporation of smoking cessation, and ability to order follow-up testing. Although some primary care physicians may be able to orchestrate all of these elements themselves, it is far more efficient for hospitals to develop a comprehensive lung cancer screening program with standardized management protocols.

September 30, 2021

Categories
Physician Retirement Planning

The Closing Window Of Opportunity For Roth IRA Conversions

The best time to do a Roth conversion is in the next 4 years. There are two situations when contributing to a Roth IRA is particularly advantageous: when the stock market plummets and when income tax rates are low. In 2016, Congress voted to reduce income taxes, beginning in tax year 2017. Without additional legislation, those tax reductions will expire in 2025. Given historical precedent and the amount of Federal spending that has occurred in the past 2 years in combating COVID and in infrastructure spending, it seems likely that income tax rates will return to the 2016 levels in 2025. That means that we have 4 years  left to take advantage of some of the lowest income tax rates in recent memory. It also means that we have 4 years left to take advantage of lower-cost Roth IRA conversions.

To understand why Roth conversions are going to be less expensive now than in 2025, you first have to understand how income taxes work. In a previous post, I discussed the differences between income tax brackets and effective marginal income tax rates. The bottom line is that we place way too much emphasis on the tax brackets. What we actually pay in income tax depends on the effective tax rate and not the bracket. The effective tax rate goes slowly and steadily up for every additional dollar we earn. The income tax brackets simply determine the slope and position of the curve of the effective tax rates. In the graph to the right, you can see last year’s income tax brackets in the dotted line but the actual income tax rate a person pays is always less than the bracket that they are in, as shown in the solid line.

When congress voted to reduce the tax brackets beginning in 2017, the effect was to shift the curve of the graph downward so that everyone at all income levels paid lower effective income tax rates. Depending on one’s taxable income, the effective tax rate dropped by 3.5 to 6.0 percentage points. The graph on the right illustrates the difference in the effective tax rate for annual taxable incomes between $40,000 and $700,000 for 2016 (before the tax cuts) and 2020 (after the tax cuts). For example, a family with a taxable income of $250,000 per year had an effective income tax rate of 21.5% in 2016 but that dropped by 4.6 percentage points to an effective income tax rate of 16.9% in 2020. Looked at in a different way, that family paid $53,750 in federal income tax in 2016 but only paid $42,250 in 2020.

So, what do lower income taxes mean for Roth conversions?

Roth IRAs have two important advantages over other retirement savings accounts: (1) you do not have to pay taxes when you take money out of the Roth account and (2) you do not have to take required minimum distributions at age 72 like you do with a 401k or other deferred income accounts. There are two ways that you can contribute to a Roth IRA: direct contribution and conversion contribution. If you are married filing jointly, then you can annually contribute up to $6,000 ($7,000 if over age 50) directly to a Roth IRA if you make less than $198,000 (you can do a partial contribution if you make between $198,000 and $208,000). If your income is over $208,000, then you cannot contribute directly to a Roth. However, you can do a Roth conversion by first contributing to a traditional IRA and then converting those funds into a Roth IRA within 60 days. This sometimes called a backdoor Roth approach.

It is easiest to do a Roth IRA conversion from a traditional IRA, especially if both the traditional and Roth IRAs are in the same investment company. It is also possible to convert funds from a 401(k), 403(b), or 457 plan into a Roth IRA but it can be more complicated. You generally must be over age 59 1/2 and also no longer employed by the employer that sponsored the 401(k), 403(b), or 457 plan. Also, the administrator of the 401(k), 403(b), or 457 plan may not permit you to convert funds directly into a Roth IRA and so you may have to first rollover funds from the 401(k), 403(b), or 457 plan into a traditional IRA and then convert the traditional IRA into the Roth IRA within 60 days. Of critical importance is that when you convert funds from a tax-deferred account (such as a 401(k), 403(b), or 457 plan) into a Roth IRA, that money is subject to regular income tax the year that you do the conversion. This means that not only do you have to pay income tax on the value of the conversion, but the amount converted adds to your total taxable income so it will push you up to a higher income tax rate the year that you do the conversion. The extra steps involved in doing this type of conversion can be a headache; however, as we will see, it can be worth it from a tax savings standpoint.

Although I personally think that everyone should have a Roth IRA as component of a diversified retirement portfolio, there are 2 situations when it is especially advantageous to do a Roth conversion: (1) when there is a significant drop in the stock market and (2) when your income tax rate is lower now than it will be when you are retired.

  • When the stock market falls. If you already have money in a traditional IRA, then the best time to convert that money into a Roth is when the value of the IRA is at the lowest (and therefore you pay the least amount in income taxes). The best example of this in recent years was in March 2020 when the S&P 500 index fell by 32% as a consequence of the COVID pandemic. If you had $1,000 in a stock index mutual fund traditional IRA on February 10, 2020, then it was only worth $680 on March 16, 2020. However, by August 2020, the stock market had completely recovered back to its January 2020 value. If your effective tax rate was 16.8%, then you would have paid $168 in taxes to do a Roth conversion of the total amount of the traditional IRA in February but only $114 in taxes to do the conversion in March. If you are older than 59 1/2 and retired, then you could also have done a Roth IRA conversion from a 401(k), 403(b), or 457 account. The stock market inevitably goes up, goes down, and then goes back up again. Take advantage of the drops in the stock market to do the Roth conversions – that way, when the stock market rises in the future, the recovery in value of your investment will all be tax-free. How much does the stock market need to drop to trigger a Roth conversion? That is a matter of opinion but a 20% drop is a reasonable trigger.
  • When your income tax rate is lower. For most people, income tax rates will be lowest when they first start out in the work force and their taxable income is relatively low. Their income tax rates will be highest in the years just before retirement when they are in their peak earning years. In retirement, their income tax rate will usually fall to a rate somewhere in-between their lowest and highest income earning years while working. Therefore, for most people, the best time to do a Roth conversion is early in their careers, when their taxable income (and thus their income tax rate) is still relatively low. However, the other time that a Roth conversion is advantageous is when everyone’s income tax rates are low but will go up in the near future.

History tells us that tax rates, like the stock market, periodically go up and periodically go down, as illustrated in the graph to the right. The problem is that no one can predict with certainty exactly when tax rates will go up or down. Federal income tax rates are low now so it is highly likely that they will go up in the future. The current lower tax rates are set to expire in 2025 at which time they will revert to the higher 2016 rates (unless congress votes to extend them). Which political party is in charge of congress and the White House will have a big impact on whether taxes will go back up in 2025 (as planned) or stay low (requiring additional legislation). However, unless there is a significant reduction in federal spending in the next 4 years, then it is likely that there will be no alternative to letting the tax rates go back up in 2025.

Therefore, if your income remains relatively constant, it will cost you less to do a Roth conversion now than it will cost beginning in 2025. As an example, in 2021, a person making $200,000 has a federal income tax rate of 15% but in 2025, a person making $200,000 will have a 20% income tax rate. So, by doing a $50,000 Roth IRA conversion in 2021 (and thus increasing their taxable income to a total of $250,000), this person would pay a total of $42,250 in income tax but if they wait to do the Roth IRA conversion in 2025, this person would pay a total of $53,750 in income tax. In other words, as shown in the calculation below, this person will pay $11,500 more in income tax to do a Roth conversion in 2025 than in 2021:

In fact, a person would need to make $380,000 per year in 2021 to be taxed at the same rate that an income of $200,000 will likely be taxed in 2025. Therefore, a person making an annual income of $200,000 in 2021 can convert an additional $180,000 into a Roth IRA this year and still pay the same income tax rate that they will pay on an income of $200,000 (with no Roth conversion) in 2025.

Know the rules about Roth Conversions

The tax laws regarding Roth IRA withdrawals are complicated and depend on your age, how long ago you opened the Roth IRA, whether you are withdrawing the contribution (amount you originally put in) versus earnings (amount you made off of the contributions), and whether the contribution was a direct contribution or a conversion contribution. For direct contributions (eligible for couples filing jointly with an income of < $198,000), you can take money out of the Roth contributions anytime but you cannot take money out of the Roth earnings until you have had the Roth account open for at least 5 years and you are at least 59 1/2 years old. For conversion contributions, the conversion must have occurred at least 5 years previously, regardless of your age, before you can withdraw the contributions from the Roth account. The IRS uses a “first in, first out” rule when tracking the conversions so that every conversion amount that you make to a Roth IRA has its own 5-year requirement before you can withdraw it. In other words, consider the amount of each Roth IRA conversion to be locked up for 5 years.

Roth IRAs are not subject to required minimum distributions, unlike other deferred compensation accounts (such as traditional IRAs, 401(k)s, 403(b)s, and 457s). Required minimum distributions are a certain percentage of the deferred compensation accounts that the IRS requires you to withdraw each year after age 72. If a person has a lot of money in these deferred compensation accounts at age 72, this can result in taxable income high enough to push the person’s effective income tax rate up. Therefore most retirees will start to preferentially draw down their traditional IRAs, 401(k)s, 403(b)s, and 457s before age 72 and hold off on taking withdrawals from their Roth IRAs until after age 72 in order to maintain the lowest income tax rates during their retirement years. In general, you cannot convert required minimum distributions into a Roth IRA.

