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Inpatient Practice Outpatient Practice

Supplemental Oxygen: Sometimes Less Is Better

Supplemental oxygen is one of the most commonly prescribed treatments in the hospital. Patients with acute or chronic lung disease depend on supplemental oxygen to stay alive. As a natural and necessary substance, oxygen would seem like a safe thing to prescribe for patients that need it. But sometimes too much of a necessary thing can be harmful. So, when is too much oxygen bad for patients? We can take a lesson from vitamins.

The supplemental vitamin industry is based on the tenet that if our bodies need a small amount of a vitamin to live, then it must follow that by supplementing larger and larger amounts of that vitamin, our bodies will function better and better. Americans love this concept and we spend $30 billion every year on supplements. But frequently, too much of a good thing turns out to be a bad thing. Take Vitamin A – it is necessary for normal health and without vitamin A, we can lose night vision and become immunocompromised. A small amount of vitamin A in our diet keeps our bodies functioning normally. But if a person ingests too much vitamin A from supplements or from a dietary source that is high in it (such as polar bear liver), death can result from vitamin A toxicity. The same is true for water: drinking too little and a person dies of dehydration but drink too much and a person dies of hyponatremia. For decades, we thought oxygen was somehow different and that it was always better to err on the side of prescribing too much oxygen than risk prescribing too little. It turns out that we were wrong.

There are a lot of different oxygen delivery options: home concentrators, portable concentrators, compressed oxygen gas tanks, liquid oxygen, etc. In the hospital, oxygen is usually delivered through a medical gas panel that will have outlets for medical grade oxygen, regular air, and wall suction. The oxygen that comes out of these outlets is generally at a maximum pressure of 55 PSI. Conventional oxygen delivery devices (nasal cannulas and simple face masks) in the hospital usually are capped at a maximum flow rate of 15 liters per minute. Heated high flow nasal cannulas can deliver very high oxygen flow rates of up to 60 liters per minute. Mechanical ventilators can blend pure oxygen with room air to achieve anywhere from 21% to 100% inhaled oxygen concentrations (FiO2). As a result, physicians can adjust the amount of supplemental oxygen that a patient receives from a very small amount to a very large amount.

In the past, when EMS personnel would bring a patient with shortness of breath to the emergency department, they would put a mask on that patient and turn the oxygen up to a 15-liter flow rate to achieve close to 100% inhaled oxygen. In the hospitals, doctors would prescribe a high flow of oxygen and then not decrease that flow rate until a patient’s condition was improving and it was time to wean the oxygen down. In our emergency departments, ICUs, operating rooms, and hospital wards, we would give the patient as much oxygen as it took to raise their blood oxygen saturation to 100% and leave the oxygen at that flow rate for hours or days. But it turns out that we were probably harming patients by doing so.

In the past several years, there have been studies showing that prescribing excessively high oxygen flow rates can worsen patient outcomes in adults with lung disease. A study published in this week’s JAMA extended those findings to children. This study looked at 1,567 children, ages 1 – 4 years old, at 14 hospitals in Australia and New Zealand who had respiratory failure. The children were randomly assigned to receive either standard oxygen therapy or high-flow oxygen therapy. The high-flow group received as high as 40 liters per minute, depending on body weight. The standard-flow group received up to 2 liters per minute that was titrated to keep the blood oxygen saturation above 92%. The children receiving high-flow oxygen had a significantly longer length of hospital stay (1.77 vs. 1.50 days), longer duration of time on oxygen (1.07 vs 0.75 days), and higher rate of admission to the ICU (12.5% vs 6.9%).

Other studies have shown that excessive supplemental oxygen can be harmful in adults. A study of 429 patients given supplemental oxygen after resuscitation for cardiac arrest found that 40.7% of those receiving a conservative oxygen flow rate died but 50% of those receiving a liberal (i.e., higher) oxygen flow rate died. A meta-analysis study of 16,037 critically ill patients treated with conservative vs. liberal oxygen therapy found that those treated with liberal oxygen therapy (higher flow rates) had a higher mortality than those treated with conservative oxygen therapy (lower flow rates). A 2022 study of inpatients receiving supplemental oxygen during COPD exacerbations found that those who had arterial oxygen saturations of 88 – 92% had the lowest mortality rate and those patients given greater amounts of supplemental oxygen to maintain arterial oxygen saturation > 92% had significantly higher mortality rates.

For patients having out-of-hospital cardiac arrest, the conservative oxygen approach may be risky, however, A 2022 study from Australia found that cardiac arrest patients treated by EMS personnel with a conservative oxygen strategy (targeting a blood oxygen saturation of 90 – 94%) had a higher mortality rate than those patients treated with a liberal oxygen strategy (targeting a blood oxygen saturation of 98 – 100%). Because there was a tendency to frequently undershoot the oxygen saturation in conservative oxygen therapy group, it is possible that even brief periods of low oxygen saturations can be harmful in patients immediately after a cardiac arrest which may have resulted in the higher mortality rate.

Adverse effects of too much oxygen

So, if oxygen is so necessary for us, how can it harm us? There are several effects of excessive oxygen that can result in harm:

  • Oxygen toxicity. High oxygen concentrations can damage lung cells by oxidant injury resulting from the production of substances such as superoxide anion, hydroxyl radical, and hydrogen peroxide. We sometimes see this in the intensive care unit in respiratory failure patients who require 100% oxygen concentrations for long periods of time who get into a vicious cycle of pneumonia requiring supplemental oxygen and then the high oxygen concentrations cause further lung damage resulting in the patients needing even higher oxygen concentrations in order to get enough oxygen into the blood stream to keep the body’s organs alive. These patients can end up with permanent lung scarring and never get off of the mechanical ventilator. Lung damage depends on how long a person is exposed to high concentrations of oxygen – brief periods are less harmful than breathing very high concentrations of oxygen for longer periods of time. This mainly applies to those patients in the ICU left on 60% – 100% inhaled oxygen for several days.
  • Drug-induced lung disease. Many drugs can cause damage to the lung resulting in inflammation and scar in the lungs (interstitial lung disease). Certain drugs are particularly likely to do this when combined with high concentrations of inhaled oxygen. The two biggest offenders are bleomycin (used in cancer chemotherapy) and amiodarone (used in heart rhythm disorders). When a patient is breathing room air, these drugs are usually safe but when breathing high concentrations of oxygen, these drugs can become very toxic. Bleomycin is particularly notable because the risk of pulmonary toxicity from breathing high oxygen concentrations can persist for many years after the patient was given bleomycin.
  • Radiation-induced lung disease. Excessively high amounts of radiation to the chest can cause interstitial lung disease but moderate amounts can be used safely to treat lung cancer. However, when a patient is using high oxygen concentrations, those moderate amounts of radiation can cause interstitial lung disease. Thus, like amiodarone and bleomycin, oxygen therapy can increase the risk of radiation-induced pulmonary fibrosis.
  • Adsorptive atelectasis. Room air contains about 21% oxygen and 78% nitrogen. Oxygen readily passes from the alveoli of the lungs (air sacks) into the blood stream but nitrogen does not cross as easily. Because of this, nitrogen in the air helps keep the alveoli of the lungs propped open, similar to using PEEP (positive end-expiratory pressure) on a mechanical ventilator, thus preventing atelectasis. When a person breathes very high concentrations of oxygen, the nitrogen in the alveoli gets “washed out” and as a result, the lungs are more prone to developing atelectasis that can in turn worsen oxygenation. Once again, the patient can get into a vicious cycle of worsened blood oxygen levels leading to the doctor increasing the supplemental oxygen concentration leading to worsened atelectasis leading back to worsened blood oxygen levels.
  • Carbon dioxide retention. Our breathing rate is determined by the blood oxygen level (PO2) and carbon dioxide level (PCO2). Patients with COPD are sometimes less sensitive to rising carbon dioxide levels and more dependent on the blood oxygen level to determine respiratory rates. In this setting, by giving too much supplemental oxygen, the patient can lose their respiratory drive and begin to hypoventilate, resulting in a high blood carbon dioxide level. Although this effect on PCO2 levels is usually small, it can be important when combined with other things that can suppress the respiratory drive centers, such as sedatives and opioids.
  • Longer oxygen weaning times. When a patient with acute respiratory failure in the hospital begins to improve, the doctor will generally order the respiratory therapist to wean the oxygen off (or back down to the patient’s normal home supplemental oxygen flow rate). The respiratory therapist will then reduce the oxygen flow rate by 1-2 liters per minute, wait a couple of hours, recheck the blood oxygen saturation, reduce the flow rate by another 1-2 liters, etc. It takes less time to wean oxygen off if a patient is on less oxygen to begin with than if they are receiving higher flow rates of oxygen. The doctors generally wait until the oxygen is completely off (or down to the normal flow rate the patient uses at home) before the patient is allowed to be discharged. As a result, longer oxygen weaning times can sometimes lengthen the patient’s hospital stay.

So, what is the right amount of supplemental oxygen?

Our bodies require oxygen to live. If we don’t get enough oxygen, our tissues become damaged. On the other hand, too much oxygen is also bad for our bodies. Here is what we can do in our hospitals to draw the right balance between not enough and too much:

  1. In emergencies, it is better to give too much than to give too little. In settings such as cardiac arrest, myocardial infarction, and stroke, brief periods of low blood oxygen levels can worsen clinical outcomes. If too much emphasis is placed on using the least amount of supplemental oxygen, there is a greater risk of undershooting the oxygen flow rate and causing low blood oxygen levels for seconds or minutes. Situations where this applies include during transport of cardiac arrest or stroke patients by emergency squads, during CPR for cardiopulmonary arrest, and during the first hours of a myocardial infarction or stroke.
  2. Target a blood oxygen saturation of 88 – 92%. After the initial resuscitation, titrate the supplemental oxygen flow rate (or the FiO2 on the mechanical ventilator) to the least amount necessary to keep the oxygen saturation between 88 – 92%. For years, physicians have written orders to “Wean supplemental oxygen to maintain oxygen saturation > 92%”. This is probably too high and our default oxygen weaning orders in our electronic medical records need to be revised.
  3. In the ICU, use other measures to improve oxygenation when patients need more than 60% FiO2. This could include increasing the PEEP on the ventilator, using prone ventilation, giving sedatives, controlling fever, or using neuromuscular blockade.
  4. Avoid unnecessary use of 100% FiO2 during surgery. In the past, anesthesiologists would sometimes leave patients on 100% FiO2 throughout surgical operations so that there would be no risk of the patient desaturating during surgery. Not only can this increase the risk of post-operative absorptive atelectasis, but it can be particularly harmful if patients have previously received sensitizing drugs or radiation. One of my colleagues was a physician who had been treated with bleomycin years previously for lymphoma. He underwent an elective gall bladder surgery and was left on 100% FiO2 during the procedure. He developed acute lung injury post-operatively and died from bleomycin-induced acute oxygen toxicity.
  5. We need pharmacologic 2,3-DPG. 2,3-Disphosphoglycerate (2,3-DPG) is a chemical in red blood cells that helps hemoglobin molecules release oxygen. Physiologically, this can result in a  shift in the oxy-hemoglobin dissociation curve to the right. This means that oxygen can pop off of hemoglobin easier, allowing the red blood cells to release more of their oxygen to tissues that need it. In other words, 2,3-DPG allows the tissues to get by when there is less oxygen in the blood. Normally, red blood cells release about 30% of their oxygen when they pass through tissues; 2,3-DPG allows them to release more than 30%. What is important to our bodies is not the amount of oxygen in the blood but rather the amount of oxygen that our tissues get. 2,3-DPG allows our tissues to function normally when the blood oxygen saturation is lower. If we could increase red blood cell 2,3-DPG levels pharmacologically, we could use lower amounts of supplemental oxygen in patients with acute respiratory failure.
  6. Not everyone with a low oxygen saturation needs supplemental oxygen. Insurance will not pay for supplemental oxygen unless a patient has an oxygen saturation of < 89%, either at rest, during exercise, or during sleep. But that does not mean that every patient with brief oxygen saturations < 89% needs supplemental oxygen. The LOTT study showed that COPD patients with oxygen saturations 89 – 92% at rest that desaturated to 80 – 90% with exercise had no benefit from supplemental oxygen, including death rates, hospitalization rates, COPD exacerbations, and quality of life. In my own clinical practice, I have also been hesitant to prescribe oxygen in hyperemic patients who are at fire risk, including those who smoke, have smokers in the home, or use gas cooking stoves. These patients are often more likely to be injured or die from fire caused by supplemental oxygen than they are to die from hypoxemia without supplemental oxygen.

It’s time for auto-titrating oxygen delivery devices

Auto-titrating oxygen devices adjust the oxygen flow rate based on a patient’s oxygen saturation. A 2019 meta-analysis showed that compared to manual oxygen titration, these devices shortened hospital length of stay by shortening oxygen weaning times. A 2020 study of outpatients found that by using auto-titrating oxygen devices, patients had improved 6-minute walk distances and improved dyspnea. It is not surprising that these devices are effective in the hospital – a respiratory therapist cannot be in a patient’s hospital room 24 hours a day to constantly adjust the supplement oxygen flow rate but the auto-titrating oxygen delivery device can. Not only can these devices reduce excessive supplemental oxygen flow rates in hospitalized patients, but they can also reduce excessive oxygen flow rates in outpatients.

The cost to hospitals to buy and implement auto-titrating oxygen delivery devices would be considerable. However, these costs could potentially be off-set by shortened hospital length of stays and by reduction in utilization of respiratory therapists. These devices would also take some of the guesswork out of ordering oxygen flow rates for hospitalized patients resulting in a more standardized and consistent use of supplemental oxygen by hospitalists and intensivists. In addition, there is a potential for a reduction in hospital mortality rates by avoiding excessively high amounts of supplemental oxygen.

There is both an art of medicine and a science of medicine. It is time to harness science to guide the use of supplemental oxygen.

January 26, 2023

Categories
Emergency Department Inpatient Practice Medical Economics

It’s Time To Do Away With Observation Status

“Observation status” was originally conceived of as a way to watch patients presenting to the emergency department for a few hours in order to determine whether or not they needed to be admitted to the hospital. The purpose was to reduce unnecessary inpatient hospitalizations and thus reduce overall healthcare costs. But there has been a creep in the use of observation status as well as the healthcare bureaucracy to administrate it. The result is that observation status has now increased overall healthcare costs. It is time to consider eliminating observation status in the United States.

Summary Points:

  • In observation status, hospital admissions are considered to be outpatient rather than inpatient admissions
  • As an outpatient visit, patients are responsible for more of the hospital charges than they would be for an inpatient visit
  • Medicare will not pay for skilled nursing facility care for patients in observation status
  • Observation stays reduce Medicare costs by transferring costs to the individual patient
  • Overseeing observation status is expensive for hospitals
  • Overall per capita U.S. healthcare costs can be reduced by eliminating observation status

How did we get here?

Prior to 1960, emergency departments were staffed by residents and general practitioners. The doctor who saw you in the ER was generally the same doctor who took care of you in the hospital. Emergency medicine became a specialty in 1968 with the creation of the American College of Emergency Medicine. The first emergency medicine resident began training in 1970 and the first board examination in emergency medicine was offered in 1980. The result was that the doctor that took care of a patient in the ER was no longer the same doctor who took care of them once they were admitted to the hospital. In 1983, DRGs were first used to determine the amount of money that Medicare would pay hospitals for inpatient admissions for any given diagnosis. After the introduction of DRGs, it became immediately clear that there needed to be some way of determining which patients were sick enough to warrant admission to the hospital from the emergency room, otherwise, the hospitals would be incentivized to admit as many people as possible, even if they were not very sick.

Initially, that determination was left to the emergency room physician. But that ER doctor needed to find an inpatient physician who would agree to admit the patient. During my residency, we had a designated “medical admitting resident” each day who would make the decision about which patients were sick enough to require admission. Some residents got the reputation of being “sieves”, meaning that they would admit everyone that the ER physician called them about whereas other residents got the reputation of being “walls”, meaning that they would block admissions from the ER unless the patients were at death’s door. You always wanted to be on-call at night with a resident who was a “wall” because that meant you would have to do fewer history and physical exams, your inpatient service census would be lower, and you might actually get a few hours of sleep that night.

In order to provide some rules for which patients warranted inpatient admission, Medicare directed that patients who could be sent home within 24 hours should be observed in the ER rather than admitted to the hospital. However, keeping a lot of patients in ER beds for 24 hours was impractical so hospitals started putting those observation patients in regular hospital beds to avoid congestion in the emergency department. The unintended consequence was that this simply led to keeping patients in the hospital for longer than 24 hours, just so they could be classified as inpatients. This was especially a problem with outpatient procedures when many hospitals kept patients overnight for procedural recovery and then billed Medicare for both the outpatient procedure plus an inpatient hospital admission. Medicare countered in 2002 by agreeing to pay hospitals specifically for observation stays in order to provide an alternative to inpatient admission for those patients who were only mildly ill or who needed extra time to recover from an outpatient procedure. Initially, the only diagnoses that could be billed as observation stays were heart failure, chest pain, and asthma. In 2008, Medicare began paying for observation stays for all diagnoses.

