Medical Economics

Who Really Pays For Medicaid?

Here is the thing… people get sick. And they get sick whether or not they have health insurance. And when they get sick, they come to the emergency room. And EMTALA law says that when they come to the emergency room, if they are sick enough, we have to admit them and treat them. So from society’s economic standpoint, is it better to increase availability of Medicaid to low-income people (i.e., “Medicaid expansion”) or is it better to have people go uninsured?

If you hate paying higher taxes, then you probably want to reduce Medicaid because it an entitlement and you don’t want your taxes going to pay for someone else’s benefit. But as with almost everything in life, it is not as simple as it appears on the surface. The reality is that society will end up paying the same cost to provide care to low income people whether you have Medicaid or not.

To understand this, you have to understand the difference in funding for Medicare versus Medicaid. Medicare is largely paid for by payroll taxes – these are 2.9% of all worker’s income. There is no cap on taxable income, unlike social security tax. However, people earning over $200,000 ($250,000 if filing jointly) pay an additional 0.9% for a total of 3.8%.

So, everyone who works pays for Medicare.

Medicaid is paid for by income taxes and not payroll taxes. Most of this comes from federal income taxes and a portion also comes from state income taxes. Herein lies the big difference between Medicare funding and Medicare funding – everyone pays for Medicare but you only pay for Medicaid if you pay income taxes and income tax revenues mostly come from the wealthy. This is because low income workers fall below the threshold that they have to pay income tax, in fact, 45% of American households paid no federal income tax in 2015. The highest earning 20% of Americans paid an average of $50,000 in federal income taxes – that equates to 87% of all income tax received by the federal government. The top 1% of Americans (income > $2.1 million) paid 44% of all income tax received by the federal government. And the top 0.1% of Americans (income > $9.4 million) paid 20% of all income tax received by the federal government.

Therefore, Medicaid is primarily funded by the highest income-earning Americans.

So, what happens if we reduce or eliminate Medicaid? These patients still come into the emergency department and still come into the hospital. In fact, before Ohio’s Governor, John Kasich, enacted Medicaid expansion, about 12% of all patients admitted to our hospital were uninsured and after Medicaid expansion, that dropped to 2.3%. Uninsured patients still require doctor’s time, they still need tests, they still eat hospital food, and they still have to get medications. So, where does the money come from to pay for all of this?

Rarely, it comes from the uninsured patients themselves. For example, a few years ago, we had a patient who owned a 1,000 acre farm that had been in his family for generations. He was a healthy guy so he didn’t buy health insurance. Out of the blue, he developed pancreatitis complicated by respiratory failure and was in the ICU for weeks followed by several months of recovery. He had to sell the family farm to pay his medical bills that approached a million dollars. However, he is the exception – most uninsured patients don’t have any money to pay their bills so the hospitals and the doctors have to write those bills off. But in order to make up for it, the doctors and the hospital have to charge more to everyone else. Since Medicare charges are fixed, this means that most of the money to pay for the uninsured comes from increasing the charges to patients insured by commercial insurance companies.

This is where the analysis gets interesting. Commercial insurance premiums are not paid as a percentage of a worker’s income (like Medicare payroll tax). These premiums are usually a fixed amount and average $6,000 for an individual and $18,000 for a family.

Therefore, everyone pays equally to provide care to the uninsured, regardless of one’s income.

You can’t pass a law to keep poor people from getting sick and needing healthcare services. So, there are really three ways to provide healthcare to the poor:

  1. Continue Medicaid programs and pay for them out of Medicare payroll taxes. In this way, all working Americans contribute to healthcare for the poor as a fixed percentage of one’s income.
  2. Continue Medicaid programs and pay for them out of income tax. This is what we currently do. In this way, the healthcare for the poor is primarily paid by the wealthiest Americans.
  3. Eliminate Medicaid coverage and let the poor be uninsured. This would require those services to be paid for by increasing commercial insurance rates which means that all working Americans would pay the same amount to provide healthcare for the poor, regardless of how much money each working American earns.

So, what’s my take on all of this? Well, option #3 is bad economics – it really hurts the middle class and all of the uninsured people would not have access to basic preventive care or treatment for chronic conditions. This promotes sickness that results in more hospital admissions for patients who can’t pay anything and keeps people from getting well enough to go back to work. Option #1 is not a bad option and it forces everyone to take responsibility for care of the poor. However, this option also increases the amount that middle class Americans would have to pay, just not as much. Option #2 is not a bad option either and it places the responsibility to care for the poor primarily to wealthy Americans.

Every successful society in history has some people who are wealthy and some who are poor. Medicaid is our societal insurance against being poor or disabled. No matter what we do, these poor and disabled will consume healthcare resources. However, it is our choice how and who pays for it: all working Americans or mainly the wealthiest Americans?