Now is the time to do a Roth conversion

If the 2016 tax cuts are left to expire in 2025, then there will be 4 more years of lower income taxes before income tax rates go back up. Therefore, it will cost you less to do a Roth IRA conversion in 2021, 2022, 2023, and 2024 than it will to do a Roth conversion in 2025 and later. The best Roth strategy depends on a person’s age:

If you are younger than 59 1/2: Do a direct Roth IRA contribution if your income is less than $198,000 (married filling jointly). If your income is higher, then you can make a contribution to a traditional IRA (up to $6,000 per person under age 50 and $7,000 per person over age 50) and then promptly convert the traditional IRA contribution into a Roth IRA (backdoor Roth). A common question that comes up is whether it is better to contribute to a deferred income account such as a 401(k)/403(b)/457 (pre-tax dollars) or better to contribute to a traditional IRA and do a backdoor Roth conversion (post-tax dollars). If your employer offers a matching contribution to your 401(k)/403(b)/457, then it is always better to contribute to the 401(k)/403(b)/457. There are two situations when doing a backdoor Roth is advantageous:

    • You have already contributed the maximum to your 401(k)/403(b)/457 and you have some additional post-tax money that you want to invest for retirement. In this situation, if you put the money into a regular investment, you will eventually pay capital gains tax on the earnings but if you put the money into a backdoor Roth, you pay no taxes on the earnings.
    • You believe that you will have a higher income tax rate in your retirement years than your current tax rate. Remember, however, that by contributing to a 401(k)/403(b)/457, you are lowering your taxable income for the contribution year and thus lowering your tax rate that year. Conversely, your income tax rate will be higher if you do not contribute to your 401(k)/403(b)/457 and do the backdoor Roth instead. Nevertheless, for the next 4 years, if you do not have a lot of extra cash on hand in your checking account, you may be better off to reduce your 401(k)/403(b)/457 contributions by enough to give you $6,000 after-tax ($7,000 if over age 50) and then put that $6,000 into a traditional IRA followed by a backdoor Roth conversion.

If you are between 59 1/2 and 67: You can do a direct contribution (if your income is low enough) or a backdoor Roth. But you should also consider converting a portion of your traditional IRA, 401(k), 403(b), or 457 into a Roth IRA. The optimal amount to convert will depend on how much higher you project your taxable income will be in 2025 than it is in 2021. If your taxable income is going to be about the same, then you may be able to convert up to $100,000 – $150,000 and still come out ahead from a tax standpoint. If you project that your income will be higher in 2025 than it is now (and thus have an even higher income tax rate), then you can convert more than $100,000 – $150,000. If you project that your income will be lower in 2025 than it is now, then it still may be advantageous to do a conversion now but the conversion amount should be less. If you are still working, you can do a Roth conversion from your traditional IRA but you probably will have to wait until retirement to do a Roth conversion from an employer-sponsored 401(k), 403(b), or 457 (withdrawals from these accounts while still working are usually not permitted). Importantly, remember that you will pay income tax on the amount of the conversion so you should only do the conversion if you have sufficient cash on hand to pay that extra tax.

If you are between 67 and 72: Things get a bit more complicated. Remember, each conversion contribution needs to be in your Roth account for at least 5 years in order to avoid an early withdrawal penalty. So, if you plan to start taking money out of your Roth at age 72, then the year you turn 72, you should only take an amount equal to the conversions that you did before age 67 to avoid paying the IRS penalty. This means that you have to track your Roth conversions and have a record of how much you converted each year. It may still be advantageous for you to do Roth IRA conversions between ages 67 and 72 but you should be sure that you do not plan on withdrawing those annual conversions from your Roth IRA for at least 5 years.

If you are older than 72: Doing a Roth conversion after age 72 is usually unwise. Because required minimum distributions from deferred compensation accounts are necessary starting at age 72, taking additional money out of these accounts to do Roth conversions will result in more taxable income and thus push the income tax rate up higher. Some people who are still working and contributing to a 401(k)/403(b)/457 after age 72 may be exempt from required minimum distributions and thus be in a position where a Roth conversion is still advantageous but they should check with a tax advisor because this is a very complicated area.

It’s all about the math

If the current tax rates expire in 2025 and revert to the 2016 rates as anticipated, then there is a 4-year window of opportunity for Roth conversions in order to take advantage of the lower tax rates. A carefully timed Roth conversion can save you money by reducing the total amount of income tax you pay over your lifetime. But you have to be strategic with your timing or you could end up paying more in income taxes. If you are not sure, then get help from a tax expert.

September 7, 2021

Categories
Epidemiology

Why The Purveyors Of COVID Misinformation Keep Winning

Physicians and scientists keep asking why so many Americans are so gullible as to believe in many absurd claims about COVID-19 and the COVID vaccine. For those of us who are taught to be able to read and interpret an article from a medical journal, the reality, epidemiology, treatment, and prevention of the viral infection just seems so obvious. The safety and efficacy of the COVID vaccines seems so indisputable. But many Americans are convinced that COVID infections are not very serious and that the COVID vaccines are more dangerous than the infection.

So, what happened?

There is clearly more than one answer to this question but one of those answers is that the medical community has made information about scientific development inaccessible to the general public whereas the architects of COVID misinformation have made their falsifications readily available to the public. They are winning the information war.

Education level is the strongest predictor of vaccination status

The June 2021 U.S. Census Pulse Survey has a wealth of information about the demographics of COVID vaccination. Although we hear a lot about racial inequities in COVID vaccination, the strongest predictor of whether or not a person gets vaccinated is education level. The survey found that 90.8% of Americans with a college degree have received a COVID vaccine but only 68.6% of those with less than a high school degree have received a vaccination. Not only have those people with lower education levels not yet received a vaccination, they also say that they are not getting one in the future. These are not people who are reading science journals, they are getting their information from social media. They trust media celebrities more than they trust doctors to know about COVID treatment. They trust political pundits more than they trust scientists to know about the science of coronavirus infection.

Physicians and scientists all too often speak a language that people with a high school education or less do not comprehend. Sometimes, it is not so much that they are gullible to what the purveyors of COVID misinformation are saying as much as they cannot understand what scientists are saying. When we open our mouths, confidence intervals, means, medians, and probability values come out. When COVID miscreants open their mouths, dogma comes out. Scientists are boring, miscreants are charismatic. If we are going to sway these Americans to get vaccinated and wear masks, we have to communicate with them in a way that they understand.

Science is not accessible to most people

For decades, physicians and scientists have communicated results of medical and scientific research through journals. Every university professor knows that to get tenured, you have to publish. Publishing does not just mean writing a post for a blog, it means getting an article accepted in a peer-reviewed medical journal. But not all medical journals are equal. For an academic physician or scientist to get promoted, it is not only the number of articles that they publish but it is also the quality of journals that their articles are published in. That quality is most commonly measured by the impact factor which is a measurement of how often articles published in those journals are cited (referenced) in other journal articles. In other words, the more times articles from a given journal are cited by other researchers, the larger the impact factor of that journal. Therefore researchers try to get their articles published in journals with the highest impact factors. The most commonly used impact factor measurement is the journal citation reports by Clarivate. Examples are in the table below:

 

Most medical journals are funded by a combination of reader subscriptions and paid advertising (usually medication ads). Because of the requirement for paid subscriptions, the articles in these journals are inaccessible to anyone without a subscription. As examples, the New England Journal of Medicine and JAMA both cost $199/year. As a consequence, unless you are one of the privileged few who can either afford to subscribe to a lot of medical journals or are a faculty member of a university with a library that has an institutional subscription, you cannot read these journals.

This has been a criticism of academic medicine for many years. As a result, Patrick Brown, MD, PhD (inventor of the Impossible Burger) and Michael Eisen, PhD created the Public Library of Science (PLOS) that publishes 15 open-access scientific journals that are free on the internet for anyone to read. One of these is PLOS Medicine, with an impact factor of 11.069. The PLOS journals are funded by fees paid by the authors when they get an article published; these funds generally come from the authors’ research grants. Although open-access journals, such as the PLOS journals, are a great idea, they only account for a tiny fraction of all of the current medical journals.

The purveyors of misinformation don’t charge subscriptions

In contrast to scientific journals, anti-vaxxers and other producers of misinformation about COVID do not rely on paid subscriptions for the public to access their propaganda. They make it freely and widely available using social media. Furthermore, articles in scientific journal articles are full of technical terms and complicated statistics that even physicians and scientists often do not understand. In contrast, COVID misinformation is written for the masses, usually at a grade school level, so that anyone can understand it.

Physicians and scientists do not get tenure and do not get promoted based on their tweets and number of Facebook posts. The purveyors of COVID misinformation count their success by their number of Twitter followers and Facebook friends.

They are not subject to the torment of peer review

Scientific journals require that articles submitted to them by researchers be peer-reviewed. This process involves sending the manuscripts out to volunteer scientists working in the same area who read over the manuscript and critique the article based on how rigorous the experiments were, how accurate the statistics are, how correct the conclusions are, and how important the findings are. I have reviewed dozens of articles as a peer reviewer and it takes a lot of time – at least a couple of hours per article and sometimes many hours. The reviewers are generally anonymous so that the author of the article does not know who the reviewers are. Sometimes, the reviews can be extremely harsh – many people will say much more negative criticisms when they are anonymous than they would if the author knows who is doing the reviews. Sometimes, the reviewers can feel threatened by the findings of an article under review if that article refutes the reviewers own work or if it will beat out publication of competing research that the reviewer is also working on. Bitter reviews can be very discouraging, particularly to younger scientists. Nevertheless, despite often being painful to the article authors, the peer review system is the best way of ensuring that the information that ultimately gets published in medical journals is accurate.