In parallel with the development of reimbursement policies for observation stays, Medicare began policing hospital admissions by using the RAC (recovery audit contractors). RAC auditors would review the charts of patients who had been admitted to the hospital and if the auditor determined that there was not sufficient documentation in the chart to justify inpatient admission, Medicare would collect penalties from the hospital for overpayment. By 2014, the RAC program had collected $2.3 billion from hospital overpayments. One of the most common reasons by RAC auditors when denying an inpatient admission was that “…the patient could have safely and effectively been treated as an outpatient.” The auditors were often incentivized to deny admissions since more denials often led to bigger bonuses for the auditors. As a result, the denials were frequently capricious and arbitrary. 25 years ago, a coder for a commercial insurance company confided in me that her supervisors told her to randomly deny every 10th hospital admission because hospitals usually found that it was too expensive to contest denials. Fear of RAC audits resulted in physicians and hospitals increasing the use of observation status in order to avoid the risk of being penalized for an unnecessary inpatient admission.

A second strategy employed by Medicare was to create a list of surgical procedures that were classified as “Medicare Inpatient-Only Procedures”, meaning that those operations required an inpatient admission. Any surgical procedure not on the list was to be classified as an outpatient procedure unless there were extenuating circumstances that uniquely required a patient to be admitted to the hospital. Medicare pays much more if a surgery is performed as an inpatient (Medicare Part A) than if it is performed as an outpatient (Medicare Part B). Over time, the Medicare Inpatient-Only list shrank as more and more surgical procedures were reclassified as being appropriately done as outpatient and not requiring of hospital admission. Thus, knee and hip replacement surgeries were initially considered to require inpatient admission  but are now considered to be outpatient procedures.

Medicare also changed its definition of observation stays to be any condition that requires the patient to be in the hospital for “less than 2 midnights”. Although it could be argued that this gave hospitals longer than 24 hours to treat an observation status patient and send them home, the 2-midnight definition was somewhat arbitrary. For example, a patient presenting to the emergency department at 11:00 PM would spend 25 hours in the hospital before crossing 2 midnights but a patient presenting at 1:00 AM would spend 47 hours in the hospital before meeting the 2-midnight definition. However it is not how many midnights a patient actually spent in the hospital that Medicare auditors used when deciding whether to deny a hospital admission. Instead, it is whether the auditor believed that had the patient been managed appropriately, that patient could have been sent home before 2 midnights have elapsed. For example, if a patient came to the emergency department on Saturday evening with chest pain but the hospital could not do a cardiac stress test until Monday morning (2 midnights later), the auditor would still deny an inpatient admission since if the hospital offered 7-day a week stress tests, they could have sent the patient home on Sunday (after 1 midnight).

The observation vs. inpatient status bureaucracy

 

In order to avoid losing money from admission denials, hospitals started to go to great lengths to insure that the medical record contained sufficient documentation to justify every hospital admission. This was greatly facilitated by the development of electronic medical records that permitted realtime review of each patient’s hospital stay to ensure that the patient’s chart had appropriate documentation to meet Medicare’s requirements to bill that hospital stay as an inpatient admission. Some of the measures that hospitals now take in order to oversee their hospital admission practices include:

  1. Physician training. When a patient is admitted to the hospital from the emergency room, the admitting physician has to enter an order directing that the patient is an “inpatient” or “observation” admission. This means that the physician has to estimate how long the patient will need to be in the hospital at the very beginning of the hospital stay and that estimated length of time dictates whether a patient will be inpatient or observation status. We now train residents in how to correctly estimate length of stay. For example, patients admitted for chest pain, syncope, and dehydration are generally observation status unless there are extenuating circumstances.
  2. Nurse admission reviwers. Hospitals will generally hire a group of nurses or other healthcare workers to review every patient’s chart on a daily basis to determine if the medical record documentation justifies inpatient admission. These nurses get special training in the Medicare inpatient admission requirements. If the patient’s chart does not contain the proper documentation, the nurse’s first step is usually to contact the physician since frequently, all that is needed is an extra sentence or two in the medical record describing how sick the patient actually is. If that does not resolve the issue, the next step is to contact a physician admission advisor.
  3. Physician admission advisors. Many times, the admitting physician is uncertain whether or not a patient’s illness justifies an inpatient admission order. Or the nurse reviewer’s determination is different from the physician’s admitting order for observation vs. inpatient status. For this reason, hospitals employ physicians whose main job is to arbitrate inpatient and observation orders. Often, this will be a private physician review company where the physician reviewers can access patient charts on a daily basis. Larger hospitals usually do this internally by hiring some of its own emergency medicine physicians or hospitalists to dedicate a certain number of hours per day reviewing admissions.
  4. Hospital medical directors. When another layer of physician review of how to classify a patient’s admission is required, it then goes to the hospital medical director. Even for a small hospital, this is usually several charts to review every week. It takes about 15-20 minutes to do one of these reviews and then contact the admitting physicians to try to talk them into changing an admission order from inpatient to observation or vice-versa. Frequently, it requires the medical director to either enter an administrative note in the electronic medical record or to send the hospital utilization review office a letter so that the hospital has a documentation  paper trail in the event of a Medicare denial. More often, the medical director is sent charts for patients who had an inpatient admission order but were discharged before 2 midnights had elapsed. This is a red flag for Medicare auditors. We then have to provide written documentation for why the patient should be billed as an inpatient. Sometimes, this is easy, for example, when a patient dies from their condition in the hospital before 2 midnights elapse. But more frequently, it is because the admitting physician legitimately believed that the patient would need to be in the hospital for at least 2 midnights when that patient first arrived at the hospital. Several years ago, I attended a Medicare seminar and one of the medical administrators from Medicare told us that when this happens, we should use the phrase “The patient had an unexpectedly rapid recovery and was able to be discharged after less than 2 midnights”. Pretty much every time a patient in inpatient status was discharged before 2 midnights, one of our hospital medical directors would review that chart and send the billing office a letter using that phrase.
  5. Pre-admission testing consultation. Patients who are planned to undergo a surgical procedure will frequently be sent for pre-operative medical consultation by an internist, family physician, or specially trained advance practice provider. Although designed to identify medical co-morbidities that could increase the risk of complications during surgery, these consultations are increasingly being used to determine whether or not a given patient’s surgery should be classified as an inpatient or an outpatient surgery. And most importantly, these consultations ensure that there is sufficient documentation in the electronic medical record to justify an inpatient procedure. For example, most knee replacement surgeries are now considered outpatient procedures. But if the chart documents that the patient has sleep apnea requiring CPAP, brittle diabetes, COPD requiring supplemental oxygen, and a history of vomiting after anesthesia, then that patient’s knee replacement can be done as an inpatient and the hospital gets paid considerably more. Surgeons are trained to be experts in surgery but are not trained in the nuances of co-morbid medical illnesses that they do not normally manage. Consequently, the surgeon’s outpatient notes often do not contain documentation of the significance of those medical co-morbidities and whether they are severe enough to warrant an inpatient admission for the surgery. That is why the pre-op medical consultation is so highly valued. If the surgeon admits the patient as an inpatient to do the surgery and then discharges that patient before 2 midnights pass, the chart once again gets sent to the medical director so that a letter containing the phrase “The patient had an unexpectedly rapid recovery and was able to be discharged after less than 2 midnights” is sent to the utilization review and billing offices for a documentation paper trail in the event of an admission denial by Medicare.
  6. Utilization review staff. Every hospital employs a large number of personnel devoted solely to coding, billing, and utilization review. Before a bill goes out to Medicare or a commercial insurance company, these staff will do a final review to ensure that all of the proper documentation justifying an inpatient admission is present in the chart, including physician admission advisor notes and hospital medical director correspondence.There will also usually be personnel whose only job is to work denials when Medicare or an insurance company denies an inpatient admission. These personnel will then prepare and submit documentation contesting that denial in hopes of overturning the denial and getting paid for the hospital stay.
  7. Attorneys and peer reviewers. When Medicare or an insurance company refuses to overturn an admission denial after the billing staff contest the denial, the next step is to turn to the legal system. This usually starts by paying an independent physician reviewer to opine whether the patient’s hospital stay should be classified as inpatient or observation. Next, hospital attorneys get involved by contacting Medicare attorneys about the denial. Sometimes, contested denials require adjudication, requiring more attorney time.
  8. Medicare staff. On the other side of the bill, Medicare and commercial insurance companies employ large numbers of staff to review charts to decide whether they think that hospitalizations should be inpatient or outpatient.

So, for any given patient’s hospitalization, there is an army of Medicare nurse reviewers, physician reviewers, utilization review staff, and attorneys that face off against an army of the hospital’s  nurse reviewers, physician reviewers, utilization review staff, and attorneys. In the end, more money is sometimes spent battling an admission denial than is actually paid to the hospital for the admission. Hospitals are willing to occasionally spend the excessive cost to contest a denial since it sends Medicare or the insurance company a signal that the hospital will not go down easily for future admission denials. It is kind of like a basketball coach throwing a tantrum about a penalty call in order to try to dissuade the referee from calling future penalties.

The net result of all of this is that the United States has created an enormous bureaucracy devoted to preventing and contesting hospital admission denials.  So, why don’t hospitals just classify more patients as being in observation status and avoid all of the expense of justifying inpatient status? The reason is money.

The finances of inpatient vs. observation status

The genesis of observation status was to reduce Medicare costs by eliminating unnecessary hospital admissions. For any given diagnosis, hospitals get paid much less if a patient is designated to be in observation status than if that same patient is designated to be in inpatient status. Overall, the reimbursement is about 1/3 less for observation stays. In other words, Medicare can reduce overall Medicare costs by pressuring hospitals to put more patients in observation status. The same holds for commercial insurance companies.

Until several years ago, Medicare also paid doctors less if patients were in observation status. However, it became clear to Medicare that this was incentivizing doctors to preferentially use inpatient status rather than observation status. And since doctors are the ones who write the admission orders, Medicare realized that it could reduce inpatient admissions by removing the physician financial incentive to put patients in inpatient status. Because the physician professional fees are much, much less than the hospital fees, by paying physicians the same whether a patient was in observation or inpatient status, Medicare would pay a little more to the doctors but would pay a whole lot less to the hospitals.

But the biggest savings to Medicare in observation status is that it transfers much of the cost of the hospital stay from Medicare to individual patients. This is because Medicare considers observation stays as outpatient visits. Outpatient services are billed to Medicare Part B but inpatient services are billed to Medicare Part A. This is hugely important to patients because patients have much higher co-pays and deductibles for their Part B charges than their Part A charges.

  • Medicare Part A covers inpatient admissions including a semi-private room, nursing care, medications, meals, and tests done during inpatient admissions. Part A also covers skilled nursing facility care, home health care, and hospice care. Medicare Part A is free to Americans over age 65 who have previously worked at least 10 years (or have a spouse who worked 10 years). There are no monthly premiums and no annual deductible. The amount that Medicare covers depends on the length of stay of the hospital admission:
    • $1,600 deductible per admission
    • Days 1-60: Part A covers in full
    • Days 61-90: patients are responsible for $400 per day co-pay, either by co-insurance or out of pocket if the patient lacks co-insurance
    • Days 91-lifetime reserve limit days: patients are responsible for $800 per day co-pay, either by co-insurance or out of pocket if the patient lacks co-insurance
    • After lifetime reserve limit days (total of 60 over the entire lifetime): Part A pays nothing and patients (or their co-insurance) are responsible for the entire costs
  • Medicare Part B covers hospital outpatient charges and physician professional charges. Unlike Part A, there is a monthly premium for Part B of $165/month with higher premiums for those with higher incomes. There is an annual deductible amount of $226. Patients also have additional deductibles and co-pays that are either paid by secondary insurance or out of pocket if there is either no secondary insurance or the insurance policy has limited benefits:
    • 20% co-pay for all physician charges
    • 20% co-pay for hospital outpatient charges (hospital room, nursing care, meals)
    • 20% co-pay for x-rays and procedures
    • Part B does not cover medications so the patient (or their Part D insurance) is responsible for medication charges during observation stays

The net result of these differences is that the patient will have greater out of pocket expenses for an observation stay than for an inpatient admission. This is especially true for the 7.5% of Americans over age 65 who are enrolled in Medicare Part A only and do not enroll in Medicare Part B – these patients pay the entire cost of their observation stay out of pocket.

Another financial implication of observation vs. inpatient stays is in skilled nursing facility (SNF) coverage. Medicare Part A pays for 100% of SNF charges for up to 20 days (there is a $200/day co-pay for days 21-100). However, Medicare will only pay for SNF care if a person first has an inpatient hospital stay of at least 3 days. Medicare will not pay for SNF care after an observation stay. If a patient is in observation status (or has an inpatient stay of < 3 days) and gets transferred to a SNF, the patient is responsible for all of the SNF charges.

Why observation status is really, really dumb

CMS absolutely loves observation status. It reduces Medicare costs by paying the hospitals less for any given diagnosis and it also reduces Medicare costs by transferring much of the costs directly to the patient. This allows CMS officials to report to Congress that they are reducing federal spending on healthcare. Congressional representatives can then report to voters that they are reducing government spending. But there is no such thing as free healthcare… the cost of healthcare does not go away, it just gets transferred to the patient. The individual American ends up with more out of pocket costs for co-pays, medication charges, and SNF costs that would have otherwise been covered by Medicare Part A had their hospital stay been inpatient status as opposed to observation status. So, in the long run, the average American does not save any money by being in observation status.

Nationwide, 16% of all hospital stays are observation stays and 84% are inpatient stays. But this percentage can vary widely from hospital to hospital. A tertiary care referral hospital will usually have a lower percentage of observation stays since its patients tend to be sicker with more complex medical problems. On the other hand, a community hospital, especially one that cares for underserved patients, will have a higher percentage of observation stays, typically 25% or more. About the best a hospital can hope for is to break even on observation patients – most hospitals actually lose money on observation stays.

It’s bad enough that observation status does not really save money by transferring the cost of care to the individual patient rather than Medicare. The worst part about observation status is that it actually increases U.S. healthcare expenses. Not only do hospitals have to spend an enormous amount of money justifying inpatient admissions and working inpatient denials, but Medicare spends an enormous amount of money paying staff who police admissions in order to deny inpatient admission charges.

The net result is that observation status represents the epitome of U.S. healthcare dysfunction. It has led to an enormous bureaucracy devoted entirely to deciding whether Medicare or individual patients should pay for hospital care. And that bureaucracy is enormously expensive.

How can we fix this?

Americans pay way more for healthcare than people in any other country. In 2021, the average per capita healthcare cost in the U.S. was $12,914. It will undoubtedly be much higher in 2023. One of the contributors to this is too much of the healthcare costs go into trying to decide whether Medicare or the individual American will be responsible for paying for healthcare. Getting rid of the observation status designation can reduce U.S. per capita healthcare costs. Here is how to do it:

  1. Create low-acuity DRGs. For conditions that are currently commonly managed by observation status (chest pain, syncope, dehydration, etc.), CMS can create inpatient DRGs that pay the hospital less, thus simulating the amount that CMS would have paid for an observation stay.
  2. Require a modest Part A co-pay for hospitalization. The biggest argument against eliminating observation status is that Medicare costs would go up since co-pay costs currently paid by patients would go back to Medicare. The solution to this would be to require a small co-pay for hospitalization days 1-60. The amount to keep Medicare’s annual budget neutral could be as little as $10 or $20 per day.
  3. Outpatient should mean outpatient. How in the world we ever got to the point that we define outpatient care as needing to be in the hospital for more than 2 midnights is baffling. Either a patient needs to be in the hospital or they don’t. I once had a admission denial for a patient in respiratory failure admitted from the ER to our ICU on a mechanical ventilator. The Medicare reviewer said that in his opinion, I should have been able to correct the respiratory failure, extubate the patient, and discharge her before 2 midnights passed. Really?
  4. Eliminate the SNF 3-day rule. The whole idea behind the 3-day rule was that Medicare wanted to see if a patient really needed SNF care before it would pay for it. But the unintended consequence is that if one of our patients needs to go to a SNF, we have to figure out a way to admit them to the hospital for at least 3 days first. This means that we have to wait until they fall at home and break their hip or wait until they get septic from an infected decubitus ulcer if they are unable to get out of bed. For patients undergoing surgery, such as a knee replacement, we have to keep them in the hospital for 3 days after their surgery before they can go to a SNF for rehabilitation, even if they live alone and cannot walk after their operation.
  5. Eliminate the observation industry. By eliminating observation status, hospitals would no longer have to spend money on nurse admission reviewers, physician admission advisors, and medical directors who laboriously review charts for inpatient justification. Hospitals could reduce their utilization management staff and Medicare could reduce its admission reviewer staff. Hospitals, patients, and Medicare would have less need for attorneys to contest admission denials. Yes, a lot of people would lose their jobs but the overall U.S. healthcare costs would drop.

Elimination of the observation status designation would make everyone happy. Patients would not be surprised by unexpectedly high hospital bills. Doctors would not have to spend time entering unnecessary documentation in their hospital notes to justify why a patient warrants an inpatient admission. Hospitals would not have to pay as much for staff to oversee admission determination. A fundamental concept of industrial engineering is that the more complex a process is, the more energy it takes to keep that process working. Observation status has created a terribly complex process. It is time to simplify the U.S. admission process.

January 22, 2023

Categories
Outpatient Practice Public Health

A Pulmonologist’s Opinion About Gas Ranges

Recently, there have been health concerns raised about gas ranges. This has led some cities to prohibit their installation in new homes, including Los Angeles, New York and San Francisco. I am interested in these health concerns for two reasons. First, as a pulmonologist, I want to be sure that the people in our community are safe from health risks. Second, I am getting ready to buy a new range for myself. So, what are the health risks of gas ranges and should you be worried about them?

The basics of cooking ranges

First, some definitions. Many people use the terms “range”, “stove”, and “oven” interchangeably. Technically, an oven is the enclosed box that you bake in. A stove is the surface heating area that you heat pots on. A range is when a stove and an oven are combined into a single appliance. Sometimes the term “cooktop” is used when the stove is separate from the oven. For the purpose of this post, I will use the term “range” for the appliance that combines an oven with a stove.

In the United States, there are essentially four types of ranges: electric, gas, duel fuel, and induction. Electric ranges work by passing an electric current through a metal coil that heats up as it creates resistance to that current. These electric coils (“burners”) can be exposed on the top of the stove or covered underneath a flat sheet of glass. Electric ranges also use electric heating elements inside the ovens. Gas ranges work by igniting a jet of natural gas. The resultant flame is used to heat pots and pans on the stove. Gas ranges also use gas flames inside the oven for baking purposes. Duel fuel ranges use gas flames for the stove to heat pots and pans but use electric heating elements in the oven for baking purposes. Induction ranges work by using electricity to create a magnetic field on the stove that then heats up any pot or pan placed on the stove that contains iron or steel. Induction ranges generally use a standard electric heating element in the oven for baking purposes.

For many years, electric ranges dominated the U.S. appliance market. However, gas ranges are preferred by many cooks because of the better control over the amount of heat generated, for example, allowing the cooking surface to instantly increase or decrease in temperature. Duel fuel ranges combine the advantages of the gas stove for surface cooking with the more even heating of an electric oven for baking. Induction ranges offer the advantages of using electricity, thus avoiding an open flame, while also offering the advantage of being able to instantly control the temperature applied to the pot or pan. Consumer Reports found that induction ranges out-performed electric and gas ranges in cooking tests.

As a general rule, when things burn, the resultant products of combustion are bad for our lungs. Whether that be burning cigarettes, military burn pits, house fires, or indoor wood/charcoal cooking. Natural gas is often called “clean-burning” because it does not produce visible smoke, unlike a wood fire or charcoal fire. However, just because we cannot see or smell the products of combustion from natural gas does not mean that those products of combustion cannot hurt us.

What is natural gas?

Natural gas is a type of fossil fuel produced by the decay of long-dead plants. It accumulates in large gas pockets deep underground and then can be removed by drilling gas wells into those pockets. The main component of natural gas is methane which in pure form, creates water and carbon dioxide when it burns. However, natural gas is not pure methane and instead contains small amounts of other gases and chemicals. The typical components of natural gas include:

  • Methane
  • Ethane
  • Butane
  • Propane
  • Hydrogen sulfide
  • Carbon dioxide
  • Oxygen
  • Nitrogen
  • Trace elements: helium, hydrogen, Xenon, and Neon

When natural gas is burned, these components produce new gases, including carbon dioxide, nitrous oxide, methane, carbon monoxide, formaldehyde, nitrogen dioxide, and particulate matter. Many of these gases can cause lung disease.

Carbon dioxide

It is estimated that a typical U.S. family cooking with a gas stove produces slightly less than a pound of carbon dioxide each day from the combustion of natural gas. This is about the same amount of carbon dioxide produced by coal or gas power plants to generate the amount of electricity required to cook using an electric range or an induction range. So, we don’t really produce more carbon dioxide by using a gas range but we do concentrate that carbon dioxide inside our homes. To illustrate this, I measured the concentration of carbon dioxide in my kitchen before and during the use of my gas range. At baseline, the carbon dioxide level in my kitchen was 646 parts per million.

After turning on 4 burners on the gas stove for five minutes, the carbon dioxide level increased to 1609 parts per million.

I then turned on the overhead exhaust fan for five minutes and the carbon dioxide level fell to 821 parts per million.

Carbon dioxide is a by-product of living animals. Our bodies normally produce carbon dioxide that we exhale with every breath. If the levels of carbon dioxide in our bloodstream builds up, it can be toxic to the human body. Similarly, if the level of carbon dioxide in the air increases and then we breath that air, we can suffer ill health. NIOSH considers breathing air containing over 5,000 parts per million over the course of a 10-hour day to be toxic and over 30,000 parts per million for a 15-minute period to be toxic. It would require cooking for a long period of time in a poorly ventilated kitchen to reach these levels using a gas range.

Carbon monoxide

Like carbon dioxide, carbon monoxide is produced when things burn. However, carbon monoxide is much more toxic to humans than carbon dioxide. It is an invisible, odorless gas. When inhaled, it tightly binds to the hemoglobin molecules in our red blood cells thus preventing oxygen from binding to those hemoglobin molecules. Without oxygen, the cells in our bodies suffocate. We all inhale small amounts of carbon monoxide from our environments so there are always low levels of carbon monoxide in our blood stream. Cigarette smokers have higher levels of blood carbon monoxide than non-smokers. Very high levels of carbon monoxide are fatal. This is how most people die in house fires or die by suicide from running their car in a closed garage. Lower levels of carbon monoxide can cause headaches, ringing in the ears, and confusion. Every house with a gas range should have a carbon monoxide detector installed.

Nitrogen dioxide

The air we breathe is mostly made up of nitrogen – it constitutes about 80% of the gases in air. Nitrogen gas is considered inert – it does not cause any direct harm to the body except when nitrogen dissolved in the bloodstream “boils” and creates nitrogen gas bubbles in the tissues when SCUBA divers ascend too rapidly and get the bends. But when gases are burned, pure nitrogen can be converted into nitrogen oxides. One of these is nitrogen dioxide, which can be very toxic and poses the greatest health risks to our lungs from gas ranges.

Nitrogen dioxide can also build up from decay of certain types of plant materials. In pulmonary medicine, an important result of nitrogen dioxide toxicity is in “silo-filler’s disease”. This occurs when nitrogen dioxide builds up inside of poorly ventilated silos storing silage. If a farm worker enters that silo and inhales high concentrations of nitrogen dioxide, the lungs can become injured. In the short-term this can result in ARDS (acute respiratory distress syndrome), where the lungs are damaged and fill up with inflammation and fluid, thus blocking air from getting into the lung’s alveoli (air sacks) where oxygen normally transfers into the bloodstream. In the long-term, small airways in lungs exposed to high concentrations of nitrogen dioxide can fill up with scar tissue, resulting in permanent blockage of air getting to the alveoli. This is called “bronchiolitis obliterans“. A famous event resulting in pulmonary nitrogen dioxide toxicity occurred in Cleveland in 1929. At that time, a fire arose in the Cleveland Clinic in a room where large amount of old x-rays films that were made of nitrocellulose were stored. The resultant nitrogen dioxide gas produced by the burning x-ray films resulted in 129 deaths, including one of the Clinic’s founders, Dr. John Philips.

In lower concentrations, nitrogen dioxide can irritate small airways causing asthma. This can be particularly insidious because nitrogen dioxide does not cause allergic reactions, unlike many allergic triggers of asthma such as cats dander or pollens. For this reason, most people with asthma worsened by nitrogen dioxide do not realize that it is their gas cooking range that is making them sick. A 2013 meta-analysis of 41 studies found that indoor gas stove use increases the incidence of asthma in children. A recent study estimated that 12.7% of childhood asthma is due to nitrogen dioxide and other by gases produced by gas ranges. Adults with asthma may be less affected by gas ranges than children based on a 2003 study of 445 subjects.

Formaldehyde

Every middle school student who accidentally opened the jar of preserved frogs in biology class knows how noxious inhaling formaldehyde is. It is another toxic by-product of natural gas combustion. Formaldehyde is also produced by burning cigarettes and can be released by wood adhesives in newly constructed houses. It is often one of the suspected culprits in patients with “sick building syndrome”. When inhaled, formaldehyde can cause eye irritation, nose irritation, throat irritation, and cough. Meta-analyses in 2010 and 2018 showed that environmental formaldehyde in homes is associated with asthma in children. Formaldehyde is also considered a carcinogen. A 2018 study found that using even 1 gas burner turned on low increased air formaldehyde levels above safe thresholds.

Particulate matter

Natural gas is often called “clean-burning” but that is not exactly true. Tiny particles (< 10 μm) of soot are produced when gas is burned, even if those particles cannot be easily seen with the naked eye. Breathing particulate matter can cause cough and worsened asthma. It is one of the main causes of respiratory symptoms when outdoor air quality is poor, due to air pollution. Some particulate matter is produced from food as it is cooked, however, gas ranges produce particulate matter even if there is no food being cooked.

Fire

Accidental house fires are another harmful consequence of gas ranges. It surprises me that there are not more of these. Spilled cooking oil or a dishtowel accidentally dropped onto an open flame can quickly develop into a kitchen fire. The National Fire Protection Association estimates that there are 179,500 fires due to cooking in the United States, accounting for 49% of all house fires. Ranges account for 61% of cooking-related house fires and 87% of cooking-related fire deaths. Interestingly, electric ranges are more likely to cause house fires than gas ranges. There is very little research in fire risk from induction ranges compared to electric or gas ranges but given that induction cooktops produce no heat if a pan is removed, it would seem that there would be less risk of fire if the induction range was accidentally left on after cooking. Grease fires may also be less frequent given the absence of a flame (gas ranges) or hot electric coil (electric ranges).

Fire is a particular risk for people with lung disease who require supplemental oxygen. As pulmonologists, we caution our patients to never use their oxygen in the kitchen when using a gas range. However, there is no risk of fire when using supplemental oxygen around an induction range.

Thermal injuries

Both electric ranges and gas ranges produce high heat. Small children who don’t know any better can get severe hand and finger burns from reaching up to an electric or gas burner. Even experienced cooks often burn their hands from accidentally touching a hot burner. Induction ranges substantially reduce the risk of burns. Only the bottom of a pot or pan gets hot; the surface of the range does not heat up. So unless a toddler touches the bottom of a pan, there is no danger of thermal injury with an induction range.

So, what are the downsides of induction ranges?

The main problem with induction ranges is that they are expensive. The cheapest electric or gas range is several hundred dollars less than the cheapest induction range. However, a provision of the Inflation Reduction Act to discourage gas ranges provides a tax credit of up to $840 to replace gas ranges with electric or induction ranges. This only applies to Americans with lower incomes. Those with middle incomes can qualify for a reduced amount of the tax credit while those with higher incomes are not eligible for any tax credit. Although induction ranges can be expensive, it is anticipated that prices will come down in the future as the market for induction ranges increases. Consumer Reports recently rated ranges and found that the top rated induction ranges cost about the same as the top rated gas or electric ranges. The least expensive of the top four rated induction ranges costs $1,200.

A second problem with induction ranges is that the bottom of pots and pans must contain iron or steel. Copper, purely ceramic, aluminum, and glass cookware will not work with an induction range. If you have to buy all new steel/iron plated cookware, it can considerably add to the cost of a new induction range. An easy way to determine if a given pot or pan will work is to see if a refrigerator magnet sticks to the bottom.

A final problem with induction ranges is that you cannot generate extremely high heat. This is especially a problem for restaurants using very high heat output gas flames for wok cooking. These high heat levels are generally not achievable with an induction cooktop. However, there are now “induction woks” being marketed that surround the wok bowl with an induction element, thus permitting cooking temperatures similar as can be produced using high-output gas burners.

“I have a gas stove. What can I do to reduce the risk of harm?”

If you have a gas range, the most important step you can take is to ventilate the kitchen. This can mean opening kitchen windows when the weather outside permits. If you have a fan that you can put in that window, even better. If you have an exhaust hood above your range, then turn it on when cooking. An exhaust hood that blows air outside is optimal. If a child in the house has asthma, then try to keep that child out of the kitchen when cooking. If you are unsure of how effective your kitchen ventilation is, you can buy a home CO2 monitor for about $80. If the CO2 level increases significantly when you are cooking, then your ventilation is likely inadequate.

A second way of minimizing harm from a gas range is to use other kitchen appliances for cooking instead of the range whenever possible. For example, an electric kettle can be used to heat water rather than boiling water in a pot on the gas stove. An air fryer can replace the use of a gas oven for many foods. And a slow cooker can be used instead of the range range for chili, stews, and soups.

“Should I switch out my gas range for an induction range?”

The short answer is that most people do not need to ditch their gas ranges if they already have one. However, if your kitchen is poorly ventilated or lacks an exhaust fan over the range, then replacing your gas range with an electric or an induction range may make sense. Also, if there are children in the house, the health risks of a gas range increase significantly, especially if one of the children has asthma or another lung disease. If someone in the home uses supplemental oxygen, then getting rid of the gas range can reduce the risk of a house fire, particularly if the oxygen-user does the cooking.

For climate-conscious people, changing gas to electric or induction ranges can appear on the surface to be the more responsible choice. However, if your local electricity producer uses fossil fuel power plants, then there really is not much advantage in electric or induction ranges since the overall CO2 production is similar. Here in Ohio, we can choose our electricity provider and for several years, I have purchased electricity from providers that only produce electricity from wind and solar sources. So for me, an induction range will result in less overall CO2 production than a gas range. People in other parts of the country where the electrical grid sources electricity from hydroelectric power-plants can also reduce their CO2 footprint by switching from gas to electric or induction ranges.

For me, I don’t have any lung disease and no longer have children in the house. I like breathing clean air in the home and I like to minimize my personal CO2 footprint. However, I also like the ability to easily regulate the cooking temperature that in the past was only achievable with a gas stove but is now achievable with induction stoves. We are building a new house and had to decide what kind of appliances to install. So, I just ordered my new induction range.

January 15, 2023

Categories
Physician Retirement Planning

The Best Way To Do A Roth IRA Conversion? Try “Reverse Dollar Cost Averaging”

Dollar cost averaging is an investment strategy where a fixed amount of money is invested on a regular basis, for example, monthly. There are several advantages to the investor to utilize dollar cost averaging. These same advantages apply to converting money in a traditional IRA into a Roth IRA. However, the conversion advantages of this strategy is to minimize income tax incurred from the conversion and thus maximize long-term investment returns.

Summary Points:

  • In dollar cost averaging, an investor purchases a set amount of an investment monthly.
  • In “reverse dollar cost averaging”, an investor regularly sells shares of a traditional IRA to convert money into a Roth IRA.
  • By using this strategy, an investor can maximize long-term investment returns

 

What is a Roth IRA conversion?

There are essentially two types of IRAs: traditional IRAs and Roth IRAs. The rules about who can contribute to them and how they are taxed are a bit complicated. Both types of IRAs are subject to federal and state income tax but the differences are in when you pay those taxes: when you put the money in (during your working years) or when you take the money out (during retirement years).