Anti-vaxxers, anti-maskers, and other curators of COVID misinformation are not subject to peer review. They can say anything they want and if it appears in print or on the internet, then to the average lay person, it seems just as legitimate as a peer-reviewed scientific article. Twelve people are responsible for 65% of all of the COVID misinformation on the internet. These are the so-called disinformation dozen:

  1. Joseph Mercola, DO
  2. Robert F. Kennedy, Jr.
  3. Ty Bollinger
  4. Sherri Tenpenny, DO
  5. Rizza Islam
  6. Rashid Buttar, DO
  7. Erin Elizabeth
  8. Sayer Ji
  9. Kelly Brogan, MD
  10. Christiane Northrup, MD
  11. Ben Tapper
  12. Kevin Jenkins

These 12 operate businesses and organizations that financially benefit from COVID misinformation such as selling potions and “natural” remedies on-line or selling books and classes about COVID misinformation. In other words, they are professional anti-vaxxers and anti-maskers who make their living by producing COVID misinformation content. The more outrageous the claims they make on social media, the more attention they get. The more attention they get, the more stuff they sell. The more stuff they sell, the more money they make.

In contrast, scientists do not get paid anything for the articles that they publish. Indeed, many journals charge the authors of scientific articles a publication fee (especially open access journals). Furthermore, if the author of a scientific article has a conflict of interest that would result in them profiting from the publication of their experiments, then they have to publicly acknowledge that conflict of interest and the editor of the journal may not allow publication.

Five of the disinformation dozen are physicians and having “Dr.” in front of their names gives them instant credibility. So who are the Doctors of Disinformation? Joseph Mercola, DO has claimed that mobile phones cause cancer and  HIV does not cause AIDS; he has an alternative medicine business that sells tanning beds to prevent skin cancer. Sherri Tenpenny, DO famously testified to the Ohio Legislature that COVID vaccines cause people to become magnetized. Rashid Buttar, DO practices alternative medicine and uses intravenous hydrogen peroxide and EDTA to treat cancer.  Kelly Brogan, MD practices “holistic psychiatry” and advocates using coffee enemas to treat depression. Christiane Northrup, MD is a gynecologist who uses Tarot cards to diagnose disease and believes that her wisdom comes from her experiences in her previous life in Atlantis. A sixth member of the disinformation dozen, Ben Tapper, is a chiropractor who introduces himself Dr. Ben Tapper to claim legitimacy for his beliefs that face masks cause disease.

So, how do we get the truth out?

It costs a lot of money to operate a medical journal. You have to pay the editors and the staff salaries. You have to rent office space. You have to pay print and mailing expenses. To cover those costs, the journal either has to sell advertising, sell subscriptions, or charge the authors publication fees. I’ve always been a bit uncomfortable with the fact that much of the costs of our journals are paid for by medication advertisements by pharmaceutical companies that at some level seems itself like a conflict of interest. Subscription fees create a barrier for dissemination of scientific information to the general public. Charging the authors of scientific articles seems like the least bad funding mechanism. Whatever the solution, making journal articles open access for anyone to read is needed.

If if science eventually becomes freely available to everyone, the medical profession needs to beat the purveyors of COVID misinformation at their own game. If the general public gets its information about COVID from Facebook and Twitter, then we need to use these same forums for spreading information about the benefits of vaccines and masks.

As physicians, we should demand that doctors who profit from creating misinformation, such as Sherri Tenpenny, be reviewed by their state medical boards to determine if their medical licenses should be revoked. In 1998, British transplant surgeon, Dr. Andrew Wakefield, falsified research claiming that the measles, mumps, and rubella (MMR) vaccine caused autism; he was struck from the UK medical register and barred from practicing medicine ever again. Those doctors who profit from disseminating COVID misinformation should be treated the same. They are a stain on our profession.

The public also bears responsibility to advocate social media business, such as Facebook and Twitter, to ban those who profit by marketing misinformation. Just as journal editors reject articles using bad science, social media companies should reject account applications from individuals such as the disinformation dozen.

Whether you are trying to sell a product or win a political campaign, there are few things more powerful than advertising. To date, advertising about COVID has relied on public service announcements. With the approval of the Pfizer COVID vaccine, I hope that Pfizer will contract with American advertising companies to create vaccine advertisements. Advertisers know how to sell products better than doctors or scientists. I look forward to the day that Pfizer vaccine ads appear on the Fox News Channel.

September 1, 2021

Categories
Intensive Care Unit

Your Right To Get COVID Stops Where Our ICU Begins

This post is on behalf of all physicians, nurses, and respiratory therapists who work in U.S. intensive care units.

To all anti-vaxxers and anti-maskers:

For months, you have been telling us that you deserve the freedom to choose: to choose whether or not to get a COVID-19 vaccine and to choose whether or not to wear a face mask in public places. In other words, you have been saying that it is your right to get infected with COVID and that measures to prevent it are an assault to your freedoms as an American. Although it is true that you do have the right to do a lot of dangerous things that jeopardize your health and your lives, you do not have the right to do dangerous things that jeopardize our health and our lives. And when you get COVID, you are doing just that.

  • You have the right to smoke cigarettes. But when you get lung cancer, your metastases are not contagious to the oncologist.
  • You have the right to promiscuous unprotected sex. But when you get gonorrhea, your sexually-transmitted disease is not contagious to the nurse in the emergency department who takes care of you.
  • You have the right to use intravenous heroin and fentanyl. But when you overdose, your respiratory failure is not contagious to the respiratory therapist.

You say you have the freedom to choose to not wear face masks and to not get a vaccination. But as healthcare workers, we do not have the freedom to refuse to take care of you when you become infected with COVID and need us to care for you in our ICUs.

Currently in the United States, 30% of all patients in our ICUs have COVID. In many parts of Texas, Florida, Louisiana, and other southern states, the majority of patients in ICUs have COVID. Although nearly two-thirds of American adults have gotten a COVID vaccine, 98% of all of the hospitalized COVID patients are unvaccinated. In many U.S. cities, there are no empty ICU beds left and that means that when a patient comes in with a heart attack, pneumonia, or a stroke, we do not have an ICU bed to care for that patient.

Your self-professed freedom to get COVID means that we have to work extra shifts, sometimes 24 or 36 hours straight, because there are too many COVID patients in our ICUs to take care of with our normal number of staff. Every time we walk through the door into an ICU room to care for a patient with COVID, we are exposing ourselves to the deadly contagious virus and we are risking our lives to take care of that patient.

In the beginning of the pandemic, before vaccines were available, we worked tirelessly when our ICUs were overwhelmed with sick and dying COVID patients. We did it because it was our duty to take care of all of the innocents who could not prevent their viral infections. It is what we signed up for. The emotions of sadness, fear, and exhaustion that we felt in the summer of 2020 have been replaced by the emotion of resentment because in the summer of 2021, almost all COVID ICU admissions were avoidable.

Like the intravenous drug users who occupy beds in our ICU because of an overdose, you are occupying our ICU beds because of your bad life choices. Unlike those intravenous drug users who will wake up and get out of our ICUs after a day or two, you will spend an average of 14 days in our ICUs and 20% of you will die in our ICUs. During those 14 days, you are taking up beds needed by other patients with diseases that were not caused by bad life choices.

The average cost of a hospitalization for COVID is $20,000 and if that hospitalization includes admission to the ICU, the cost is 5-10 times that much. In July 2021 alone, the hospitalization costs of unvaccinated COVID patients in the U.S. was $1.5 billion. Those costs are paid by health insurance companies and passed on to all of the rest of us by increased health insurance premiums and Medicare payroll taxes. In other words, your self-declared freedom to get COVID is paid for by higher insurance costs to those of use who got vaccinated and wear face masks. We are tired of paying for your bad life choices.

We watch on the news as you angrily demonstrate against vaccines and face masks at our statehouses. We read on social media about your delusions that vaccines cause disease. We hear you call us fascists because you are required to wear face masks when you enter the restaurants we eat in, stores we shop in, and hospitals we work in. And all the time, we are desperately trying to save your lives when you get sick from COVID infections that you could have prevented. It is as if Satan has taken over your minds and now our entire country needs an exorcism.

But we will continue to take care of you in our hospitals and in our intensive care units. The code of ethics that we are bound by dictates that we must. We only wish that your code of ethics was as virtuous.

August 29, 2021

Categories
Epidemiology

The Lunatic Fringe

From time to time, I get letters in response to some of my posts. In the interest in providing an equal opportunity to present opposing viewpoints, I am posting a letter responding to my recent post entitled “Anti-Vaccine Laws Are Anti-Business Laws“.

Dear Dr. Allen,

I am writing to you about your recent blog post where you said that businesses ought to be allowed to mandate vaccines for their employees. I could not disagree more. The legislation proposed in Ohio House Bill 248, introduced by Representative Jennifer Gross, will prevent businesses, schools, and hospitals from mandating their employees and students get vaccines. This bill a great idea because everybody knows that vaccines make your body become magnetic but it needs to go further. I’m tired of so many government mandates that interfere with American freedoms. I believe that this bill needs to include amendments prohibiting other intrusive mandates.

The first mandate that needs to go is the requirement that restaurants mandate employees have to wash their hands after using the bathroom. Why should a business require its employees to wash their hands? I saw on Facebook that washing your hands causes hand cancer – these restaurants are simply mandating that their workers get hand cancer. Before you know it, everyone is going to be running around with their hands amputated off because of hand cancer. And then if no Americans have hands any more, then who is going to keep all of the illegal immigrants out? Unbelievable! I also read in People magazine that Ashton Kutcher doesn’t take baths or showers. The doctors say that washing your hands is good hygiene but who are you going to believe, Ashton Kutcher or a bunch of doctors? I’ll take Ashton any day.

And speaking of restaurants, I’m sick and tired of seeing signs on the doors that say “No shirt, no shoes, no service”. They have no right to mandate that I wear clothes into their building. I was born naked and if that is good enough for God, then it sure ought to be good enough for these restaurants! Besides, these signs are unconstitutional. It clearly says in the second amendment that Americans have the right to bare arms. So, if we have the right to bare arms, don’t we also have the right to bare feet?