  • Traditional IRAs. In 2023, you can contribute $6,500 into a traditional IRA ($7,500 if you are over age 50). For tax purposes, the IRS divides money in your IRA into two categories: the amount you initially contributed (the IRA contribution amount) and the amount that you made in profit from that initial contribution (the IRA profit amount). Everyone pays regular federal and state income tax on the traditional IRA profit amount when that money is taken out of the traditional IRA in retirement. But when it comes to the contribution amount, things get complicated and taxation depends on your annual income for the year of that contribution and your IRS filing status for that year.
    • Filing single. If you are covered by an employer retirement plan and your 2023 income is less than $73,000, then your traditional IRA contributions are all pre-tax, meaning that you do not pay income tax on those contributions until you withdraw the money in retirement. If your 2023 income is greater than $83,000, then your traditional IRA contributions are all post-tax, meaning that you pay income tax on those contributions this year, when you earned the money for those contributions. Then, in retirement, you do not have to pay any income tax on the withdrawals for the amount that you initially contributed. If your income is between $73,000 and $83,000, there is a phase-out, meaning that some amount of your contributions are pre-tax and some amount are post-tax.
    • Married filing jointly. If you are married and the spouse making the IRA contribution is covered by a workplace retirement plan, the income limit for pre-tax contributions is $116,000. All contributions are post-tax if the annual income is greater than $136,000. There is a phase-out if the income is between $116,000 and $136,000. However, if you are an IRA contributor who is not covered by a workplace retirement plan and is married to someone who is covered, the phase-out range increases to between $218,000 and $228,000
  • Roth IRAs (direct contributions). There are two ways you can contribute to a Roth IRA, either directly or by doing a traditional IRA to Roth IRA conversion. All contributions to Roth IRAs (regardless of annual income) are post-tax meaning that you pay federal and state income tax this year on any contributions you make this year. When money is withdrawn in retirement, all withdrawals are tax-free. The amount that the IRS allows you to contribute directly to a Roth IRA depends on your annual income for the year that you make the contributions.
    • Filing single. If your 2023 income is less than $138,000, then you can make direct contributions to a Roth IRA of up to $6,500 (or $7,500 if you are over age 50). If your annual income is greater than $153,000, then you cannot contribute any amount directly into a Roth IRA. If your income is between $138,000 and $153,000, then there is a phase-out, meaning that you can contribute directly to a Roth IRA but less than the usual maximum amount of $6,500 ($7,500 if over age 50).
    • Married filing jointly. The income limit for direct contributions to a Roth IRA is $218,000. If the annual income is less than that, then both spouses can directly contribute up to $6,500 each ($7,500 if over age 50) into a Roth IRA. If the household income is greater than $228,000, then neither spouse can make direct contributions to a Roth IRA. There is a phase-out if the income is between $218,000 and $228,000 resulting in a maximum direct contribution to a Roth IRA of less than $6,500 ($7,500 if over age 50).
  • Roth IRAs (conversion contributions). The second way of contributing to a Roth IRA is by doing a traditional IRA to Roth IRA conversion. This is sometimes called a “backdoor Roth” since the IRS code allows a person to first contribute money into a traditional IRA and then promptly convert that money into a Roth IRA. This strategy is used by people whose income is too high to directly contribute to a Roth IRA but it is also used by anyone who already has money in a traditional IRA and wants to move some of that money into a Roth IRA. There is no limit to the amount that you convert in any given year – you can convert as much as you want. However, the conversion is considered taxable income for that year, so the more you convert, the higher your annual income and therefore the higher your marginal tax rate becomes. Also, you must leave the amount that you convert in the Roth IRA for at least 5 years before you can withdraw that money without incurring an IRS penalty. You can make as many conversions as you want in any given year. The amount of income tax you pay when doing a Roth IRA conversion depends on whether your previous contributions to your traditional IRA were post-tax contributions, pre-tax contributions, or a mixture of the two.
    • Pre-tax traditional IRA contributions. If all of your previous contributions to your traditional IRA were made with pre-tax money, then you will pay regular federal and state income tax on the full amount that you convert to a Roth IRA.
    • Post-tax traditional IRA contributions. If all of your previous contributions to your traditional IRA were made with post-tax money, then you will pay regular federal and state income tax on the profit amount of the traditional IRA but you will not pay income tax on the contribution amount that you made to that IRA. This require you to keep a record of the amount of post-tax contributions that you make to your traditional IRA every year. When you convert a portion of your traditional IRA into a Roth IRA, the IRS requires you to calculate the percentage of the conversion that is from the profit amount and the percentage that is from the contribution amount in order to determine your income tax.
    • Mixed traditional IRA contributions. Here is where things get difficult. You must keep a record of the amount of pre-tax and post-tax contributions to your traditional IRA that you make every year. When doing a conversion to a Roth IRA, you must first determine the percentage of the conversion that is from the contribution amounts and the percentage that is from the profit amounts. Next you determine what percentage of the contribution amounts is from post-tax contributions. You do not pay regular income tax on that percentage of post-tax contributions but you do pay regular income tax on all of the rest of the conversion.

When is the best time to do a Roth IRA conversion?

There are two situations when it is advantageous to do a traditional to Roth IRA conversion. The first is when your current income tax rate is lower than your anticipated income tax rate in retirement. For most people, this is early in their career, when their annual income is lower than it will be later in their career. However, if a person is out of work for a period of time, then their annual income can fall that year, making a Roth IRA conversion worthwhile. Another situation when your income tax is lower is when Congress lowers income tax rates. It is impossible to predict what future income tax rates will be in 5, 10, or 25 years. However, the tax cuts passed in 2017 have given us some of the lowest federal income taxes in memory and it is doubtful that they can go much lower in the future without severe cuts in government programs.

The second situation when it is advantageous to do a traditional to Roth IRA conversion is when there is a significant fall in the stock market.  When the value of a traditional IRA falls, then you will pay less income tax on the conversion. Ideally, you would wait for the market to drop and then convert investments in your traditional IRA into similar investments in your Roth IRA. When the market eventually recovers, you will have paid less in taxes than if you had waited and taken the money out of the traditional IRA in retirement. Ideally, you would wait until the market is at its lowest, then do the conversion. The problem with this is that no-one has a crystal ball to see into the future to know when the market has bottomed out. However, it is clear that 2022 was a terrible year for both U.S. stocks (down 19% over the past 12 months) and U.S. bonds (down 13% over the past 12 months).

Reverse dollar cost averaging in 2023

Eventually, the stock and bond markets will recover and the prices for stock and bond mutual funds will increase. It is possible that the markets have already reached a bottom and the only way that they will go is back up. But it is also possible that stocks and bonds will continue to fall in value in 2023. That is the thing about predicting future stock and bond values – you just don’t know until you know and you don’t know until it has already happened. In other words, no one can predict future market values in the short-term. However, we can predict that future markets will be higher in the long-term.

So, 2023 would seem to be a good year to do a traditional IRA to Roth IRA conversion. The stock and bond market has lost a lot of value and we are currently living in a time of historically low income taxes (the 2017 income tax cuts will expire in 2025). But exactly when in 2023 should you do the conversion? This is where the concept of “reverse dollar cost averaging” comes into play.

In dollar cost averaging, a person invests a set amount at regular intervals throughout the year, typically monthly. By doing so, the person buys a lot of shares of of a mutual fund when they are cheap and buys fewer shares when they are expensive. This is a great strategy to ensure that you stick to a retirement savings plan. It also keeps you from trying to “time the market” (no one can accurately predict the future market so trying to time the market is generally unsuccessful). The “average” in dollar cost averaging refers to the result that by buying a few shares each month, then after 12 months, you will have a lot of shares with an average purchase price over the entire year. If you put a certain an amount of your paycheck into your 401k, 403b, or 457 each month, then you are already doing dollar cost averaging.

To see how dollar cost averaging works, let’s take the example of an investor who had $12,000 to invest on January 1, 2022. In the first scenario, the investor thought that the stock market was only going to go up in 2022 and invested the entire amount on January 1st. In the second scenario, the investor invested $1,000 every month for the full year. As it turned out, 2022 was a terrible year for stocks, dropping 19% for the year. The graph below shows the 2022 performance of the Russell 3000 Index, which is a benchmark for the total U.S. stock market.

 

In the first scenario, the investor who tried to time the market and put the entire $12,000 into a Russell 3000 index fund would have $9,669 at the end of the year. In the second scenario, the investor who used a dollar cost averaging strategy and put $1,000 into a Russell 3000 index fund every month would have $11,050 at the end of the year. Both investors will have lost money but the investor who used a dollar cost averaging strategy would have lost considerably less than the investor who tried to time the market.

You get the same benefit by spreading out your Roth conversions over the entire year. If an investor converted $12,000 of a traditional IRA invested in a Russell 3000 index fund into a Roth IRA that is also invested in a Russell 3000 index fund in January 2022, that investor would have 4.38 shares of the index fund at the end of the year. On the other hand, if an investor converted $1,000 of that traditional IRA into a Roth IRA every month in 2022, then at the end of the year, the investor would have 5.01 shares of the index fund. Now let’s assume that over the next 10 years, the Russell 3000 Index increases by an average of 8% per year. In 10 years, the investor who did one single $12,000 conversion would have $20,876 in the Roth IRA. But the investor who did twelve $1,000 conversions would have $23,857 in the Roth IRA. In other words, the reverse dollar cost averaging approach resulted in the investor having $2,981 more after 10 years.

“Sell high but convert low”

When it comes to maximizing investment returns, the old adage is “buy low and sell high”. But just the reverse is true for Roth conversions when long-term returns can be maximized by converting when the price is low. In essence, in a Roth conversion, you are selling an investment to yourself so that you are selling your traditional IRA low but also buying your Roth IRA low. When you eventually sell your Roth IRA tax-free in retirement, you will come out ahead.

In summary, it is looking like 2023 will be a good year for many people to do a traditional IRA to Roth IRA conversion. But resist the temptation to do one big conversion all at once. Instead, do 12 smaller conversions every month or 6 conversions every two months. When you are retired, you will be happy that you did.

January 7, 2023

Categories
Hospital Finances Inpatient Practice

Understanding The 2023 Medicare Hospital Readmission Penalty

Every year, the Centers for Medicare & Medicaid Services (CMS) penalizes hospitals with excessively high readmission rates. The monetary penalty for every U.S. hospital in 2023 was recently released by CMS. In theory, a higher penalty should indicate lower quality and vice-versa. However, the methodology used in calculating the penalties is complex and nuanced with the result that the readmission penalty may not be entirely reflective of a hospital’s overall quality of care.

Summary Points:

  • For 2023, 60% of U.S. hospitals were eligible to receive a financial penalty for excessive 30-day readmissions.
  • 75% of eligible hospitals received a Medicare penalty.
  • The average hospital penalty is 0.43% of 2023 Medicare revenue.
  • COVID impacted the readmission penalty formula in several ways.
  • There are a number of problems with the readmission penalty methodology and potential solutions are discussed that could improve the Hospital Readmissions Reduction Program

 

Background

One of the provisions of the Affordable Care Act of 2010 (aka “Obamacare”) was to direct CMS to penalize hospitals with high rates of patients requiring readmission to a hospital within 30 days of an inpatient hospital stay. The first penalties were assessed in 2013; this is the 11th year of the penalty program. The calculations are only made for a few specific diagnoses and are based on data during 3 previous years. CMS calculates the amount of every hospital’s penalty in October or November each year and then that penalty is applied to the following year’s Medicare payments. The maximum penalty is 3%, meaning that for a hospital receiving the maximum penalty, CMS will reduce the amount that it pays that hospital for all of the Medicare services the hospital charges by 3% the next calendar year. Because many hospitals operate on razor-thin margins, even a relatively small reduction in what it gets paid by Medicare can be financially devastating. This is especially true for hospitals that operate on a July to June fiscal year, such as most academic medical centers, that can find themselves with an reduction in Medicare payments in the middle of the fiscal year. This can make it very difficult for these hospitals to accurately forecast their annual budgets since they do not know what they will get paid from Medicare services during the second half of their fiscal year.

You can look up every U.S. hospital’s readmission penalty for 2023 here. CMS uses a 4-step process to determine the amount of each hospital’s penalty.

The actual equation that CMS uses to calculate each hospital’s penalty is complex with the result that even most hospital administrators do not fully understand it:

Lurking behind the equation are a lot of subtleties that affect how the public should interpret the readmission penalty.

COVID affected the calculations

Normally, CMS looks at historical readmission data from between 2 and 5 years in the past. Thus, normally, CMS would base the 2023 readmission penalty on data from July 2018 to June 2021. This has always been a source of criticism since the penalty is based on what a hospital did 5 years ago rather than what it has done more recently in the past 2 years. Consequently, a hospital with poor readmission performance 5 years ago could have a large readmission penalty even if its readmission performance was stellar during the past 2 years.

The first 6 months of the COVID pandemic was a trying time for most hospitals. Many exceeded their maximum inpatient capacity. To care for inpatients, many had to recruit doctors and nurses who did not normally provide inpatient care. Because of this, CMS excluded all data from January 2020 to July 2020. As a result, rather than being based on 3 years of historical readmission data, this year’s penalty is based on 2.5 year of data.

A second effect of COVID was on the diagnoses used for penalty determination. Normally, CMS looks at readmission rates only for patients with one of six diagnoses: acute myocardial infarction, heart failure, pneumonia, COPD, coronary artery bypass surgery, and hip & knee replacement surgery. COVID disproportionately affected patients coded with pneumonia. As a result, CMS dropped pneumonia as one of the diagnoses used for readmission calculations. Therefore, the penalties were based on 5 diagnoses this year rather than 6.

A third effect of COVID on the readmission penalty calculation was that any patient with COVID as a primary or secondary admission diagnosis was eliminated from the hospital’s readmission calculation. Thus, a patient admitted with an acute myocardial infarction who was found to also have COVID on admission was excluded from the hospital’s data.

A fourth effect of COVID was on comorbidity determination. CMS adjusts every individual patient for that particular patient’s medical co-morbidities. So, for example, a patient with an admission for COPD who requires mechanical ventilation is expected to have a higher readmission rate than a COPD patient who does not require mechanical ventilation. Similarly, a patient undergoing knee replacement who is over age 65 and has diabetes is expected to have a higher readmission rate than a knee replacement patient who is younger than age 65 and not diabetic. This year, CMS added history of COVID within the past year as one of the co-morbidities used in the readmission calculation for all five of the readmission diagnoses. Thus, a patient admitted with COPD who had a COVID infection 8 months previously would be expected to have a higher 30-day readmission rate than a COPD patient who had never had COVID in the past.

Not all hospitals are included

CMS excludes about 40% of U.S. hospitals from the readmission penalty program. These include pediatric hospitals, Veterans Administration hospitals, psychiatric hospitals, rehabilitation hospitals, long-term acute care hospitals, and critical access hospitals. In addition, a hospital must have had more than 25 eligible patients for each of the 5 diagnoses. Thus, a hospital that only performed 24 coronary artery bypass surgeries during the 2.5 year period would not be subject for readmission penalties for CABG surgeries. CMS also excludes all hospitals in Maryland from readmission penalties because of an agreement between CMS and Maryland.

It is impossible for hospitals to monitor their readmission rates

Every autumn, hospitals await the CMS report on their readmission data with no advance knowledge of what the hospital’s readmission rate will be. These are sent to the hospital as a “Hospital Specific Report”. For most other quality metrics, hospitals can continuously monitor their performance internally. For example, any hospital should be able to determine on any given day what their mortality rate, C. difficile incidence, and emergency department wait times are. But readmission rates are unique. Medicare looks at admission to any hospital within 30 days of an inpatient discharge, not just the the hospital that the patient was originally admitted to. The original hospital will know if a patient gets admitted again to that hospital but has no way of knowing if a patient gets admitted to some other hospital. For example, if a patient is discharged from the Ohio State University Medical Center, OSU can track any readmissions to an OSU hospital. However, if that patient gets admitted to a non-OSU hospital in Cincinnati, OSU will not know about it. On the other hand, Medicare gets billed by every hospital that a patient is admitted to so Medicare will know whenever a patient is admitted to any hospital in the United States. This phenomenon has little impact on small, rural or community hospitals since a patient admitted to that hospital will likely return to that same hospital given that it is the only hospital in the region. But for tertiary care or referral hospitals, patients often live hundreds of miles away and readmissions are more likely to occur at their local community hospital rather than at the tertiary care hospital. Thus a tertiary care hospital will have no idea what its readmission rate performance is until CMS sends out the Hospital Specific Reports.

Hospitals normally institute a continuous quality improvement process for quality metrics. This requires real-time monitoring of that quality metric so that the hospital can continuously change its procedures and policies to make their quality outcomes better. This turns out to be difficult for reducing 30-day readmissions because the readmission data that Medicare gets is 2-5 years old. To make an analogy, imagine how difficult it would be for a coach to improve his or her basketball team if the coach did not know the outcome of each game until 5 years after it was played.

All hospitals are not treated the same

One of the main criticisms of the initial formula that CMS used in the first years of the readmission penalty was that hospitals that cared for a large number of poor people were disproportionately penalized compared to hospitals caring for a largely affluent patient population. Poor individuals are less likely to have insurance, less likely to be able to afford medications, less likely to have transportation for doctor office visits, and less likely to have a primary care physician. All of these factors contribute to higher hospital readmission rates but these are factors that are largely not under the hospital’s control. In response to this criticism, several years ago, CMS changed the methodology used in readmission calculation to adjust for the percentage of poor and underserved patients that each hospital cares for. The current methodology uses the percentage of “dual-proportion” patients. This is based on the percentage of Medicare patients that also have full Medicaid benefits. Medicaid is used as a marker for low-income patients. CMS divides U.S. hospitals into one of five quintiles based on the percentage of a hospital’s dual proportion patients. Quintile #1 includes hospitals with fewer than 14% of its Medicare patients having dual coverage with Medicaid. Quintile #5 includes hospitals with more than 31% of its Medicare patients having dual coverage with Medicaid.  The breakdown of hospitals based on their percentage of dual proportion is seen in the graph below:

All hospital stays are not treated the same

Medicare classifies each patient’s hospital stay as either an “inpatient” stay or an “observation” stay. The rules for how to classify any given patient are complicated but in general, a patient who is expected at the time of arrival to the hospital to be in the hospital for less than 2 midnights is considered to be in observation status. Overall in the U.S., about 84% of hospital stays are designated as inpatient and about 16% are designated as observation. The financial difference in the two types of hospital stays is very significant, both for the hospital and for the patient. An observation stay is considered an outpatient visit and is thus subject to Medicare Part B billing rather than Medicare Part A billing. This means that the patient in observation status is responsible for all medication charges and is responsible for a 20% co-pay of the cost of the hospital stay. CMS pays the hospital much less for an observation stay than for a regular inpatient stay. Observation stays are less expensive for Medicare because much of the healthcare costs are passed on to the patient.

Because observation stays are considered outpatient visits from a Medicare perspective, these hospital stays are not included in the hospital readmission calculation. For a readmission to count, both the initial hospital stay must be an inpatient stay and the second hospital stay within 30 days must also be an inpatient stay. This is also the same when CMS calculates a hospital’s mortality rate – only inpatient stays are included and deaths occurring when a patient is in observation status do not count against the hospital’s mortality rate.

Hospitals can “game the system” by putting certain patients in observation status in order to improve their readmission data and their mortality data. For example, take a patient who is admitted for a COPD exacerbation on February 1st. That patient then comes back to the hospital on February 20th after having a cardiopulmonary arrest following a drug overdose. The patient is intubated, receives mechanical ventilation, and placed in the ICU but it is clear that the patient has had severe brain and heart damage and is not expected to live beyond 24 hours. The person overseeing the hospital’s quality data will advise the ICU physician to admit the patient as an observation stay so that the hospital stay does not count as a readmission and so that the death does not count as an inpatient mortality. On the other hand, the person overseeing the hospital’s finances will advise the ICU physician to admit the patient as an inpatient stay so that the hospital gets paid more from Medicare. Whichever of the two hospital administrators is most persuasive (or most vocal) will usually win out. The result is that hospitals that more liberally designate patients as being in observation status can lower their CMS readmission penalty. The goal of Medicare auditors is to pay hospitals as little as possible so they will penalize hospitals who put patients in inpatient status who should really be in observation status. However, those auditors do not care if a hospital puts patients in observation status who should really be in inpatient status since it saves Medicare money.

This can also be an effective strategy for hospitals that have a low volume of patients with one of the five diagnoses used in the readmission calculation. For example, if a hospital has 24 heart failure inpatient admissions over a 3-year period, then putting the next heart failure patient in observation status ensures that the hospital will not have any heart failure readmission penalty since there would still be fewer than 25 heart failure inpatient admissions during that 3-year period. The cost to the hospital is that they might get paid $4,000 less by putting that patient in observation status rather in inpatient status. But by avoiding a 0.2% readmission penalty for all medicare charges for the next year, that hospital might avoid a total $80,000 penalty. That is a $76,000 net return on investment for putting that one patient in observation status rather than inpatient status!

For some hospitals, it is cheaper to pay the penalty

In the United States, the average hospital has 19.8% of revenue from Medicare, 13.1% from Medicaid, and 68.4% from private commercial insurance. The hospital with the highest annual net patient revenue in the U.S. is New York Presbyterian Hospital at $5.7 billion. However, the average U.S. hospital’s total annual patient revenue is much lower at about $200 million. Thus, the average hospital has annual Medicare revenue of about $40 million ($200 million x 19.8%). A maximum Medicare readmission penalty of 3% would therefore be about $1.2 million for that average hospital. Only 17 hospitals were fined the full 3% for 2023 and only 231 hospitals will pay more than 1% penalty. 25% of hospitals will pay no penalty at all. The average hospital penalty is 0.43%.

Given that the average hospital has $40 million in annual Medicare revenue and that the average hospital has a 0.43% Medicare penalty in 2023, that average hospital will have a $172,000 penalty. Implementing a readmission reduction program in a hospital can be very costly. It requires hiring data analysts to monitor readmissions, instituting costly discharge transition clinics, and increasing the percentage of patients in observation status. For many hospitals, the total cost to reduce readmissions sufficiently to avoid a CMS penalty can be considerably more than the expense of the penalty. In general, the larger the hospital and the higher the percentage of Medicare patients in a hospital’s payer mix, the more likely it will make financial sense for a hospital to devote a lot of money into a readmission reduction program. Furthermore, because the readmission penalty is based on the hospital’s performance between 2-5 years previously, it will take 5 years before money spent today on a readmission reduction program will fully affect the annual CMS penalty. And it is likely that CMS will continue to revise the readmission penalty formula so that the formula will look considerably different over the next 5 years.

How can the process be improved?

Medical care in the United States is more expensive than anywhere else in the world and it is essential for our economy that we reign in healthcare costs. Because hospitalizations are expensive, reducing unnecessary hospital admissions is central to controlling those healthcare costs. Readmissions to the hospital within 30 days of hospital discharge are frequently avoidable if processes are in place to ensure that patients get appropriate outpatient care. This includes filling medication prescriptions, keeping office appointments with medical providers after discharge, access to outpatient physical & occupational therapy, etc. Penalizing hospitals for excessive readmissions is one way to reduce costs by incentivizing hospitals to institute processes that reduce hospital readmissions. However, after eleven years of the CMS Hospital Readmissions Reduction Program, it is clear that the program can do better. Some specific improvements include:

  1. Provide hospitals with real-time readmission data. This is probably the single most important change that CMS can make and it really should not be terribly difficult. Ideally, hospitals should know what their current readmission rates are every month so that the hospital can employ continuous improvement processes to reduce those readmissions. The current model of basing the penalty on a hospital’s readmission rates from 2-5 years in the past makes improving readmissions very difficult. Ideally, CMS should provide every hospital with its current rolling 3-year average readmission rate and this should be updated monthly.
  2. Eliminate observation status hospital stays. Currently, hospitals spend an enormous amount of money to determine whether any given patient should be in observation status or inpatient status. Medicare loves observation status because CMS does not have to pay as much to hospitals for patients in observation status as opposed to inpatient status. Instead, those additional costs are passed on to the individual patient. So, the net overall cost to the country as a whole is the same, regardless of whether a patient is in observation or inpatient status. When the overhead expense of monitoring and policing observation stays is included, the overall cost of having observation status actually increases the country’s overall healthcare costs. When it comes to readmission rates, some hospitals game the system by preferentially putting readmitted patients in observation status instead of inpatient status. It is time to eliminate observation status and simply pay hospitals for patient stays, regardless of whether or not the patient’s hospital stay crosses two midnights.
  3. Base the penalty on the overall readmission rate rather readmission rates for only 6 diagnoses. Every hospital is different. Not all hospitals perform coronary artery bypass graft surgery and not all hospitals perform knee & hip replacement surgery. Currently, hospitals focus their readmission rate reduction strategies on just the 6 conditions that CMS penalizes them on. Savvy hospitalists know that they can readmit patients who have had a stroke, diverticulitis, or a drug overdose every week without having to worry about any penalty. By using overall readmission rates (for all diagnoses), the quality process will be simpler for hospitals and will benefit all patients and not just those patients who have one of the 6 conditions that CMS currently uses in readmission penalty determination. However, CMS would need to determine a different method of risk-adjustment for comorbidity since the current method is by using specific comorbidities for each of the 6 eligible diagnoses.
  4. Eliminate hospital exceptions. Currently, about 40% of U.S. hospitals are not subject to readmission penalties. This is understandable for pediatric hospitals (few, if any, Medicare patients) and Veterans Administration hospitals (funded by the VA and not by CMS). Psychiatric hospitals are excluded because they do not normally admit patients with the 6 conditions that CMS bases the readmission penalty on. Long-term acute care hospitals, rehabilitation hospitals, and critical access hospitals are also excluded. Ideally, CMS should use data for both Medicare and Medicaid patients since it can track readmissions for both groups. By focusing on total readmission rates rather than the 6 currently used diagnoses, many of the currently exempted hospitals can be included in the readmission reduction program. However, there may need to be different readmission rate benchmarks for psychiatric hospitals, long-term acute care hospitals, etc.

January 4, 2023

Categories
Outpatient Practice

Does Your Hospital Need A Cancer Survivorship Clinic?

Prior to 1946, cancer was a surgical disease. If a cancer could not be completely removed during an operation, then it was incurable. But in 1946, two Yale University pharmacologists, Dr. Louis Goodman and Dr. Alfred Gilman, published their findings that by treating a patient dying of lymphoma with nitrogen mustard, the patient’s tumors shrank. The impetus for their experiment was the observation during World War I that soldiers who survived mustard gas attacks developed low white blood cell counts and were susceptible to infections. Goodman and Gilman hypothesized that the same chemical used in gas warfare could treat white blood cell malignancies. Thus, the era of cancer chemotherapy was born.

When I was a medical student 40 years ago, chemotherapy rarely cured anyone – it merely postponed dying from cancer by a few months. However, since then, the number of chemotherapy drugs has dramatically increased. Now, we also have immunotherapies, driver-directed therapies, and hormonal therapies to treat cancers. These treatments are much more effective than early chemotherapies and can not only offer the hope of long-term suppression of cancer but can also often cure cancer. And each of these treatments has its own set of short-term and long-term complications. Currently, there are 18.1 million cancer survivors in the United States and that number is expected to grow to 22.5 million over the next ten years. Of those cancer survivors, 16.3 million will live for more than 5 years. The good news is that we now have more people surviving cancer than ever before but the bad news is that we now have more people living with the side effects of cancer treatment than ever before.

Historically, oncologists were in the business of treating cancer. Once cancer was cured, the oncologist discharged the patient to the care of their primary care physician so that the oncologist could focus on their next patient with newly diagnosed cancer. But primary care physicians are largely untrained in managing the medical complications attendant to cancer treatment. As a result, we have an unfilled gap in medical care – patients in a no-man’s land of medical problems that their primary care physician is unfamiliar with and that their oncologist often places a lower priority on. This unfilled gap is cancer survivorship.

There are four major components to cancer survivorship care:

  1. Surveillance. Cancer can recur and early detection of recurrence leads to early treatment of recurrence which in turn leads to the best long-term survival. However, the  surveillance monitoring guidelines frequently change and each type of cancer requires different radiographic or blood test monitoring.
  2. Prevention. Cancer treatments can cause medical conditions by themselves but they can also make patients more susceptible to other medical problems. Preventive care can often avert these problems.
  3. Treatment side effects. Every cancer therapy has its own set of side effects and if untreated, these side effects can often be debilitating.
  4. Coordination of care. The management of cancer survivors can be complicated, often requiring multiple specialists simultaneously.

A cancer survivorship clinic should ideally incorporate all four of these components.

Surveillance

Cancer screening falls squarely in the purview of the primary care physician. Family physicians and general internists are accustomed to being responsible for ordering routine screening mammograms, pap smears, and colonoscopies. But once a patient is treated for a cancer, the guidelines for those tests change and primary care physicians are often uncertain what tests to order and how often to order them. Current guidelines include the following:

  • Breast cancer. Survivors should have an office visit with history and physical examination every 3-6 months for the first three years, every 6-12 months for the next two years, and annually thereafter. A diagnostic mammogram should be performed annually for the first 3-5 years and then a screening mammogram performed annually thereafter. All women with breast cancer should be offered genetic testing and genetic counseling.
  • Prostate cancer. Prostate cancer is unique among cancers because there is a wide spectrum of severity. Some prostate cancers grow so slowly that they do not require any treatment whereas others can rapidly metastasize and be fatal. The PSA (prostate-specific antigen) blood test is the mainstay of prostate cancer surveillance. For patients with localized disease, it should be tested every 6-12 months for the first 5 years and then annually thereafter. For patients with more extensive disease, it should be tested every 3-6 months.
  • Colon cancer. For patients with stage I disease, a colonoscopy should be performed 1 year after surgery and then every 3 years thereafter. Patients with stage II or III disease should also have regular colonoscopy but should additionally have a history and physical examination plus a CEA blood test every 3-6 months as well as a CT scan of the chest/abdomen/pelvis every 6-12 months.
  • Lung cancer. The chest CT is the mainstay of surveillance for lung cancer survivors and, along with a history & physical examination, should be performed every 6 months for the first two years and then annually thereafter. After five years, changing to a low-dose screening annual chest CT can be considered.
  • Other cancers. There are different surveillance recommendations for melanoma, testicular cancer, lymphoma, thyroid cancer, and brain cancer. The surveillance for every cancer is unique and may require interval history and physical examinations, blood testing, and/or radiographic imaging.

Prevention

Preventive medicine recommendations are fairly similar for all cancer survivors. Healthy living strategies for one cancer are generally the same for other cancers. A healthy diet, weight loss if overweight, regular exercise, and appropriate vaccinations are appropriate for cancer survivors as well as for the general population. Because many cancer survivors may have lingering immunity impairment from chemotherapy, vaccinations are especially important.

Smoking cessation is an essential component of cancer survivorship. Approximately 12-15% of cancer survivors are current smokers. The patient cured of their lung cancer by lobectomy will be at increased risk of a second lung cancer if cigarette smoking continues. Smoking cessation can also help prevent laryngeal cancer, bladder cancer, pancreatic cancer, kidney cancer, esophageal cancer, and others,

As more and more cancers are found to have genetic contributions, genetic testing has become routine in oncology. Ideally, genetic testing be done after genetic counseling but with the widespread availability of gene testing, any provider can order these tests. At the least, referral to a genetic counselor should be made for all patients with abnormal cancer-related genes. Not only can this improve early diagnosis and prevention of other cancers in the patient but it can also improve cancer diagnosis and prevention in susceptible family members.

Treatment side effects

Each kind of cancer has its own specific treatment. And each treatment has its own specific side effects. As the number of cancer treatments has increased exponentially in the past decades, so have the number of treatment side effects. The result is that cancer survivorship has almost become a sub-specialty of its own. To a degree, this has been met by other subspecialties. For example, we now have “onco-nephrologists” who are kidney specialists who sub-specialize in managing the renal complications of cancer treatments. We have “onco-pulmonologists who sub-specialize in pulmonary complications of cancer treatments. Similarly with cardiology, infectious disease, and gastroenterology. But these sub-specialists are few in number and only located in large, tertiary care, academic medical centers. Moreover, their expertise is organ-specific and frequently, cancer survivors have complications affecting more than one organ or affect a part of the body that does not fall under the expertise of the nephrologist, pulmonologist, or cardiologist. Here are some of the most common medical conditions seen in cancer survivors:

  • Osteoporosis. Many cancer treatments can increase the risk of osteoporosis including chemotherapy-induced premature menopause, use of aromatase inhibitors for breast cancer, use of corticosteroids, and use of anti-androgen prostate treatments. Baseline bone density tests at treatment onset followed by regular interval bone density tests should be offered to patients receiving these treatments. Early treatment of osteopenia and osteoporosis can prevent subsequent bone fragility fractures.
  • Fatigue. Cancer survivors can have fatigue for many different reasons including side effects of radiation therapy, surgery, or medications. However, other common causes of fatigue should not be overlooked including thyroid dysfunction, sleep disorders, anemia, depression, and heart disease.
  • Peripheral neuropathy. Many chemotherapy drugs can cause damage to the peripheral nerves. Some of the more common drugs include vincristine, cisplatin, oxaliplatin, bortezomib, and paclitaxel. These are usually “stocking-glove” distribution sensory neuropathies. However, drugs such as vincristine can cause intestinal autonomic neuropathy resulting in constipation. In addition, radiation therapy can result in peripheral neuropathy from injury to nerves within the radiation ports. Peripheral neuropathy management in cancer survivors may include physical therapy, medications (such as duloxetine), and injury prevention (such as daily foot inspections).
  • Pain. Cancer-related pain is often managed by palliative medicine specialists but cancer survivors often have chronic pain, even if their cancer is cured. This often results in patients transferring care from the palliative medicine specialist to a pain management specialist. As with other causes of chronic pain, multimodality comprehensive pain management is considerably more effective than relying solely on pain medications such as opioids.
  • Cardiotoxicity. Patients receiving radiation therapy to the chest region are susceptible to developing pericarditis, cardiomyopathy, coronary artery disease, and valvular heart disease. Anthracycline drugs (such as doxorubicin and daunorubicin), fluorouracil, and trastuzumab can cause heart failure and may require serial cardiac ultrasound testing. Many other chemotherapy drugs can also cause heart disease. The management of drug-induced heart failure is similar to the management of other causes of heart failure.
  • Pulmonary toxicity. Chest radiation and many chemotherapy drugs can cause interstitial lung disease. Bleomycin is particularly notable because it can cause interstitial lung disease with respiratory failure years after treatment if a patient is inadvertently exposed to high oxygen concentrations, for example, while undergoing anesthesia. Driver-directed cancer treatments, such as tyrosine kinase inhibitors, can cause lung damage. Checkpoint inhibitors used as immunotherapy for cancer can also cause pneumonitis. In many cases, pulmonary toxicity can be minimized by early diagnosis and treatment with corticosteroids but patients may require bronchoscopy to exclude infection.
  • Gastrointestinal toxicity. Diarrhea is common with chemotherapy. Pelvic radiation can additionally result in diarrhea or incontinence. Checkpoint inhibitors can cause hepatotoxicity and colitis. In some cases, corticosteroids can relieve symptoms but patients require microbiologic testing of the stool to first exclude infection.
  • Renal toxicity. The kidney can suffer many kinds of injury from cancer treatment. Chemotherapies, checkpoint inhibitors, and driver-directed therapies can all directly cause acute kidney injury. Electrolyte disorders of potassium, sodium, phosphorus, and calcium can result from both cancer treatments or from the underlying cancer. In addition, paraneoplastic glomerular disorders, glomerular injury from tumor lysis syndrome, and glomerular injury from monoclonal gammopathies can occur.
  • Sexual health needs. Sexual dysfunction can result from post-surgical changes, chemotherapy, hormonal therapy, radiation therapy, and  premature menopause. Many cancer survivors are hesitant to initiate discussion about sexual dysfunction so it is important that providers create an environment where patients are comfortable discussing sexual health.
  • Fear of recurrence. About half of cancer survivors have mild to moderate fear or worry that their cancer will come back and 7% of survivors have these fears to a severe degree. This carcinophobia can be emotionally consuming. In mild cases, support groups can be helpful. More severe cases benefit by cognitive behavioral therapy. Other psychosocial issues such as depression, anxiety, and post-traumatic stress disorder are also common.
  • Financial insecurity. It is expensive to have cancer. Frequent office visits, costly medications, costly tests, and unexpected surgeries can be financially devastating, even for those patients with health insurance. In addition, reduced income for both patients and caregivers results from necessary time off work. Hospital financial counselors and social service staff can often be helpful.