Last month, I had to have my bunions removed and when they were taking me into the operating room, all of the doctors and nurses were wearing face masks. Face masks! Can you believe it? I asked them what in the world they were doing and they said that that face masks were mandatory when they do surgery. Everyone knows that face masks give off toxic chemical fumes and prevent oxygen from getting into your brain. I didn’t want some oxygen-starved surgeon who was high on face mask chemicals operating on me! I walked right out of that operating room and decided to leave my bunions right where they are.

And another thing, there are businesses out there that are mandating that employees have driver’s licenses. I tried to get a job as a school bus driver because I heard they make good money. A few years ago, some idiot judge took away my driver’s license just because I had 17 DUIs. Not only is the government mandating that I can’t drink a few Budweisers while I’m driving but the school system is mandating that I have to have a valid driver’s license to drive a bus. I took driver’s ed back in ’67 when I was in high school so why should I have to have a driver’s license? Ridiculous.

And what about mandatory in-service training? My brother-in-law is a pilot for Delta and he tells me that Delta is mandating that he have in-service training before he can fly one of their new jets. Can you believe it? Anyone who can fly a Cessna can fly a 737. These mandatory in-service trainings need to be against the law! And don’t even get me started about mandatory staff meetings! 

And talking about airplanes, I flew to Vegas last month and at the airport, they made me go through a TSA check. It was scandalous!. They said it was to check for weapons because the government mandates that people can’t take guns onto planes anymore. When did that happen? Ohio needs a law prohibiting TSA mandates about weapons checks. What are we going to do if the plane gets taken over by a bunch of space aliens that beam onboard? How are we supposed to defend ourselves then? If TSA takes the guns from law-abiding citizens, pretty soon the only ones on the planes who have guns will be the space aliens.

I’ve also heard that tickets are mandatory to get into Ohio State University football games. This is appalling! OSU is a state-supported university and I am an Ohio taxpayer so why should I have to buy a ticket to get in to see a football game? Whats next – are they also going to mandate that you have to pay for hotdogs and beer at the concession stand too?

For years, people have been telling me that I’m a left-wing extremist on the lunatic fringe. Well, even though Ohio Representative Jennifer Gross is a Republican, I’m still glad to have her join me in the lunatic fringe!

Sincerely,

Mr. I.M. Stultus

August 26, 2021

Categories
Hospital Finances Inpatient Practice

Avoid Losing Money On Medical Admissions: 30 Tactics

Every hospital medical director knows that the hospital makes money on surgical admissions and loses money on medical admissions. A highly efficient hospital can at best hope to break even on medical admissions. Nevertheless, those medical admissions are a crucial part of a hospital’s obligation to provide comprehensive community healthcare. The profitability of surgeries and surgical admissions is why there was a proliferation of surgical specialty hospitals between 1995 and 2010.

The number of hospitals and hospital beds has dropped significantly over the past 45 years. In 1975, there were 9,156 hospitals in the U.S. and in 2019, that number had fallen to 6,090 hospitals. In 1975, there were 1.5 million hospital beds in the United States but by 2019, there were only 920,000. However, in the past decade, the market size of specialty hospitals has grown from $46 billion in 2011 to an estimated $51 billion in 2021. The majority of specialty hospitals are long-term acute care hospitals (LTACHs) or rehabilitation hospitals but 6% of specialty hospitals are dedicated to orthopedic surgery and 5% to cardiac surgery. Some of the greatest opposition for surgical specialty hospitals has come from the American Hospital Association because of concern that surgical specialty hospitals will “skim off the cream” of revenues from general hospitals, making it more difficult for general hospitals to continue to stay in business.

In the past, the majority of surgical specialty hospitals (70%) were physician-owned, typically by the surgeons who operated there. The Affordable Care Act restricted the growth of new physician-owned surgical specialty hospitals in 2010 but allowed existing physician-owned specialty hospitals to be grand-fathered and continue to operate. So, for now, general hospitals can retain their surgical volume but these hospitals must also seek ways to keep from losing money on medical admissions.

CMS publishes the amount that it reimburses hospitals for every type of diagnosis, by DRG. These datasets show reimbursement averaged across the country, by each state, and by each individual hospital.  The most recent data is from 2018. Of the top 20 most common admission DRGs, 18 were medical (red bars in the graph below) and only 2 were surgical (blue bars).

However, if we look at the top 10 most common medical DRGs and the top 10 surgical DRGs, there is a dramatic difference in total payments (the amount paid by Medicare plus the amount paid by the patient or by co-insurance). The average total hospital payments for the top 10 medical diagnoses was $8,833 but the average total payments for the top 10 surgical diagnoses was $23,971. In fact, the lowest reimbursing surgical DRG ($14,761) still paid more than the highest paying medical DRG ($13,881).

So, with medical admissions predominating in the United States and with hospitals at best maintaining a razor-thin margin on those medical admissions, how can hospitals stay in business? The simple strategy is to do more surgeries. This is why hospitals are always eager to build new operating rooms, subsidize high surgeon salaries, and provide surgeons amenities such as physician assistants and nurse practitioners to attract more surgeons to their medical staff. But the other strategy hospitals can take is to avoid losing money on medical admissions. Because of the greater number of medical admissions, small improvements in throughput efficiency of medical patients can have a huge impact on the overall financial margin. Here are 30 specific tactics hospitals can take:

  1. Measure length of stay accurately. In a previous post, I outlined why using the midnight census as a measure of length of stay is obsolete. It is more insightful to measure length of stay in terms of total hours of hospitalization plus daytime hours of hospitalization. This can provide the hospital with much more meaningful data about throughput efficiency. Longer length of stay means more costly hospital stays. In order to decrease length of stay, first you must be able to measure it in a meaningful way.
  2. The work-up starts with the admission orders. Medical admissions tend to peak in the early evening. By this time, the night shift hospitalists are on duty. In many hospitals, the culture is to tuck patients in at night and then leave the work-up to the daytime medical team. As a consequence, a single hospitalist is often tasked with doing a large number of admission history and physical exams at night. A hospitalist doing 10-15 admissions a night does not have time to do much diagnostic planning – all he or she can do is put out fires. If a patient comes in with heart failure, the orders for a cardiology consult or cardiac echo is often left up to the daytime physician. This can result in delays of hours or even an entire day, depending on what time of day the daytime physician rounds. Establish an expectation that the night shift hospitalist put in orders for tests and consults necessary for that patient’s work-up. Also, ensure that the hospital is adequately staffed with physicians and/or advance practice providers during times of peak admissions. This may require a swing shift hospitalist or short shift hospitalist to help during the busy evening hours.
  3. The day shift hospitalist should not have to re-do the admission history and physical exam from a night time admission. This can be a waste of time and delay getting necessary diagnostic testing performed. The H&P done at night needs to be readily available first thing in the morning. If the hospitalists use a dictation service, then ensure that the transcription turn-around time of the dictated H&P is short enough that the day shift hospitalist can see it first thing in the morning. If the H&P is performed using electronic medical entry key entry, then ensure that the impression and plan is thorough and insightful – not just a list of symptoms and physical exam abnormalities at the end of the H&P.
  4. Consult frequently and consult early. I see this as one of the most common reasons for delayed discharges. Maybe the hospitalist wants to wait to see what the cardiac echo shows before consulting the cardiologist. Or maybe wait to see if the patient with a COPD exacerbation starts to turn around after a couple of days of steroids and bronchodilators before ordering a pulmonary consult. In some hospitals, the culture is that the hospitalist who consults liberally is not a good enough doctor to take care of the patient by themself. There should be a clear expectation that a consult is not a sign of weakness. This expectation should be both on the part of the hospitalist and on the part of the specialty consultants. The specialist who complains that he or she gets consulted too often is unworthy of any financial support from the hospital and has no place on the medical staff. In teaching hospitals, residents and fellows involved in consultation need to be educated that there is no consult question too small. Inpatient medical care is a team sport, not an individual sport – the faster the team is assembled, the faster the patient gets better.
  5. Consultants should place their own orders. One of the best ways to extend a patient’s length of stay is to prohibit consultants from placing orders. Sometimes this occurs because the hospitalists are territorial about orders and do not want anyone other than themselves entering orders on their patients. Sometimes this occurs because the consultants are fearful of the responsibility of putting in order, are lazy, or just do not know how to put orders into the electronic medical record. Hospitalists generally round once a day on their patients and if they round early in the morning and a consultant recommends a test or medication change in their consult note later in the morning, that consultant’s recommendation may not be seen for a full day. I’ve seen too many discharges delayed because the gastroenterologist would not place an order for a colonoscopy prep or a neurologist would not place an order for a brain MRI.
  6. Utilize protocol-driven de-escalation. One very effective protocol that our hospital used was a nurse-driven urinary catheter removal protocol. As soon as a patient met certain criteria, the nurse was empowered to remove the Foley catheter without a specific order from a physician to remove it. Other examples are pharmacist-driven IV to PO medication conversion protocols and respiratory therapist-driven de-escalation of nebulizer treatment frequency.
  7. Be a 7-day a week hospital. Patients are no less sick on Sunday as they are on Wednesday. Not every hospital has the staff or resources to provide every procedure or test on weekends but it is important to identify those tests that need to be done on the weekend to avoid delays in discharge. One way of doing this is to compare the number of tests or procedures done on Mondays compared to other weekdays. If you find that there is a spike in PICC line placements, cardiac stress tests, or duplex ultrasounds on Mondays, then that may be a sign that those procedures need to be offered on Saturdays and Sundays. Sometimes the weekend delay is due to a delay in a second, downstream procedure. For example, if the pathology lab only processes biopsy specimens on weekday mornings, then there is no point in doing a bronchoscopy or a CT-guided needle biopsy between noon on Fridays and 8:00 AM on Monday since specimens will not be processed in the lab until the following Monday. If you get resistance to offering tests on the weekend because “…the procedure volume isn’t there“, then see if part of the procedure schedule can be filled with elective outpatients. You may find that there are many outpatients who do not want to take a day off of work during the week to get their screening colonoscopy or their knee MRI and would prefer to get them done on a Saturday or Sunday.
  8. Discharge planning starts on admission. It usually takes several days to arrange for a nursing home bed and the sooner your case management staff can start to work on discharge planning, the faster you can get the patient out of the hospital.
  9. Be creative when it comes to long-term IV antibiotics. Drug abuse is rampant in the United States and people who abuse drugs get osteomyelitis and endocarditis, often requiring 6-8 weeks of intravenous antibiotics. Because of their drug use history, home healthcare companies will not accept them for home IV therapy so they stay in the hospital. For that 6-8 week hospitalization, the average hospital payment by Medicare is $10,476 for osteomyelitis and $13,042 for endocarditis. With those payments, the hospital starts losing money after about day #4. Consider tamper-resistant PICC lines for drug abusers so that they can get their IV antibiotics as outpatients. When can the patient be safely changed to an oral antibiotic to complete therapy – for example, can oral Bactrim be substituted for IV vancomycin? There are several recent studies demonstrating the safety and efficacy of treating these patients with oral antibiotics but many national special society practice guidelines have not been updated and still advise IV antibiotics for the entire treatment duration. Your hospital may need to create its own evidence-based practice guideline to empower the physicians to complete treatment for osteomyelitis and endocarditis with oral antibiotics. If a patient is uninsured, it is going to be less expensive for the hospital to give the patient a daily IV antibiotic in an outpatient infusion suite than as an inpatient. The same goes for expensive oral antibiotics that the patient may not be able to afford as an outpatient, such as daptomycin.
  10. LTACHs are your friend. Long-term acute care hospitals (LTACHs) are one of the most common types of specialty hospitals. All too often, we think about LTACHs as a discharge option for patients late in their hospitalization. Frequently, these patients met LTACH criteria earlier in their hospitalization but by the time the referral goes to the LTACH, the patient no longer meets criteria. Even if they do still meet criteria, it often takes several days to get insurance approval for the LTACH. Consider putting together a protocol that any patient admitted in the ICU for more than 3 days gets an automatic consult to your local LTACH. That consult does not obligate you to discharge the patient to the LTACH but it can shave valuable days off of the length of stay for those patients who ultimately do benefit by transfer to an LTACH.
  11. Don’t forget about physical therapy. As a pulmonary consultant, one of the most common orders I would place was for physical therapy because the primary inpatient physician did not think about it. For patients who will eventually be discharged home, the physical therapist can get them strong enough to be discharged earlier. For patients who may need to be discharged to a skilled nursing facility, the physical therapist’s assessment can be instrumental in getting started on the SNF referral earlier in the hospitalization. If your COPD exacerbation and heart failure exacerbation patients have not gotten out of bed in the first 4 days of their hospitalization, you are going to lose money on that hospital admission.
  12. Don’t order expensive stuff if you don’t have to. There are certain tests that are very expensive to perform and there are tests that take days or weeks to get the results back. Often, the results of those tests are not necessary for the outcome of an inpatient hospitalization. When ordered as an outpatient, these tests are individually charged to Medicare or the insurance company. But when ordered as an inpatient, the hospital assumes the cost of performing these tests as part of the global DRG payment that the hospital gets for whatever primary diagnosis the patient has. In some cases, the cost of the test is more than the total amount that the hospital gets for the patient’s DRG. The biggest offenders here are genetic tests. Each year, Medicare publishes its Clinical Diagnostic Laboratory Fee Schedule, which is the amount that Medicare will pay for any given lab test. Some of the more expensive tests that you should avoid ordering as an inpatient include exome sequence analysis ($12,000), gene analysis of breast tumor tissue ($3,873), gene analysis for colon cancer ($3,116), and epilepsy gene analysis ($2,448). Wait until the patient returns for an outpatient appointment to order these tests. Similarly, if a patient admitted with pneumonia mentions that he has had knee pain for the past 5 years, don’t order an inpatient knee MRI, instead schedule an outpatient rheumatology appointment and let the rheumatologist order the MRI.
  13. You need a robust antimicrobial stewardship program. A commonly held belief among physicians is that if a little is good then more must be better. This does not always apply to antibiotics. Sometimes an older, generic antibiotic is not only considerably less expensive than the newest generation cephalosporin but that older antibiotic many actually be the better drug for a given infection. Your hospital will pay twice for excessive use of antibiotics – first in the initial cost of expensive antibiotics and later in a rise in drug-resistant hospital-acquired infections that will result from over-zealous use of broad-spectrum antibiotics. A responsive antimicrobial stewardship program will keep both of these costs down.
  14. Capture all of the CCs and MCCs. Co-morbid conditions (CCs) and major co-morbid conditions (MCCs) are used like adjectives to the DRG. If a patient with sepsis also has hyponatremia and leukemia at the time of admission, then the hyponatremia is a CC and the leukemia is an MCC. The more adjectives you attach to that DRG when the hospital submits its bill to Medicare or an insurance company, the more money the hospital gets paid for that particular DRG. The CCs and MCCs also make the case mix index higher which can affect metrics such as mortality index and length of stay index. One of the problems is that the CCs and MCCs need to be listed in a physician’s history and physical exam or be listed in a progress note as being “present on admission”. Hospitalists are not inherently rewarded for tediously listing out all of the CCs and MCCs since they get paid the same amount for doing an H&P no matter how many CCs and MCCs a patient has. Therefore, the hospital either has to find a way to financially incentive listing out CCs and MCCs (for example, incentives based on case mix index) or find another mechanism for identifying CCs and MCCs (such as having nurse charting specialists review every patient chart at the time of admission and then having them ask the hospitalist to make addendums to their H&Ps accordingly).
  15. Leave the procedure schedule open in the morning. In most hospitals, diagnostic tests are performed on both outpatients and inpatients in the same location. The schedulers will usually fill up the schedule by starting with the earliest appointment of the day. Consequently, outpatients who are scheduled days or weeks in advance will be put in the morning slots, leaving inpatients to get their tests at the end of the day. At best, that results in a several hour discharge delay for many patients and at worst, it results in an entire day delay in discharge. If you have a relatively predictable number of these tests that are commonly done on inpatients, then block out the first morning appointments on the outpatient schedule so those inpatients can get their tests early in order to get them discharged faster. Procedures where this tactic can be useful include cardiac stress tests, cardiac echos, cardiac catheterizations, duplex ultrasounds, and colonoscopies/endoscopies.
  16. Manage long length of stay patients. A hospital is not a hotel. The hotel gets paid by the number of nights a customer is in a room. The hospital gets paid a set amount based on the patient’s DRG regardless of how many nights a patient is in a room. Once the hospital generates expenses equal to the DRG, the hospital loses more and more money each day that patient remains in the hospital. A weekly workgroup consisting of case management, social service, hospitalists, psychiatry, the medical director, and legal can identify those long length of stay outliers and develop strategies to get them out of the hospital. I would review the hospital census weekly and call the hospitalists responsible for patients with a length of stay greater than 2-3 weeks to ask what I could do to help expedite discharge. Sometimes, all it took was that phone call to get the discharge ball rolling.
  17. Don’t overdo observation status. When a patient arrives in the emergency department, if it appears that the patient’s condition can be treated within 2 midnights, then that patient is placed in observation status. This is an outpatient designation and as such, the patient will be responsible for a generous co-pay and be responsible for their medication charges. These charges frequently go unpaid (especially by lower income Medicare and Medicaid patients) and the hospital has to write them off. If the financial margin is thin for medical inpatient admissions, it is non-existent for observation status patients. Most of the observation status patients are there for a medical condition, such as chest pain, syncope, or heart failure. A disconnect between the hospitalists and the hospital is that the hospitalist gets paid exactly the same by Medicare or commercial insurance whether the patient is an inpatient or observation status. However, entering enough justification data into the H&P to warrant inpatient admission (versus observation status) can be tedious and so some hospitalists will take the path of least resistance in borderline patients and put them in observation status. Measure your observation length of stay and if it is > 2.0 days (or > 18 daytime hours), then you have a problem. Either you are keeping the observation patients in the hospital too long or you are mislabeling patients as being in observation status that should really be in inpatient status. If it is the former, then consider creating an observation unit that specializes in protocol-driven care of observation status patients (perhaps staffed by NPs/PAs). If it is the latter, then work with the hospitalists to be sure that they are educated about the difference in observation status versus inpatient status and eliminate any hidden incentives that are causing them to preferentially put patients in observation status.
  18. Use disease-specific order sets. You have an electronic medical record, now harness it. If you want to be sure that patients admitted with a COPD exacerbation are getting oral steroids and oral generic azithromycin rather than IV Solu-Medrol and IV levofloxacin, then create a COPD order set with the desired medications in it. Same goes for ensuring that patients with heart failure get a cardiology consult and a cardiac echo. I have admitted thousands of patients to the hospital and when entering orders a al carte, it is way too easy to forget to order a needed test or to order an expensive drug when a cheaper drug would have been as good or better. Order sets make it simple for the admitting hospitalists to treat medical conditions efficiently and effectively.
  19. Get the pharmacists up on the patient floors. I cannot overstate the value of hospital pharmacists. They are way overtrained for how we too often use them. Allow them to practice at the top of their license. They know more about medications than the doctors do and can be an invaluable resource for discontinuing drugs that are no longer needed (such as antibiotics), eliminating duplicate medications, avoiding drug-drug interactions that can prolong hospital stays, dosing medications correctly for renal function/liver function/age, etc. In the best of all worlds, the pharmacists would round with the physicians daily as part of multidisciplinary rounds. At the least, a pharmacist should meet with the hospitalists daily to do a quick medication review of each patient.
  20. Get eligible patients signed up for Medicaid. When Medicaid expansion came to Ohio, our hospital’s self-pay rate fell from 13.0% of all inpatient admissions to 2.5% of admissions. Many patients who are eligible for Medicaid do not sign up for it on their own either because they didn’t think they would need it before they got sick or because they didn’t know how to sign up. Our patient financial services staff were outstanding and identified these patients at the time of admission and assisted them in getting on Medicaid. Although hospitals do not make much on Medicaid patient admissions, it is more than they make on uninsured patient admissions.
  21. Focus on the ICU. The most expensive care that most medical patients receive is in the intensive care unit. It therefore follows that the hospital will get the greatest cost savings by reducing ICU length of stay and ICU expenses. Specific measures can include respiratory therapy-driven ventilator weaning protocols, daily multidisciplinary rounds, and use of “ventilator bundle” order sets. Palliative medicine is almost never able to be self-supportive based on physician billings alone and can be very expensive for the hospital to subsidize. The ICU is one location where the cost of palliative medicine can be more than offset by the expense reduction that palliative medicine can bring.
  22. Support the inpatient psychiatry consultation service. Patients with pure psychiatric conditions, such as suicidal ideation and decompensated schizophrenia, generally go straight from the emergency department to an inpatient psychiatry hospital. However, if those same patients also have an uncontrolled medical condition, then they get admitted to a general hospital as medical admissions. Like palliative medicine, psychiatry consult services usually require hospital support and cannot survive on physician professional billing alone. Patients with dual diagnoses (medical plus psychiatric) often have the longest length of stay. Ensure that daily inpatient psychiatric consultation is available and utilized early in these patients’ hospital stay.
  23. Avoid boarding in the emergency department. When a patient in the emergency department has an inpatient admission order placed but there are no available inpatient beds, then that patient remains in the ER as a “boarder”. Boarders are patients languishing in a purgatory between the inpatient world and the outpatient world. The ER physicians no longer considers the patients their responsibility and the hospitalists are usually up on the inpatient floors and not physically present in the ER to attend to the boarders. The patients become the lowest priority for the ER nurses, tests do not get done, and consultants do not come down to see the patients in the ER. If you have a lot of boarders, then you have a long length of stay and a congested emergency department. Usually boarders mean that the length of stay of your inpatients is too long or you just don’t have enough inpatient beds. If boarding usually occurs on the same day of the week, then look at your elective surgical admissions to see if they can be better spread across all days of the week to prevent boluses of surgical admissions on certain days.
  24. Manage the hospital formulary. Most physicians have absolutely no idea how much medications cost. They may read an article about a new drug that they now want to prescribe or be lobbied by a pharmaceutical company representative to get an expensive new drug on the hospital formulary. Maybe you have several strong-willed physicians who have strong personal opinions about different drugs used to treat the same thing with the result that you end up with a lot of duplicate drugs on the formulary. If the formulary is too large, then there is a danger of having to waste too many expired drugs and danger that a more expensive drug will be used when a less expensive drug would have done the same thing. The formulary committee that takes an evidence-based approach to putting new drugs on the hospital formulary can keep costs down.
  25. Transition care clinics. Hospitalists and primary care physicians live in different worlds that do not intersect. Hospitalists want to get the patient fully “tuned up” before releasing that patient to the wild unknowns of the outpatient world. Transition clinics can be very helpful to give the hospitalists the confidence to discharge patients as soon as they are ready to be discharged rather than waiting “just one more day to be sure they’re ready to fly on their own…“. The specialties that are most amenable to transition clinics are pulmonary, heart failure, and diabetes.
  26. And a word about TB… OK, as a pulmonologist, I have a pet peeve. When a patient comes in with respiratory symptoms and tuberculosis is even a remote consideration, then that patient is placed in a negative airflow room and nothing happens until that patient has 3 negative sputum AFB stains. In the past, this meant 1 sputum sent to the microbiology lab every day for three days. This is unnecessary. The sputum samples only need to be separated by 8 hours so patients should be able to come out of discharge-delaying airborne isolation in just 1 day instead of 3 days. Make sure that the hospitalists order the sputum AFB samples every 8 hours, the nurses collect them promptly every 8 hours and the lab performs AFB stains 7 days a week – it will take 2 days off of these patients’ length of stay.
  27. Do you need an inpatient hospice? An inpatient hospice that is separate from the host hospital (i.e., has a different corporate taxpayer ID) can help earlier discharge of patients going to hospice and can avoid many ICU patients spending their last days of life in the intensive care unit after a decision to withdraw supportive care is reached. In order to be financially viable, most hospice organizations will not want to create an inpatient hospice unit unless they can be assured of keeping at least 4 hospice beds full before they will lease space from the host hospital. This may not be possible for small hospitals but can be very effective for larger hospitals. If you cannot justify an inpatient hospice unit in your hospital, then build a partnership with a free-standing inpatient hospice.
  28. Partner with SNFs and home healthcare agencies. Strong relations with skilled nursing facilities that you trust to provide high quality can be mutually advantageous. They get preferred provider referrals from you and your patients get to the top of their wait list. Similarly, strong relations with home healthcare companies and home oxygen companies can ensure that home nursing care or home oxygen can be readily available at the time of a medical patient’s discharge, even if that discharge happens on short notice.
  29. Get the right culture about quality. Fundamentally, the quality department should be focused on patient safety and infection control. But the scope of quality has expanded over the past 20 years and now issues such as hospital readmission rates, inpatient length of stay, and physician coding compliance often fall under the purview of the quality department. As a result, the quality department has become the messenger of all things bad to many physicians. A phone call from the medical director of quality is about as welcome as a phone call from an IRS auditor. As a consequence, many physicians have come to fear the quality department. Instead, the physicians and the quality department should be working together toward mutual goals of infection control and patient safety. If the hospitalist is worried about getting a call to the office of the director of quality because the hospital readmission rate is going to result in a $20,000 annual Medicare readmission penalty to the hospital, that hospitalist is going to increase his/her patient length of stay in order to be sure that the patients are good and ready to be discharged and not come back, even if the cost of that increased length of stay results in an extra annual $500,000 of hospital expenses.
  30. Avoid the “dailies”. Do your ICU patients on ventilators really need a daily chest x-ray to check the position of their endotracheal tube? Does your patient with heart failure getting diuresed on a medical unit really need a daily CBC? If you ask your hospitalist or intensivist why they order daily labs and x-rays, they will usually say that it is because that’s the way they’ve always done it. Many times, these are unnecessary. Similarly, the Q shift I/Os can cost an extra 15 minutes of nursing time every day and are not necessary for every inpatient. A daily weight may be an extra 5 minutes.