Coordination of care

With care simultaneously being provided by physicians from many different specialities, cancer survivors often find themselves asking: “Who is in charge of my medical care?”, especially after cancer treatment has finished. Coordination between the patient’s medical oncologist, surgeon, radiation oncologist, internal medicine specialists, social worker, psychologist, genetic counselor, and neurologist can be challenging. Although primary care physicians are adept at coordination of care for patients with chronic disease, the unique multidisciplinary care needs of cancer survivors can often be overwhelming for the primary care office. Coordination of care can be the responsibility of the medical oncologist in some situations, the primary care physician in some situations, or patient navigators in others. The important thing is that every cancer survivor knows who is coordinating their care and that all of the various providers involved in that patient’s care also know who coordinating care. This is particularly essential to ensure that recommended tests and medication changes actually get done.

Cancer survivorship clinics

So, does your hospital need a cancer survivorship clinic? And if so, who should run it? In some hospitals, cancer survivorship is the purview of the medical oncologist. But the medical needs of cancer survivors can last for years or decades after the cancer is cured and many oncologists simply do not have the bandwidth to meed these needs for dozens or hundreds of cancer survivors while still meeting the needs of patients being actively treated for their cancer. Some primary are providers are able to assume the oversight and coordination of care for cancer survivors. But cancer survivorship care has become fairly specialized with the result that many primary care providers lack the training or experience in the unique chronic care of the cancer survivor.

A solution in some communities is the dedicated cancer survivorship clinic. This could be staffed by an oncologist, a general internist with a special interest in cancer survivorship, a physical medicine specialist, or even an advanced practice provider with training in the care of cancer survivors. Although large cancer specialty hospitals have dedicated survivorship clinics, this is an unmet medical need in most community hospitals.

It is time that medical directors and hospital administrators at community hospitals take responsibility for creating cancer survivorship clinics. One out of every 17 Americans is a cancer survivor and these cancer survivors are often hiding in plain sight in every small community in the United States. A community does not need to have a tertiary care oncology practice in order to support a cancer survivorship clinic. Indeed, such a clinic can be overseen by a general internist or a family medicine physician.

As cancer treatments continue to advance, so do the needs of cancer survivors. It is time that we bring survivorship clinics to our community hospitals.

December 27, 2022

Categories
Hospital Finances Inpatient Practice Physician Finances

How Do You Define A Hospitalist FTE?

A reader recently emailed me to ask: “How do you define a hospitalist FTE?” It turns out that it is a great question with a very nuanced answer. Twenty years ago, an FTE was whatever a physician wanted it to be. Physician earnings were directly tied to physician billing and so a physician would work as much as they wanted in order to generate the income that they wanted. But over the past 2 decades, revenue from physician professional services has not changed appreciably – in 2002, Medicare reimbursed physicians at $36.20 per RVU; in 2022, an RVU was worth $34.61.

To put that in perspective, $1.00 in 2002 is worth $1.66 in 2022 whereas an RVU is now worth $1.59 less than it was in 2002! In order to keep physician incomes constant, hospitals have had to increasingly subsidize physicians. As a result, most physicians are now hospital-employed, rather than independent practitioners. This is especially true for hospitalists who rarely, if ever, are able to support their full salary on billings alone. In the past, the physicians defined what working full-time constitutes but today, it is the hospitals that define what working full-time means for a hospitalist.

Hospitals typically subsidize hospitalist groups based on the number of FTEs (full-time equivalents) that are required in order to cover the hospital’s inpatients. But defining exactly what an FTE is can be complicated and often a source of disagreement between the hospital and the hospitalist group. There are a number of equally valid ways of defining “full-time” and no one definition works best in every hospital. There are several steps to determine the best model in your hospital.

Step 1: Determine the number of patients per hospitalist per day

The number of patients each hospitalist should see per day will vary considerably from hospital to hospital and from nursing unit to nursing unit. There are 19 factors to consider when determining this number as outlined in a previous post:

      • Case mix index
      • Residents versus no residents
      • Admitting service versus consultative service
      • Presence or absence of advance practice providers
      • ICU versus general ward patients
      • Day shift versus night shift
      • Observation status versus regular inpatient status
      • Ease of documentation
      • Shared electronic medical record with primary care physicians
      • Non-clinical duties
      • Shift duration (hours)
      • Hospitalist experience
      • Patient geographical location within the hospital
      • Average length of stay
      • Inpatient census variability
      • RVU productivity
      • Quality of case management
      • Local hospitalist employment market
      • Patient demographics

There has to be flexibility, however, and rigid adherence to a given number of patients is a recipe for dissatisfaction on both the part of the hospital and the part of the hospitalist. If the hospital inpatient census falls, then the hospital will be unhappy that each on-duty hospitalist is not seeing enough patients. On the other hand, if the inpatient census surges, then the hospitalists will be unhappy since they have to see more patients than they agreed on in their contracts. Many hospitals will have a “risk-call” hospitalist each day who is on standby to come in to work if needed when the inpatient census is higher than normal.

Step 2: Determine how the hospitalists will be scheduled

Early in the hospitalist era, scheduling was simple: a shift was 12 hours long and there were two shifts – a day shift and a night shift. Hospitalist schedules have gotten a lot more complex in recent years as outlined in a previous post. Now, hospitalists often have 8-hour short day shifts and evening swing shifts to cover ER admissions in the early evenings. As a result, scheduling hospitalists has become much more complex. Here are some of the scheduling models:

The 12-hour shift model. This was the original hospitalist scheduling model and typically will have two 12-hour shifts per day, a day shift and a night shift. The day shift is typically 6:00 AM to 6:00 PM or 7:00 AM to 7:00 PM. The night shift starts when the day shift is over. Day shifts and night shifts are treated equally but since night shifts are considered less desirable by most hospitalists, there needs to be a “shift differential” to provide extra payment for covering night shifts. Many hospitals will also provide additional pay for hospitalists who work on holidays. Because most patient care (work rounds, interdisciplinary rounds, daily charting, discharges, family meetings, etc.) occurs during the day shift, hospitals will typically have 1 night shift hospitalist for every 3 -4 day shift hospitalists. High acuity patient care areas, such as the intensive care unit, may require 1 night shift hospitalist for every 1 day shift hospitalist.

The long-shift, short-shift model. In this model, one or more hospitalists works the entire 12-hour day shift but other hospitalists leave earlier in the day, after their work is done. The short-shift hospitalists check out to one of the long-shift hospitalists when leaving. The long-shift hospitalist is then responsible for any admissions that come in later in the day. Some hospitalist groups will have the short-shift hospitalists continue to take phone calls from nurses, the lab, and consultants after they leave the hospital; other hospitalist groups will have the long-shift hospitalists cover calls. Some hospitals will have a specific check-out time for the short-shift hospitalists, for example, 3:00 PM. Other hospitals will have the short-shift hospitalists check out whenever their work is completed, whether that be 1:00 PM or 5:00 PM. An advantage of this model is that it avoids having a lot of hospitalists sitting around doing nothing in the late afternoon, after all of their work is done. In addition, this model is very attractive to hospitalists with children, since they can be home when the kids get out of school.

The swing-shift model. In most hospitals, the peak in admissions from the emergency department occurs between 3:00 PM and midnight. After midnight, the admissions slow down, the inpatients go to sleep, and the hospitalist workload drops. To optimize patient care coverage, some hospitals will create a “swing-shift” to cover the surge in admissions during the evening. Every hospital’s pattern of ER admission is different so swing-shifts could be from 3:00 to midnight, 5:00 to 10:00, etc.

The comprehensive services model. In many hospitals, the hospitalists do more than just serve as the attending physician for inpatients. For example, they may perform medical pre-operative consultation in an outpatient pre-admission testing clinic. They may provide medical consultation for surgical inpatients. They may have a designated “triage attending” to serve as a liaison between the hospitalist services and the emergency department or the outside referring hospitals. Or they may provide on-site supervision of infusion centers. In these situations (except for triage attending), the duration of a shift is determined by whenever the work is done, rather than by a specific time of day or number of hours. In general, these other services require fewer than 12 hours per day. These types of services are often attractive to hospitalists with young children since they are generally able to get home earlier than they would with a traditional 12-hour inpatient hospitalist shift.

Step 3: Determine how a 100% FTE will be defined

Once the hospital has determined how many inpatients a rounding hospitalist should cover and how the hospitalists are to be scheduled, the next step is to determine what will constitute a 100% FTE hospitalist. There are several ways of defining an FTE.

The shifts per month model. This works best when all of the hospitalists work 12-hour shifts. A full-time hospitalist is typically defined as 15 or 16 shifts per month (180 – 192 shifts per year). It generally takes about a half hour to check out at the end of every shift with the result that a 12-hour shift is really a 12.5-hour shift. This works out to about 43 – 46 hours per week on average. Some hospitals will grant additional time off for vacations and CME with the result that full-time may be fewer shifts per year, for example, 170 shifts.

The hours per month model. This model works when there there are different hospitalist shifts of varying durations. In this model, a hospitalist may be scheduled for shifts of a variety of durations up to some pre-agreed upon number of total hours per month. This results in a great deal of scheduling complexity and often requires considerable effort by the scheduler to ensure equity among the hospitalists. Many jobs define an FTE as 40 hours per week, however, most physicians work more than that. Although physician time surveys vary, most find that physicians average closer to 50 hours per week. If we extrapolate from the 15 – 16 twelve hour shifts per month model that results in 43 – 46 hours per week, then this would equate to 2,236 – 2,392 hours per year. Rigid adherence to a specific number of hours per year is difficult. Unlike other hospital employees, hospitalists do not punch in and out on a time clock. There are always some days when a hospitalist needs to stay in the hospital past the end of their shift to finish charting, complete the H&P on a late admission, or provide care for a critically ill patient. In addition, some hospitalists may check-out early to one of their peers once they complete their daily work.

The number of billed wRVUs model. If you look in the annual MGMA physician salary survey, you can find the mean, median, 25th percentile, 75th percentile, and 90th percentile of work RVUs  produced by physicians in every specialty. Using wRVUs as a general guide of FTE productivity can be useful for many specialties but as discussed in a previous post, it is inadvisable to pay individual hospitalists by the wRVU. Nor is it advisable to use wRVU targets to define an FTE. If wRUVs are used to benchmark hospitalist productivity, the RVU targets need to be for the entire hospitalist group and not for individual hospitalists. There is too much variation in RVU production intrinsic to different types of hospitalist shifts – fewer RVUs with night shifts, more with ICU shifts, and none for triage attending shifts. In other words, rather than requiring each of your 10 hospitalists to produce 4,300 wRVUs per year, instead require the entire group of hospitalists to produce 43,000 wRVUs per year.

The traditional workweek model. Most outpatient physicians define full-time as traditional office hours, working Monday through Friday, 8:00 – 5:00. With physician offices often closed on weekends, evenings, and holidays, this works fairly well for outpatient medicine. This model is harder to apply to hospitalists because illnesses requiring inpatient care are just as likely to occur on weekends and holidays as they are on weekdays. Therefore, hospitalists need to cover every day of the year. Nevertheless, some hospitals will have a core group of hospitalists who cover Monday through Friday day shifts. Part-time hospitalists or moonlighters cover weekends. And nights are either covered by home call, by inpatient advance practice providers, or by nocturnists. This model can sometimes work in smaller hospitals that care for lower acuity patients but is impractical in larger hospitals. The weekday hospitalists typically take care of their daily rounds and any admissions. They then leave the hospital in the afternoon, after their work is done. A typical full-time hospitalist in this model might work 46 weeks with 4 weeks of vacation, a week of CME, and a week for holidays. This equates to 230 working days per year.

The academic hospitalist model. In many teaching hospitals, the attending physicians on medical inpatient services are hospitalists who oversee care provided by internal medicine, family medicine, or pediatric residents. In this situation, the residents typically cover a given inpatient service for 4-week blocks. The attending hospitalist typically covers the teaching service daily for 2 weeks, although at some hospitals, the hospitalist covers the service for shorter (1 week) or longer (4 week) blocks. Because residents are in the hospital to perform H&Ps and care for any acute medical problems, the hospitalist can often leave the hospital after rounding with the resident and completing charting. This results in the hospitalist typically being in the hospital for 5 – 8 hours per day. The attending hospitalists generally provide back-up coverage to the residents at night by home call, either individually for their particular inpatient service or on a group rotational night call basis. Unlike the traditional workweek model, the academic hospitalist model generally requires both weekday and weekend coverage in order to ensure continuity of patient care and continuity of resident education. Thus, full time is considered less than 46 weeks and may be anywhere from 6 months (182 days per year) to 8 months (243 days per year) of service time.

Step 4: Determine how a part-time FTE will be defined

Once there is agreement between the hospital and the hospitalists on what will constitute a full-time FTE, it then becomes easier to assign a percent effort to part-time physicians and to determine how those part-time hospitalists will be paid.

For compensation of hospitalists who work less than 100% FTE, the easy answer is to make their base pay the same percent as their FTE. However, that can pose more cost to the employer since there are certain employer-paid expenses that are fixed, regardless of whether a hospitalist is 100% or 70% FTE. For example, the employer’s portion of health insurance premiums and life insurance premiums is the same for part-time employees as it is for full-time employees. Similarly, the employer’s cost of recruitment and credentialing is the same whether the hospitalist is 100% or 70%. In other words, it costs the employer more to have 2 hospitalists who each work 50% FTE than to have 1 hospitalist who works 100% FTE. Most hospitals are willing to cover those higher costs in order to keep high-performing hospitalists who wants to work part-time, particularly if there is a reasonable chance that the hospitalist will eventually return to 100% FTE in the future. For example, an experienced hospitalist who is a parent who wants to cut back to 70% for a few years until his/her child is older.

One size does not fit all

From the above discussion, it is clear that no one single model is best for all hospitals. Each hospital (and each hospitalist group) must examine its own unique inpatient service coverage needs in order to select the definition of “full-time” that fits best. From the hospital standpoint, it is important to be flexible and work with the hospitalists to be sure that they are happy with the model. From the hospitalist standpoint, it is important to ensure that a model that optimizes their work-life balance does not interfere with optimal patient care.

Because hospital censuses ebb and flow from year to year and because new hospitalists are hired from year to year, it is important that every hospital re-examines how full-time is defined periodically to ensure that the agreed upon model best fits the dynamic nature of inpatient medicine.

December 10, 2022

Categories
Inpatient Practice

What Kind Of Mask Should You Wear?

It has now been 3 years since the SARS-CoV-2 virus first infected humans in Wuhong, China in December 2019. By now, most Americans have either had a COVID-19 infection or have been vaccinated against COVID. So, what type of mask should we be wearing in the hospital and in public places?

Our two most powerful weapons against COVID are vaccination and mask-wearing but mandates for both have been been unpopular in the United States. Since the peak of the pandemic, most mask mandates in public areas have been relaxed. However, mask mandates are still in place in many hospitals. Furthermore, as of the writing of this post, there are 25,380 patients with COVID infection currently admitted in U.S. hospitals. Consequently, healthcare workers continue to have regular exposure to infected persons. So, what kind of mask should our healthcare workers wear?

Mask-wearing is not new. Surgeons and other operating room personnel have worn masks during surgeries for more than a century. However, the purpose of wearing masks in the OR is to prevent the surgeon’s respiratory secretions from infecting the patient’s incision and not to prevent the patient’s incision from infecting the surgeon. A simple surgical mask is very effective in catching respiratory droplets if the surgeon sneezes, coughs, or talks during an operation.

Before COVID, there were situations when healthcare workers did wear masks to prevent getting infected by patients, for example, when caring for patients infected with influenza (where transmission is usually by respiratory secretion droplets). A regular surgical mask is effective in preventing infection from respiratory secretion droplets but for smaller particles, an N95 mask is necessary. For 35 years, I wore N95 masks whenever I was caring for patients infected with tuberculosis or when doing bronchoscopy on patients suspected of having TB. It only takes inhaling  one tuberculosis bacteria to become infected with TB. A respiratory secretion droplet is about 5-10 μm in size whereas a tuberculosis bacteria is about 2 μm in size. A regular surgical mask will usually stop the droplets but will not stop a TB bacteria, whereas an N95 mask will.

For an N95 mask to be effective, it must have a tight seal to the face so that air cannot get between the edges of the mask and the skin. Everyone’s face is shaped a little differently and not all brands of N95 masks fit all faces equally well. Healthcare workers are normally required to be “fit-tested” to determine which N95 mask provides an acceptable seal against the face. Passing the fit test meant that all of the inhaled air went through the mask material and did not leak between the mask and the skin. At our hospital, we required healthcare workers who worked with patients with suspected tuberculosis to be fit tested every year. A number of years ago, the Occupational Safety and Health Administration (OSHA) put out a requirement stating “The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face…“. In other words, men with beards were not supposed to use N95 masks.

Like influenza, the COVID virus is usually transmitted by respiratory secretion droplets. So, in theory, a surgical mask should be sufficient. However, there are certain situations when an infected patient’s respiratory secretion droplets can be broken down into smaller particles, in which case, a surgical mask could be insufficient and an N95 mask may be more effective. Such situations include performing endotracheal intubation and bronchoscopy. Having had a beard for 40 years, I had repeatedly passed my annual N95 fit tests despite having a beard but when COVID hit, I shaved it in order to be in compliance.

We now have several studies performed over the past 3 years of the pandemic to give us better guidance of what type of mask is most effective in preventing healthcare workers from becoming infected. Unfortunately, each of these studies have potential limitations and the studies have given mixed results.

A word about KN95 masks. An N95 mask is a NIOSH-approved mask that filters out at least 95% of particles that are 0.3 micons in size. In reality, a well-fitting N95 mask actually filters out 99.8% of particles that are 0.1 micons in size, which is also the size of a COVID virus particle. A KN95 mask is a mask approved by the Chinese government (and not NIOSH). A study of KN95 masks found that 70% of them did not meet the NIOSH standard for effectiveness. For hospital purposes, a KN95 mask can be considered as effective as a surgical mask but not as effective as an N95 mask

One of the earliest studies comparing surgical to N95 masks was published in JAMA in 2009 and randomized 446 nurses caring for patients with acute febrile respiratory illnesses to wear either surgical masks or N95 masks during patient care. An equal percentage of the nurses were diagnosed with influenza during the study and the conclusion was that the type of mask worn did not make a difference. Another study published 10 years later in JAMA in 2019 also found that among 1,993 healthcare workers randomized to wearing surgical or N95 masks, there was no difference in the incidence of influenza or other respiratory infections.

There have been several studies comparing masks to prevent COVID infection. A 2021 study examining the effectiveness of N95 versus surgical masks based on analysis of droplet size characteristics concluded that a surgical mask was theoretically sufficient to prevent COVID infection in low-virus environments but N95 masks would be theoretically more effective in virus-rich environments. A 2021 study comparing the fit of cloth, surgical, KN95, and N95 masks found that N95 masks had better fit factor scores than the other masks and that KN95 masks had similar fit factor scores as surgical masks. The study also concluded that fit is critical to the level of protection offered by masks. A 2021 meta-analysis of 8 studies involving N95 versus surgical masks found that N95 masks were more effective than surgical masks in preventing healthcare workers from becoming infected with a variety of respiratory viruses, including COVID. A 2022 study of 3,259 healthcare workers who were randomly assigned to use filtering facepiece class 2 masks (analogous to N95 masks) versus surgical masks found no overall effect on the incidence of COVID infection; however, those healthcare workers with > 20 contacts with COVID patients did have fewer COVID infections if they were wearing the filtering face piece class 2 masks. A 2022 MMWR report involved a retrospective review of 1,528 COVID-infected persons and 1,511 case controls and found that people who reported wearing N95 masks in public were less likely to become infected than those who wore surgical masks in public places. However, a major limitation of this study is presumably those wearing N95 masks were also more likely to take other precautions to avoid COVID than those who chose to wear a regular surgical mask.

The most recent study was published this week in Annals of Internal Medicine. 1,009 healthcare workers in Canada, Israel, Egypt, and Pakistan were randomized to use N95 or surgical masks during patient care for 10 weeks. Overall, there was no difference in the incidence of COVID infection between the two groups but it is notable that most of the subjects (71%) were in Pakistan or Egypt with only 29% in Canada or Israel. In Pakistan and Egypt, 82% of subjects had previously been infected by COVID before the study whereas in Canada and Israel, only 3% of subjects had a previous COVID infection. There was a trend for N95 masks to be more effective than surgical masks in Canada and Israel; however, because of the low number of subjects in those countries, the results did not reach statistical significance. Because past COVID infection confers some immunity to reinfection, it is possible that the failure of N95 masks to have superior protection over surgical masks was due to the very high percentage of healthcare workers with immunity from previous infection in Pakistan and Egypt.

The bottom line: What mask should you wear?

Medicine is a very dynamic science and recommendations change as new clinical studies are published. As a result, today’s medical dogma is tomorrow’s medical malpractice. Based on the available information a few general recommendations can be made:

  1. In hospital areas where the prevalence of COVID infection is low, wearing regular surgical masks is sufficient to prevent healthcare workers from becoming infected. This means parts of the hospital that provide care for non-COVID patients, such as general medical and surgical floors, cafeterias, public areas, and offices.
  2. In hospital areas where there is likely to be a high number of viral particles in the air breathed by a healthcare worker, N95 masks are preferable. This would include areas where the viruses are likely to be aerosolized, such as during intubation or bronchoscopy, particularly in rooms with stagnant airflow, such as those lacking sufficient number of air exchanges per hour. In locations where the virus is in respiratory droplets (as opposed to being aerosolized), surgical masks may be sufficient. Because several studies have shown that the viral loads are similar among symptomatic versus asymptomatic patients with COVID infection, the decision of whether to wear an N95 mask should not be based on the severity of the patient’s infection.
  3. Wearing surgical masks by healthcare workers is sufficient to prevent workers with asymptomatic COVID infection from infecting patients. This has been a concern for the care of patients at high risk of severe COVID infection, such as those patients who are immunocompromised, obese, diabetic, or elderly. These patient are at particular risk if in contact with a maskless infected healthcare worker. Because daily testing of all healthcare workers caring for these patients is impractical, preventative mask-wearing is prudent.
  4. Because viral loads are just as high in asymptomatic patients as in symptomatic patients, hospital visitors should wear surgical masks inside of the hospital as long as the prevalence of COVID infection in the community remains substantial or high. What constitutes “high” is a matter of opinion but the CDC defines “low” as up to 10 cases/100,000 population, “moderate” as between 10-50/100,000, “substantial” as 50-100/100,000 population, and “high” as greater than 100/100,000 population. Currently, the U.S. as a whole has a case rate of 91/100,000 population. However, hospitals are not like the country as a whole – currently 5.6% of all Ohio inpatients have COVID infections for an inpatient rate of 5,600/100,000. Because inpatients with COVID infection are more likely to have family and friends who are also infected (from home and workplace transmission), the probability of encountering a hospital visitor with a COVID infection is a lot higher than encountering a waiter in a restaurant with a COVID infection.
  5. Healthcare workers who prefer to wear an N95 mask (but are not required) should be permitted to do so. Because of non-statistically significant trends in some studies suggesting a slight benefit of N95 over surgical masks, those healthcare workers who perceive greater safety with the N95 masks should be allowed to wear them if desired and if supplies permit.
  6. Healthcare workers who are required to wear N95 masks should be fit-tested annually. Because ill-fitting N95 masks lose most of their protective benefit, there needs to be assurance that the N95 mask that the worker wears actually does what it has the potential to do. It is reasonable for hospitals to also require fit-testing for those employees who want to wear an N95 mask but are not required to wear an N95 mask, especially if the hospital is paying for the masks.
  7. KN95 masks are an acceptable alternative to wearing a surgical mask but should not be used in clinical situations when N95 masks are required. Given the reduced effectiveness of KN95 masks compared to N95 masks, a KN95 mask cannot be viewed as equivalent to an N95 mask. It may, however, be better than a surgical mask.

What about outside of the hospital? At the grocery store or airport, I generally see only 5-10% of people wearing masks. At athletic events, that percentage is even lower. The risk of becoming infected in a public place is dependent on how likely you are to come in contact with someone’s exhaled viruses. That in turn depends on the prevalence of COVID infection in the community, the number of people in an enclosed space, the size of the enclosed space, the duration of time that you are in that space, the amount of singing or shouting in the space, and the ventilation of the space. Based on viral load studies, it does not matter whether an infected person in the space is symptomatic or asymptomatic. In situations when those variables indicate a higher risk of COVID, wearing a surgical mask is prudent. Those people who feel more secure wearing a KN95 mask or an N95 mask should do so.

As for me, N95 masks kept me from getting TB despite caring for patients with tuberculosis for decades. They also kept me from getting COVID infection despite intubating and performing bronchoscopy on COVID patients in our intensive care unit. My fit-tested N95 mask is sort of like a security blanket for me. So, I think I’ll keep wearing it in public areas for now. When the case rate gets below 50/100,000 population, I’ll reconsider. And when the case rate gets below 10/100,000, I’ll feel safe without any kind of mask in public.

December 2, 2022

Categories
Academic Medicine Medical Education

Results Of The 2022 Internal Medicine And Pediatric Subspecialty Fellowship Match

Yesterday, on November 30, 2022, the results of this year’s fellowship match for internal medicine and pediatric subspecialties was released. This is for fellowship positions that will begin in July 2023. Every specialty has its own fellowship match and the dates of the match results vary from as early as May the year before the start of fellowship (vascular surgery, thoracic surgery, pediatric surgery) to January the year of the start of fellowship (sports medicine, psychiatry). The internal medicine and pediatric match results are released at the end of November.

The results of all of the fellowship match results are made available in a report published by the National Resident Matching Program in March every year. Last year’s match showed that more physicians are subspecializing, fewer foreign medical graduates applied, certain subspecialties were very competitive (surgical and OB/GYN subspecialties) and certain subspecialties were less popular (most internal medicine and pediatric subspecialties).  Although we will not know the complete results of all subspecialty fellowship matches for several months, internal medicine and pediatrics represent the largest number of fellowship positions and so we can draw preliminary conclusions for yesterday’s match results in those subspecialties.

The terminology used in physician specialization can be confusing. As an example, internal medicine is a specialty and cardiology is a subspecialty within internal  medicine. This means that a cardiologist must first complete an internal medicine residency and then do further training in a cardiology fellowship. This post will focus on the recent subspecialty fellowship match results for the specialties of internal medicine and pediatrics.

Internal Medicine

Overall, there were 2,042 different programs participating in this year’s internal medicine subspecialty fellowship match and these programs offered a total of 5,779 fellowship positions. 82.1% of programs filled all of their positions and 89.5% of all positions in the country filled. These results are similar to last year. Of the physicians who did match, 46.8% were U.S. MD graduates, 13.5% were U.S. DO graduates, 12.8% were U.S. citizens who attended foreign medical schools, and 26.7% were foreign medical graduates. This is a slight decrease in the percent filled by U.S. MD graduates and a slight increase in foreign medical graduates compared to last year.

As in the past, certain internal medicine specialties were more competitive than others. Competitive programs are those that had a higher percentage of their total positions filled. The most competitive subspecialties were cardiology and interventional pulmonary that both filled 100% of their positions, followed by gastroenterology (99.8%) and hematology/oncology (99.7%). Three subspecialties filled fewer than 65% of positions: adult congenital heart disease (63.6%), transplant cardiology & heart failure (55.9%), and geriatrics (45.4%).

Two other subspecialties had relatively low fill percentages: infectious disease (74.4%) and nephrology (72.8%). These two subspecialties are concerning because their total number of fellowship positions is considerably higher than other low-performing subspecialties. There were 441 infectious disease fellowships offered and 493 nephrology fellowship positions offered compared to adult congenital heart disease (22 fellowship positions offered) and transplant cardiology & heart failure (127 positions offered). The implication of these results is that our country will face a much larger shortfall in the number of internal medicine infectious disease specialists and nephrologists in the future compared to other subspecialties.

A second way of determining the competitiveness of a subspecialty is by the percentage of positions filled by U.S. medical school graduates (MD). In general, most subspecialty fellowships are affiliated with medical schools offering MD degrees (as opposed to DO, or osteopathic, degrees). Historically, U.S. MD graduates tend to have an advantage over U.S. DO graduates, U.S. citizens graduating from foreign medical schools, or foreign medical school graduates who are not U.S. citizens. Subspecialties with the highest percentage of U.S. MD graduates filling available fellowship positions were adult congenital heart disease, gastroenterology, hematology & oncology, and interventional pulmonary. Pulmonary medicine had a very low filling percentage by U.S. MD graduates but there were only 27 total positions offered in 2022 since most physicians instead choose to do a combined pulmonary & critical care medicine fellowship (748 positions offered).

Graduates of U.S. osteopathic (DO) schools were most likely to fill pulmonary medicine-only fellowships or critical care medicine-only fellowships. But again, these fellowships offer very few available positions since most available positions are in combined pulmonary & critical care medicine fellowships. Geriatrics, infectious disease, and nephrology all had high percentages of U.S. osteopathic graduates.

U.S. citizens attending foreign medical schools account for nearly as many filled subspecialty fellowship positions as U.S. osteopathic graduates and followed a similar trend with a high percentage in pulmonary-only and critical care medicine-only fellowships followed by nephrology, interventional pulmonary, geriatrics, and endocrinology.

The final group of physicians filling positions in the 2022 internal medicine subspecialty fellowship match was non-U.S. citizens who graduated from foreign medicine schools (foreign medical graduates). Subspecialties with the highest percentage of positions filled by foreign medical graduates were endocrinology, pulmonary-only, and nephrology.

Pediatrics

Overall, there were 919 different pediatric subspecialty fellowship programs that together offered 1,814 fellowship positions in the 2022 match for fellowships to start in July 2023. 74.9% of the programs filled and 84.7% of all positions were filled. Pediatric subspecialty fellowship positions were most likely to be filled by U.S. MD graduates (61.6%) followed by foreign medical graduates (14.8%), U.S. DO graduates (14.7%), and U.S. citizen graduates of foreign medical schools (8.8%). These percentages were unchanged compared to the previous year’s match. Compared with internal medicine, more pediatric subspecialty fellowship positions fill with U.S. MD graduates.

The most competitive pediatric subspecialty fellowships were gastroenterology, emergency medicine, and cardiology which all filled more than 97% of available fellowship positions. Similar to internal medicine, the least competitive subspecialties were infectious disease (49%) and nephrology (54%), as well as endocrinology (61%).

The pediatric subspecialties most likely to fill with graduates of U.S. medical schools were adolescent medicine, hospital medicine, and infectious disease – all of which filled 73% of positions with U.S. MD graduates. The least likely were transplant hepatology and endocrinology, each of which filled 50% of available positions with U.S. MD graduates.

Subspecialties with the highest percentages of graduates of U.S. osteopathic schools were child abuse (31%), gastroenterology (19%), and hospital medicine (19%). Subspecialties with the lowest percentage of U.S. DO graduates were infectious disease (5%) and rheumatology (4%).

There were only 135 U.S. citizen graduates of foreign medical schools who matched into pediatric subspecialty fellowships with the highest percentages in developmental-behavioral medicine (16%) and endocrinology (14%).