Parity between medical and surgical admission reimbursement is nowhere on the immediate horizon. Until such parity exists, hospitals need to both encourage more surgical admissions and better manage the costs of medical admissions. These 30 tactics will get you off to a good start.

August 24, 2021

Categories
Hospital Finances Inpatient Practice

When It Comes To Length Of Stay, We Are Measuring The Wrong Thing

Hospital length of stay (LOS) is one of the most important metrics we use to judge hospital efficiency and to predict whether the hospital is making money or losing money on different diagnoses. LOS is measured in days with each day defined as whether a patient is considered admitted to the hospital at midnight. This is the so-called midnight census. I believe that the midnight census is no longer a valid measurement for the calculation of the duration of hospitalization.

Never admit a patient between 10 PM and midnight

If your hospital judges or bonuses hospitalists based on length of stay, then those hospitalists know to avoid writing admission orders in the two hours before midnight. The simple reason is that when the midnight hour strikes, that patient is already considered to have been in the hospital for one day when using the midnight census of admitted patients to measure length of stay.

Consider two patients, patient A and patient B who both arrive in the emergency department with pneumonia on a Tuesday evening. The ER physician determines that both patients need to be admitted to the hospital and the on-duty hospitalist is called to the ER to write admission orders. Patient A has an admission order placed at 11:59 PM and patient B has an admission order placed at 12:01 AM, two minutes later. Both patients improve with medical treatment and are ready to be discharged on Friday. Patient A is discharged at 8 AM Friday morning and patient B is discharged at 4 PM Friday afternoon. By using the midnight census to measure duration of hospitalization, patient A has a length of stay of 3 days and patient B has a length of stay of 2 days. However, patient A was actually hospitalized for 56 hours and patient B was actually hospitalized for 64 hours. Using the midnight census measurement, patient B’s hospitalization was  33% shorter than patient A’s but based on hours in the hospital, patient B’s hospital stay was 14% longer than patient A’s.

Hospitalists are aware of this and if they are judged by the number of midnights their patients are in the hospital, they will delay writing an admission order until after midnight whenever feasible in order to improve their LOS numbers.

“I’m getting my discharge orders written earlier in the day, so why isn’t my length of stay improving?”

Hospital administrators want to have patients discharged as early in the day as possible so that rooms can be cleaned and ready for the next bolus of hospital admissions. By using the midnight census, a patient’s length of stay will be the same whether that patient is discharged at 7:00 AM or 5:00 PM. Thus initiatives to get patients discharged earlier in the day will not affect the length of stay as measured by the midnight census.