Foreign medical graduates had the highest representation in rheumatology (30%) and transplant hepatology (33%). They had the lowest representation in hospital medicine (1%).

Implications of the match

The overall trends of the 2022 match (for fellowships to begin in July 2023) are similar to the 2021 match. For both internal medicine and pediatrics, two subspecialties continue to be unpopular and had a high percentage of unfilled positions:  nephrology and infectious disease. In both pediatrics and in internal medicine, physicians in these two subspecialties have lower annual incomes than other subspecialties due to the current U.S. physician billing and reimbursement model. For internal medicine, these 2 subspecialties are also those with the highest percentages of foreign medical graduates filling fellowship positions.

The results of the match suggest that the United States will see an increasing shortage of both adult and pediatric nephrologists and infectious disease specialists. Pediatric endocrinology and adult geriatrics will also face physician shortages In order to attract these subspecialists, hospitals will need to subsidize their salaries as they are not able to generate competitive incomes by professional revenues alone. As these shortages become more severe, the clinical services provided by these subspecialists will need to increasingly be provided by primary care physicians and advance practice providers.

December 1, 2022

Categories
Physician Finances Physician Retirement Planning

End Of The Year 11-Point Financial Health Checklist

The end of the calendar year is the time to do a check-up of your personal finances and investments. As we enter December, there are a few important things to do in order to ensure that you are taking advantage of tax breaks, performing needed investment portfolio maintenance, and adapting your personal finances for inflation. Here is a short list of eleven tasks for your financial health to do before the end of the year.

Eleven point financial checklist

1. Do a “backdoor” Roth IRA.

I believe that everyone should have a Roth IRA as part of a diversified retirement portfolio. Unlike a traditional IRA, 401k, or 403b, once you put money into a Roth IRA, you never have to pay any taxes when you withdraw money from it. This allows you to withdraw money in retirement from different types of investments in order to take maximal advantage of your income tax situation in any given year of retirement. If your income is less than $129,000 (or $204,000 if filing a joint income tax return), then you can directly contribute to a Roth IRA using post-tax income. If your income exceeds these amounts, then you cannot directly contribute to a Roth IRA but you can do a “backdoor” Roth by first contributing post-tax income into a traditional IRA and then promptly doing an IRA conversion by transferring that money from the traditional IRA into a Roth IRA. For 2022, you can contribute $6,000 to an IRA if you are under age 50 and $7,000 if you are older than age 50.

The best time to do a backdoor Roth is when the stock market has fallen. Stocks inevitably go up and down – your goal is to buy stocks when the market falls so that you can make the most money when you sell those stocks in the future. Stocks have taken a real beating this year… and that is good for the long-term investor since this creates a buying opportunity. For example, the S&P 500 index has fallen 17% since January 1, 2022. By contributing to a backdoor Roth today, when the stock market eventually recovers to its January 2022 value, you will have made a 17% return!

In 2021, Congress proposed eliminating the backdoor Roth in the Build Back Better Act but the legislation died in the Senate leaving backdoor Roths alone for now. With the U.S. House of Representatives and the U.S. Senate now controlled by different political parties, the resultant gridlock makes backdoor Roth elimination in the next 2 years unlikely. However, predicting Congressional legislation is difficult so anything is possible. Nevertheless, now is the best time to do a backdoor Roth – when they are still legal and when the stock market is down.

2. Do a Roth IRA conversion.

If you already have money in a traditional IRA, then you can convert some (or all) of that money into a Roth IRA without doing a backdoor Roth conversion. There are 2 ways that you can contribute to a traditional IRA, with pre-tax income or with post-tax income. If your current annual income is less than $129,000 (or $204,000 if filing a joint income tax return), then you can contribute pre-tax income into the traditional IRA and then when you withdraw money from that traditional IRA in retirement, you pay regular income tax on the entire amount. If your current annual income is higher than these values, then you cannot contribute pre-tax income into the traditional IRA but you can contribute post-tax income into a traditional IRA. In this latter situation, your tax on withdrawals in retirement gets complicated – you do not pay income tax on the amount of money that you originally invested but you do pay income tax on the accrued value of the investment. This requires you to keep careful record of the amount of your contributions over the years and then do some mathematical gymnastics to calculate the percentage of any given year’s withdrawals that are taxed and not taxed.

I see no reason why anyone should put post-tax income into a traditional IRA and leave it there since you would have to pay income tax on the accrued value when you take withdrawals in retirement. If you had instead converted that post-tax money in the traditional IRA into a Roth shortly after making the original contributions to that traditional IRA (i.e., a backdoor Roth), you would never have to pay taxes on the withdrawals in retirement. So, if your traditional IRA is composed fully (or mostly) of post-tax contributions, convert that traditional IRA into a Roth now in order to minimize your taxes.

Traditional IRAs composed of pre-tax income are different and the decision of whether or not to convert these traditional IRAs into a Roth IRA requires some strategic financial analysis. Your overall goal is to pay the least amount in income taxes. When your traditional IRA is funded by pre-tax income, then when you convert money from that traditional IRA into a Roth IRA, you have to pay income tax the year that you do the conversion. In other words, that conversion to a Roth IRA counts as a withdrawal from the traditional IRA for income tax purposes. There are 2 situations when it is advantageous to do convert money from a pre-tax traditional IRA into a Roth IRA:

  1. When your income tax rate today is lower than your income tax rate in retirement. This is difficult to know with certainty since no one can predict what the income tax rates will be 30 years from now – tax rates go up and go down, depending on how much money the federal and state governments need to keep running. As a general rule, your income tax rate is likely to be lower when you are early in your career and higher after you have been working for 20-30 years. Therefore, doing a Roth conversion in your early working years is generally preferable to doing a Roth conversion later in your career.
  2. When the stock market is down. Since you pay regular income tax on any withdrawals from a traditional IRA that was originally funded with pre-tax income, you will pay less tax if you do a Roth conversion when the stock market has fallen and the overall value of the traditional IRA is lower. Then, when the stock market recovers, all of the accrued value will be in your Roth IRA and you will not have to pay income tax on it when you take withdrawals in retirement. Conventional wisdom is that when it comes to stocks, you should sell when the value of a stock is high. In order to minimize taxes when doing a Roth conversion it is just the opposite: sell (convert) when the value of the traditional IRA is low. Since the stock market is currently down 17% compared to January 1, 2022, now is a great time to do a traditional IRA to Roth IRA conversion in order to minimize the total amount of income tax that you will pay over the course of your lifetime. However, don’t forget that the amount of the conversion will add to your adjusted gross income for the year of the conversion and will result in an increase in your income tax rate that year. You will need to weigh the cost of the increased income tax rate against the benefit of the IRA conversion.

3. Contribute to a 529 plan.

The 529 college savings plans allow you to invest money today and then never have to pay any taxes when you withdraw money for college expenses in the future. Think of 529 plans as Roth IRAs for college savings. That tax-free feature of 529 plans make them an unbeatable tool to save for college and you can use the money to pay for college for yourself, your spouse, your children, or your grandchildren. There are several reasons to consider contributing to a 529 plan in December.

  1. Get a tax deduction. Each state has its own 529 plan and they all vary considerably with respect to their state income tax advantages. For example, here in Ohio, residents of the state can deduct the first $4,000 of annual contributions to an Ohio 529 plan. That tax deduction applies to each child’s account you hold so if you have 3 children, you can deduct $4,000 of annual contributions from each child’s account for a total of $12,000 state tax income deduction!
  2. The best time to contribute is when the market is down. The 529 plans are designed to be long-term investments. When you open an account at the birth of a child, that money will not be withdrawn for at least 18 years. The U.S. bond market is down 13% this year and the U.S. stock market is down 17%. This means that stocks and bonds are the cheapest that they have been in 2 years. Now is a time when you can “buy low”.
  3. They make great Christmas presents. I have a granddaughter who lives in a different state. Last year, I opened an Ohio 529 plan in her name when she was born. This year, we’ll contribute to her 529 plan for her Christmas present. Older children usually expect tangible stuff for Christmas but for toddler grandchildren, a 529 plan contribution is perfect. A Lego set will hold a kid’s attention for a couple of weeks but an education lasts a lifetime.

4. Maximize your deferred income retirement contributions.

In 2022, the maximum amount that you are permitted to contribute to a 401k, 403b, or 457 plan is $20,500 if you are younger than 50 years old and $27,000 if you are over 50. Some people (such as employees of state universities) can contribute to both a 403b and a 457. This can bring your annual contribution up to $41,000 ($54,000 if you are over age 50). If you have not yet contributed the maximum allowed amount this year, you still have time to do a one-time contribution in December to bring you up to the annual contribution limit.

In addition, this is also the time to change your monthly 401k, 403b, or 457 plan contributions. In 2023, the contribution limit to these plans will increase to $22,500 for people younger than 50 and $30,000 for people older than age 50. Be sure to get the contribution forms submitted to your human resources department now so that your monthly contributions increase in January.

5. Consider tax loss harvesting.

Tax loss harvesting is when you sell an investment that has lost value (capital loss) on in order to offset a profit that you make selling another investment that increased in value (capital gain). The amount of capital gains tax that you pay is the total of all of your capital gains minus all of your capital losses for that year. If you have more losses than gains, then you can take up to $3,000 of the excess losses and apply them as a tax deduction to your regular income tax. December is normally the best time to decide if selling an investment for tax loss harvesting makes sense and to determine how much of that investment should be sold to optimize your taxes. Because the stock market has fallen so low this year, many people have lost money on investments making tax loss harvesting a viable financial option for more people than in previous years.

There are a couple of important caveats to tax loss harvesting. First, the losses only apply when the selling price is lower than the purchase price. For example, the S&P 500 has fallen in value by 17% in 2022 but it increased in value by 27% in 2021. Therefore, if you bought an average stock on January 1, 2022, you would have a capital loss. But if you bought that same stock on January 1, 2021, you would have a capital gain if you sold the stock today, even though that stock lost value in 2022.

Second, tax loss harvesting is more of a capital gains tax-deferral strategy than a capital gains tax-reduction strategy. If you sell a losing stock today to take advantage of tax loss harvesting and then turn around and invest the proceeds of that stock sale into a second similar stock that has also lost value recently, then when that second stock eventually increases in value in the future, you’ll pay more capital gains taxes on the sale of the second stock because your capital gains will be higher. For example, say Ford and GM shares are always the same price. You buy shares of Ford in 2021 at $100 per share and then today, Ford has fallen to $80 per share. You then sell your shares of Ford for tax-loss harvesting purposes and turn around and buy shares of GM at $80 per share. In 2024, you sell your shares of GM at $120 per share. If you had held onto Ford until 2024, then you would have $20 per share in capital gains when you sold it in 2024. Instead, you would have $40 in capital gains when you sell the GM stock in 2024. In other words, tax-loss harvesting just postpones when you pay capital gains tax if you re-invest the proceeds of your investment sale.

Tax-loss harvesting can be to your benefit if you take the capital losses as an income tax deduction since most people’s federal income tax rate is higher than their capital gains tax rate. However, this can be tricky since you have to be able to estimate what your 2022 income tax rate will be in order to ensure that it is less than your capital gains tax rate. Also, many people forget that their mutual funds will usually have capital gains each year since the fund managers are constantly buying and selling the component stocks within that fund so even if you do not sell any of your shares of that mutual fund this year, you may still have capital gains from that mutual fund. You have to calculate what all of those mutual fund capital gains will be this year in order to be sure that your capital losses from tax-loss harvesting exceed those mutual fund capital gains so that you can apply those capital losses as an income tax deduction. And remember, the maximum income tax reduction from tax-loss harvesting is $3,000.

6. Optimize schedule A deductions.

The Tax Cuts and Jobs Act of 2017 increased the standard income tax deduction from $12,700 in 2017 to $24,000 in 2018 (married filing jointly). This reduced the amount of income tax that most Americans paid but it also eliminated itemized deductions for most Americans. The standard deduction for 2022 is $25,900 (married filing jointly). Therefore, you cannot make any itemized deductions unless those itemized deductions total more than $25,900. Itemized deductions can include charitable donations, mortgage interest & points, medical & dental expenses, and taxes paid (property, state, and local). However, the maximum amount of property and other taxes that you can apply to itemization is $10,000.

December is the time to estimate the amount of your itemized deductions. If those itemized deductions are close to your standard deduction amount ($25,900 if married filing jointly), then you may be able to increase your itemized deductions now so that those itemized deductions exceed the standard deduction amount. For example, you could make extra charitable contributions now rather than in 2023. Or, you could pay your next property taxes early, before December 30th. Or, you could buy the new eye glasses now that you had planned to wait until next summer to buy.

7. Contribute to an SEP.

An SEP (simplified employee pension plan) is a deferred income retirement account for self-employed people. Even if you have a regular employer but have a side gig doing consulting, getting honoraria, or selling artwork, you can open an SEP for the income that you earn from that side gig. The SEP allows you to invest pre-tax income and then pay taxes on the the withdrawals from the SEP when you are in retirement. In that sense, the SEP is functionally similar to a 401k, 403b, 457, or traditional IRA. Although you have until April 2023 to make contributions to an SEP for your income earned in 2022, it may be better to contribute to an SEP now, since the stock market has lost so much value recently – in other words, contribute to an SEP now, while stocks are “on sale”. You can contribute up to 25% of your total self-employment income and up to a maximum contribution amount of $61,000. December is a time that you should be able to reasonably estimate your total self-employment income for the past year and then calculate the amount that you can contribute to an SEP.

8. Review your beneficiaries. 

Every investment account should have a designated primary beneficiary and secondary beneficiaries in the event of your death. If you are married, the primary beneficiary will probably be your spouse. If you have children, they will probably be your secondary beneficiaries. By specifying beneficiaries on those investment accounts, you can make it faster for your family to access those funds in event of your death. Also, your heirs can avoid costly legal fees that would be incurred if no beneficiaries were listed and the accounts need to go through probate court. For most investment companies, you can do this quickly and easily online.

9. Rebalance your portfolio.

This has been a wild year for investors. The bond market is down, the stock market is down more, and real estate is down even more. Meanwhile, inflation is reducing the value of fixed income pensions and increasing the interest rates on certificates of deposit. The net result is that the relative percentages of stocks, bonds, real estate, and cash in most people’s investment portfolios has changed significantly since January.

Now is the time to rebalance those portfolios to ensure that the percentage of each type of investment is at its desired amount. For example, since real estate investments have fallen more than stocks, you may need to sell some shares of your stock mutual fund and buy some shares of a real estate investment trust (REIT) fund to rebalance. Since stocks have fallen in value more than bonds, you may need to sell some shares of your bond mutual fund and buy some shares of a stock mutual fund. Rebalancing not only ensures that your portfolio has a healthy diversification but it also results in you “selling high and buying low” in order to maximize your overall returns.

10. Increase disability and life insurance policy amounts.

The U.S. inflation rate has risen with the result that the consumer price index has increased 13% over the past two years. In other words, you need 13% more money today to buy the same amount of stuff you bought in 2020. However, most disability insurance policies and life insurance policies have not changed their values. The $100,000 life insurance policy that you bought in 2020 would only be effectively worth $87,000 in today’s money. December is a good time to critically evaluate those policies to see if the payout amounts are still appropriate – in many cases, you may need to increase those amounts to ensure that should you become disabled, you will still have enough money to live on. Or, should you die, your family will still have enough money to live on.

11. Update next year’s budget.

Inflation does not affect everything you buy equally. For example, for the 12 months ending in October 2022, the price of food was up 10.9%, gasoline was up 17.9%, new cars were up 8.4%, and clothes were up 4.1%. This means that the amount that you budgeted for all of these items a year ago has changed. Each family’s inflation is a little different. So, although housing costs nationwide are up 11%, if you bought your house a year ago and have a fixed monthly mortgage, then your housing costs may not have gone up at all. Similarly, if you heat your house with electricity, your energy costs went up 14.1% in the past year but if you heat your house with fuel oil, your costs went up 68.5% in the past year.

To prepare next year’s budget, start with your credit card statements. Most credit card companies will divide each of your purchases into different categories, for example, groceries, transportation, housing, utilities, etc. You can often do the same with your checking account. This will give you a reasonable idea of where you spent your money over the past year. You can then use the Bureau of Labor Statistics Consumer Price Report to estimate how much each of those categories will need to be increased for your next year’s budget. Keeping to that budget ensures that you will have enough cash to pay off your credit cards and loans each month without dipping into your cash emergency fund.

Your annual financial checkup should be in December

The end of the year is the best time to do your annual financial checkup. By December, you should have a good idea of your total 2022 income and know whether you are likely to get a raise next year. Retirement account contribution limits usually change in January giving you the opportunity to change your monthly contributions. Also, you should be able to estimate how much you can spend  this year on charitable contributions, 529 account contributions, IRAs, and SEPs. The best way to start the new year is to finish the old year on solid financial ground.

November 30, 2022