In order to measure hospital efficiency, the hospital must measure both the length of stay and the time of day of discharge. However, the time of day of discharge is also fraught with flaws. For example, if a hospital bonuses its hospitalists on earlier discharge orders, the hospitalists may hold off on discharging a patient who is ready for discharge in the late afternoon and instead discharge them early the following morning so that their numbers look good. Additionally, depending on when a patient was admitted to the hospital, a patient discharged in the late afternoon may actually have a shorter duration of stay (in hours) than a patient discharged early in the morning. In that case, you don’t want to penalize the hospitalist for getting the patient out of the hospital faster, simply because that patient was discharged in the afternoon.

So, why use the midnight census to measure length of stay?

Hospitals have used the midnight census for decades. In the pre-computerization era, it was the most easy and reliable way to know how many patients were in the hospital – unit clerks or nursing supervisors would write down the number of admitted patients on each nursing unit at midnight and then report that to the hospital administration the following morning. That was also an era when hospitals typically ran at a lower capacity with the result that there were always empty beds to admit patients to and consequently, there was not pressure to get patients discharged as early in the day as possible.

In the pre-computerization era, it was difficult to track the time of day that a patient was discharged since it required someone to manually go through each patient’s paper chart to collect the time of day of that patient’s admission and discharge; many doctors did not enter the time of day that they hand wrote their orders and many nurses did not enter the time of day that they took those orders off of the patients’ charts. Electronic medical records have changed all of that and now the exact time an admission or discharge order is placed and acted on can be measured with a keystroke. Yet, the midnight census remains as a hold-over from the pre-computer era.

In addition, before the institution of diagnosis-related groups (DRGs) by Medicare in 1983, it really did not matter how long a patient was in the hospital since the hospital was usually paid by number of days that a patient was in the hospital. As a result, the longer the length of stay, the more the hospital got paid. With  DRGs, hospitals got paid based on a patient’s diagnosis and not based on the length of stay. Therefore, hospitals became motivated to shorten the length of stay in order to reduce their expenses for each patient. Once again, the midnight census remains a hold-over from the pre-DRG era.

The institution of DRGs was also a turning point for the time of day that patients were hospitalized. Prior to DRGs, most hospital admissions were elective admissions and those patients often had pre-planned testing and treatments and were usually admitted to the hospital in the late morning or early afternoon. Nighttime emergency admissions through the ER were less frequent. With daytime elective admissions predominating, the midnight census was a reasonably good measure of length of stay. DRGs brought an end to most elective medical admissions with a shift to the overwhelming majority now being admitted through the emergency department with the peak in ER admissions typically in the late afternoon or early evening. With that shift, the midnight census became a less accurate metric for measuring actual length of stay.

Length of stay should be measured in hours and not in days

The midnight census is a satisfactory measure in patients with a very long length of stay – if a patient is in the hospital for 50 days, then whether that is actually 49 days or 51 days has little impact on hospital efficiency. But as the hospital length of stay becomes shorter, the midnight census becomes a less accurate measurement. Given the flaws of using the midnight census to measure length of stay, I believe that we should move to measuring LOS by the hour. Our electronic medical records makes hourly measurement quite easy.

However, there are two types of hours in the hospital – daytime hours and nighttime hours. During the daytime, hospitalists do daily patient rounds, diagnostic tests are performed, surgeries occur, and consultants evaluate patients. During the nighttime, patients receive medications but the other daytime activities do not take place. In other words, more of the stuff that needs to happen in order to evaluate and treat the patient happens during the daytime hours. For this reason, a patient will spend fewer total hours in the hospital if admitted early in the daytime than if admitted early in the nighttime. Therefore, to accurately assess hospital efficiency, length of stay should be measured in both total hours of hospitalization and daytime hours of hospitalization.

The advantages of using total and daytime hours of hospitalization, rather than the midnight census, to measure length of stay include:

  • A more accurate measure of duration of patient hospitalization, especially for shorter duration hospital admissions
  • A more accurate measure of duration of observation stays which are inherently ultra short-duration stays
  • Elimination of the measurement bias that occurs with nighttime admissions as opposed to daytime admissions
  • Better representation of the effect of early-in-the-day discharge initiatives on length of stay
  • Better identification of individual hospitalists or hospitalist groups that could benefit by patient throughput efficiency training

The biggest barrier is the length of stay index

Hospitals benchmark their length of stay to other hospitals using the length of stay index. If a hospital’s length of stay for a given DRG diagnosis is 4 days and the average of hospitals across the country for that diagnosis is also 4 days, then that hospital’s length of stay index is 1.0 and the hospital has an average length of stay for that diagnosis. If the length of stay index is 1.2, then the hospital requires more inpatient days for that diagnosis and likely has greater expenses per admission. However, if the length of stay index is 0.9, then the hospital is able to treat that diagnosis with fewer inpatient days and likely has lower expenses per admission.

Hospital length of stay benchmarks use the midnight census for length of stay calculation and as long as benchmarks continue doing so, any given hospital will need to continue to measure and report midnight census-based length of stay measurements to determine how that hospital is performing compared to other hospitals.

Nationwide change to an hour-based length of stay measurement (and thus length of stay index measurement) will not happen quickly – the midnight census measurement is just too entrenched in administrative practice and data reporting. However, a hospital that internally uses an hourly measure of length of stay will have a more accurate measurement of its own efficiency and that data can be used gain a competitive advantage.

It is time to move past the midnight census.

August 20, 2021

Categories
Epidemiology

Anti-Vaccine Laws Are Anti-Business Laws

The above is a clip from the website of a restaurant in Bar Harbor, Maine. I’ll be in Bar Harbor next month and will only order food at restaurants that I feel are safe. I’ll be taking my business to this restaurant because they advertise that their staff are all vaccinated against COVID-19.

Presently, there is proposed legislation in the Ohio Statehouse (House Bill 248) that would prevent Ohio businesses from requiring their employees get COVID-19 vaccines. As a strong proponent of free markets, I think this is an incredibly bad idea.

Businesses differentiate themselves in order to gain a competitive advantage. Businesses win by advertising that they provide something that their competitors do not have and thus attracting customers who want that something. The more the government regulates what a business can or cannot do, the less freedom that business has to differentiate itself from its competitors.

A business that can attract more customers by advertising that all of its employees are vaccinated should not be restricted by excessive governmental regulations prohibiting it from requiring employee vaccination. 

As of today, 60% of all Americans have received at least one dose of a COVID-19 vaccine. 70% of Americans over age 12 have received a vaccine dose. 91% of Americans over age 65 have received a vaccine dose. Of importance to businesses, most of the remaining unvaccinated are low income Americans whereas high income Americans are largely vaccinated. A pulse survey of the U.S. Census of 3,777,136 Americans in June 2021 found that the largest percentage of Americans who either have received or plan to receive a COVID-19 vaccine were those reporting a household income > $200,000/year. The next highest percentage of vaccinated persons were those with a household income $150,000 – $200,000. The lowest percentage of vaccinated persons were those reporting an annual household income < $25,000. The majority of Americans are getting vaccinated, particularly middle income and high income American adults who are the most likely to go to a business and spend money. Many, if not most, of these American adults are going to prefer to support businesses that have taken the same steps that they have taken with vaccination in order to keep themselves, their families, and their communities safe.

Data from the recent full U.S. census shows that two-thirds of Ohio counties lost population in the past decade. Because the population of many other states is growing faster than Ohio, we will be losing one U.S. congressional seat this year. One of the most effective ways to stop this loss of population and the loss of Ohioans’ voice in the U.S. House of Representatives is to attract businesses to Ohio, particularly businesses that pay good employee salaries. Companies that already require their employees to be vaccinated against COVID-19 will find other, more business-friendly states more attractive for their new offices, new factories, and new jobs if the proposed legislation is passed. In essence, House Bill 248 says: “If you are a business that wants to require your employees to be vaccinated, do not come to Ohio.

I have a lot of reasons to promote COVID-19 vaccines. I’ve had to find ICU beds in our hospital where ICU beds did not exist in order to care for COVID patients on ventilators. I’ve had to manage physicians, nurses, and respiratory therapists who were over-worked and burned out from caring for the surge of hospitalized patients. I had 5% of my (largely elderly and immunocompromised) outpatient pulmonary practice die of COVID prior to availability of vaccines. But I also do not want to see excessive government regulations on businesses that stifles a free market economy.

If a business wants to mandate employee vaccinations because the owner believes it will give that business a competitive advantage in attracting customers or attracting more qualified employees, then let that business have the freedom to do so… whether that business be a restaurant, a grocery store, an auto dealership, a school, or a hospital.

August 16, 2021

Categories
Outpatient Practice Procedure Areas

Designing A Pulmonary Function Laboratory

Clinical laboratories are certified by CMS using the Clinical Laboratory Improvement Amendments (CLIA). Radiology departments are accredited by certification by the American College of Radiology. There are no certification or accreditation standards for pulmonary function laboratories currently so it falls to each hospital to design its own PFT lab. After being involved in the design of 4 PFT labs over the years, these are a few of the things about lab design that I have learned.

First decide what tests will be performed

The tests that the laboratory will perform will dictate the number of rooms and space required for the lab. The initial design of a pulmonary function lab should specify which types of tests will be performed in each room in order to ensure that each room is large enough for all of the equipment and supplies required for those tests.

 

The most common tests performed in a pulmonary function laboratory are spirometry, lung volumes, and diffusing capacity. These can all be done using an enclosed plethysmograph device that the patient sits inside of, sometimes called a “body box”. Each plethysmograph should be in a separate room. A small hospital or an outpatient physician group practice may only need 1 plethysmograph but most pulmonary function labs will need 2 to 4 plethysmographs, requiring 2 to 4 separate rooms. Spirometry can also be ordered as spirometry pre- and post-bronchodilator. The bronchodilator study does not require special space but usually does require a “Terminal Distributor of Dangerous Drugs License” from the state pharmacy board.

The next most common test is the 6-minute walk test. This is generally performed in a long, straight hallway with distances marked on the floor. The patient walks as fast as comfortable and the number of laps walked in 6 minutes are calculated along with the oxygen saturation during the test. The hallway should be wide enough to accommodate an oxygen tank on wheels and should should be lightly trafficked so that it can be blocked off during the duration the test. A related test is the oxygen titration study. In this test, a patient walks until their oxygen saturation drops below 89% and then supplemental oxygen is applied in increasing flow rates to determine the proper flow rate for that patient’s oxygen prescription. The oxygen titration study can be performed in the same hallway as the 6-minute walk test or can be performed on a treadmill.

The methacholine challenge test is a broncho-provocation test done by having the patient inhale increasing concentrations of methacholine, with spirometry performed after each concentration. In the past, an on-site pharmacy was generally required to perform dilutions of methacholine; however, pre-filled, pre-diluted testing kits are now commercially available, thus obviating the need for an on-site pharmacy. This test can be done in the same room used for one of the plethysmograph boxes. A related test is the eucapnic voluntary hyperventilation test that is used to diagnose exercise-induced bronchospasm.

The cardio-pulmonary exercise test is performed by having a patient ride a stationary bicycle (or sometimes by using a treadmill) while breathing into a metatabolic cart in order to measure values such as minute ventilation and oxygen uptake. This test is generally performed in separate room dedicated to exercise testing but can be performed in a room normally used for plethysmograph testing if the room is large enough to accommodate both the plethysmograph box and the exercise test equipment.

The high-altitude hypoxia simulation test is performed by measuring the patient’s oxygen saturation while breathing a 15% oxygen/85% nitrogen gas mixture from a large medical gas cylinder via a face mask. This test is used to determine if a patient requires supplemental oxygen when flying in a commercial aircraft. Because the only equipment required is the medical gas cylinder, this test can be performed in a room used for plethysmographic testing. However, it is preferable to perform this test in a room with a treadmill (or a stationary bicycle) so that the high-altitude hypoxia simulation test can be combined with an oxygen-titration test as a high altitude hypoxia exercise test in order to determine the oxygen flow rate required when a patient is walking at a high-altitude travel destination (such as Denver).

Arterial blood gases are performed by inserting a needle into the radial artery to withdraw arterial blood. This test is most commonly performed to get direct measurement of the amount of oxygen and carbon dioxide in the blood. Arterial blood gases can also be performed while the patient breaths 100% oxygen in the physiologic shunt study.

Get infection control involved early

Patients who get pulmonary function tests are vulnerable to contagious diseases due to their underlying respiratory compromise as well as due to frequenting taking immunosuppressive medications. In addition, these patients often have respiratory infections that can be transmitted to others. Your infection control department input is crucial to ensure that patients and staff are not at risk of acquiring infections from exposures in the lab.

One of the most important aspects of infection control of respiratory pathogens is the number of air changes in each room per hour. The more air changes per hour (ACH), the faster respiratory pathogens such as tuberculosis or the coronavirus causing COVID-19 are cleared from the breathable air.


The Centers for Disease Control has recommendations for the minimum ACH for each type of hospital room. This can range from a high of 15 ACH for an operating room to 2 ACH for certain storage rooms. An exam room or a hospital inpatient room is recommended to have 6 ACH and a bronchoscopy room is recommended to have 12 ACH. The CDC does not specify the ACH for a pulmonary function laboratory. However, the Veteran’s Administration recommends at least 8 ACH for a room used for plethysmographic testing and at least 10 ACH for a room used for cardiopulmonary exercise testing. In the era of COVID-19, the higher the ACH, the better. If the pulmonary function lab will also do sputum induction for suspected tuberculosis, then a negative airflow room is necessary.

In the past, pulmonary function testing utilized non-disposable mouthpieces, nose clips, and other equipment that required cleaning. This resulted in the requirement to have both a clean and a dirty utility room in the pulmonary function lab. Now, most labs use disposable mouthpieces, nose clips, and supplies so that there is no longer a need for a dirty utility room to avoid clean/dirty equipment conflicts.

The infection control department can also be helpful in room design. For example, selecting anti-microbial materials (such as copper) for door handles and other fixtures. Flooring should be made out of resilient tile with minimal seams. There should be hand washing sinks and wall-mounted hand sanitizer in each room used for diagnostic testing.

Efficiency and flexibility

Patients coming in for pulmonary function testing are often in wheelchairs and are often using supplemental oxygen. Doors to testing rooms need to be wide enough to accommodate the width of a bariatric wheelchair (48 inches). Similarly, diagnostic rooms need to contain bariatric-sized chairs. Because of the impaired mobility of many pulmonary patients, the lab should be located as close to building entrances and elevators as possible.

To optimize staff efficiency, a shared patient registration area that can serve multiple outpatient services is preferred for all but the largest pulmonary function labs. Shared waiting areas can optimize efficient use of building space; however, waiting areas should be designed so that staff can maintain line of sight observation of patients. Similarly, when possible, share resources for linen storage, housekeeping, general storage, waste storage, and staff support areas.

Most pulmonary function labs will require hemoglobin testing as part of the diffusing capacity test. Also, most pulmonary function labs will perform arterial blood gas testing. If these specimens must go to a central clinical chemistry lab, then the PFT lab should be close to that lab (at least within the same building). Most PFTs labs find it easier to perform point-of-care testing for arterial blood gases and finger-stick hemoglobin, however. Regardless of where these tests are run, sharps containers are needed in all diagnostic rooms.

Human needs

In addition to a close-by, adequately-sized waiting area, there needs to be restrooms and a staff break room near the lab (you don’t want your staff eating in the diagnostic area). The interior design should convey the appearance of a healthcare setting. There must be adequate lighting in all rooms and hallways. Be sure to have televisions in waiting areas and wifi access in all public areas. Artwork should be chosen carefully – for example, if there is a sizable Afghanistan war veteran patient population, avoid pictures of desert mountains. Similarly, pictures of happy people doing recreational activities can be depressing to patients confined to wheelchairs or oxygen tanks. Attention to privacy in door and window location can ensure that patients undergoing diagnostic testing cannot be easily seen from the hallway.

If there are exterior windows in the area of the building, it is preferable to locate rooms used for diagnostic testing where there are windows and then use windowless interior rooms for support purposes, break rooms, restrooms, staff offices, etc. Some patients get claustrophobic when enclosed in a plethysmographic box and having an exterior window in the room can lessen that claustrophobia. The plethysmograph box should be positioned so that the patient can see out the window when sitting in the box.

Room acoustics are frequently overlooked when designing the PFT lab. If you have ever stood outside of a room where spirometry is being performed, then you have inevitably heard a PFT technician shouting “Blow, blow, blow, as hard as you can…“. Performing PFTs is a loud process. Include acoustic ceiling tiles and adequately insulated walls in the initial design.

Physical layout

Rooms used for plethysmographic testing should ideally be at least 12 ft x 10 ft in size in order to accommodate the plethysmograph box, a workstation for the PFT technician, a chair, sink, equipment storage, trash can, sharps container, etc. Most plethysmographic boxes are about 7 feet tall so the ceiling height also needs to be considered. For hallway throughput safety, doors should open into the room rather than into the hallway. Data entry keyboards used by the staff should either be on mobile workstations-on-wheels or should be on swing-mounts on a wall but positioned so that the technician is facing the plethysmograph box and so that an opened door does not block the ability of the staff to see the patient in the plethysmograph box. Most plethysmograph boxes are 36 to 42 inches in diameter so having a 48 inch doorway is preferred to be sure you can get the box into the room.

Rooms used for exercise testing generally should be to be at least 12 ft x 20 ft in order to accommodate a treadmill and metabolic cart.

The hallway used for 6-minute walk testing should be adjacent to the diagnostic area. Wall-mounted medical gas outlets in the diagnostic rooms are convenient to support the needs of patients requiring supplemental oxygen but most labs can get by with re-fillable oxygen cylinders. Even if medical gas outlets are available in the diagnostic rooms, portable oxygen cylinders will still be required for tests such as oxygen titration studies; therefore a room dedicated to oxygen cylinder storage is required. Staff charting areas should ideally be in a location where staff can maintain visual observation of patients.

One of the most common mistakes in lab design is failing to plan for future growth. Most PFT labs have seen a steady increase in testing volume over the past 20 years. It is far easier (and less expensive) to expand an existing lab than to either build an entirely new larger lab or build a second satellite lab when the demand for services increases. Having adjacent space that can be readily re-purposed is wise. For example, staff offices adjacent to the lab can be relatively easily moved to a different location in the hospital or clinic building so that those offices can be converted into PFT lab expansion space in the future.

Patients who come in for pulmonary function testing are also frequently coming in to see their pulmonologist or coming in to do pulmonary rehabilitation. The best PFT labs are co-located with pulmonary physician offices and pulmonary rehab areas. Having a “one-stop-shop” for pulmonary patients can improve patient satisfaction and can give the clinic or hospital a competitive edge. Having close proximity to a physician or advance practice provider is also useful in the inevitable situations when patients develop medical conditions during pulmonary function testing or exercise testing.

Planning is key

Most people have a hard time conceptualizing what an architectural plan will look like in real-life. It is a good idea to find a large, open area and tape out the dimensions of the planned rooms on the floor. Then add taped out placements for all of the equipment and furniture as well as the door swing area. Then get input from the PFT technicians, an interior designer, the pulmonologist, and the infection control staff. It is far less expensive to get everything right the first time.

August 15, 2021