March 27, 2017

Life In The Hospital

A Tale Of 2 Code Blues

Yesterday, we had two codes in our hospital’s lobbies. I get a page for every code blue that occurs at our hospital; it allows me to keep my finger on the pulse of the hospital. Code blue is the designation we give for a cardiopulmonary arrest. When a code occurs on a nursing unit, it is usually the real thing because the nursing staff are the ones calling it and they are very good at initial assessment of a patient’s condition. On the other hand, in public areas, the codes are often called by non-clinical hospital staff who are not skilled in patient assessment and so in the past, most of the code blues that occur in the lobby or the parking lot, or ambulatory clinic locations were for situations like a patient falling or fainting. Therefore, codes in those locations were seen by many physicians and nurses as being less urgent and would often be ignored by physicians who were not a designated member of the code team.

Life has changed and the 2 codes from yesterday illustrate why.

The first code was in the lobby of Talbot Hall, the drug and alcohol treatment wing of our hospital. The patient was blue as a Smurf and needed to be intubated while he was lying on the floor of the lobby because of hypoxemia and respiratory depression. He had walked into the building to see if he could get alcohol detox. It turned out that his blood alcohol level was 0.4, five-times the legal definition of intoxication. He is now getting detoxed in our ICU.

The second code was in the lobby of the main hospital building. A young woman was found by a friend semi-conscious in the bathroom of a local Wendy’s restaurant and so she packed her up in her car and drove to the hospital where she helped get her to the information desk. There, the woman collapsed so the information desk attendant called a code blue. Like the first patient, she was also cyanotic. The team started ambu-bag ventilation. Years of drug abuse had withered away all of her veins and so as the code team was preparing to place an intraosseous needle in her bone, they tried one last sternal rub to wake her up. She took a couple of breaths and so they were able to get her to the ER where she was given Narcan to reverse her heroin/fentanyl overdose. She was later discharged back to the streets.

These two patients reminded me of the first time I had to manage a code. I was a fourth year medical student in a private hospital in Columbus doing an internal medicine rotation with one of the other medical students. We were standing in line for lunch in the cafeteria when the man standing behind us dropped dead. We checked for a pulse (which he didn’t have) and one of us did chest compressions while the other did mouth-to-mouth resuscitation. The lady at the cash register called the operator who announced a code blue to the cafeteria. I looked up as I was doing CPR and saw several of the attending physicians that I knew grab their lunch trays and leave the dining area. Finally, one intern showed up and the three of us ran the code for 20 minutes in the cafeteria before pronouncing the patient dead. No other physicians came.

Code blues in public areas of the hospital are often treated as less-emergent because frequently they are non-emergent. But these codes can sometime be the real thing. Currently, an average of one person in Central Ohio dies every day due to a drug overdose – usually a combination of heroin and fentanyl. Drug and alcohol overdose patients often make their way into public areas of the hospital before they stop breathing. So now days, when a code is called to the hospital lobby, it epitomizes that cardinal rule of medicine:

You just don’t know until you know.

March 23, 2017

Emergency Department

Should Emergency Department Wait Times Be Publicly Posted?

Currently in our medical center, there is a running debate about whether the emergency department wait times should be posted on the internet. This is a polarizing question and there are very strong opinions on both sides of the issue. What most people don’t realize is that your local hospital’s ER wait times are already posted on the internet at Medicare’s hospital compare website where you can find the average number of minutes you will wait:

  • Total wait to be admitted to the hospital (national average is 5.6 hours)
  • Wait to be admitted to the hospital after a doctor decides you need to be admitted (national average is 2.2 hours)
  • Total time spent in the ER for non-admitted patients (national average is 2.9 hours)
  • Time in the ER before you are evaluated by a healthcare professional (national average is 30 minutes)

If you don’t want to go to the Medicare website, you can go to the Yelp website and search your local hospital and find the same information.

Many hospitals have responded by putting their current wait times on-line or even on billboards outside of the hospital, updated every 5-15 minutes.

But if you read the fine print, it turns out that the ER wait time can mean different things. For example, at HCA Virginia hospitals, the on-line ER wait time is defined as “…the time of patient arrival until the time the patient is greeted by a qualified medical professional” (physician, nurse practitioner, or physician assistant). On the other hand, at the INOVA hospitals in Virginia, the on-line ER wait time is defined as the “…period from registration to assignment of provider (doctor, nurse practitioner or physician assistant)”. At WakeMed in North Carolina, the on-line ER wait time is defined as “…check-in to care being initiated by a doctor, nurse practitioner or physician assistant”. At Middlesex Hospital in Connecticut, the on-line ER wait time is defined as the time “…from registration to having a physician assigned to the case”. When I checked their website this morning, The Mountain States Health Alliance in eastern Tennessee/western Virginia boasted that 8 of their 11 hospitals had an ER wait time of zero minutes but they define their ER wait time as “…amount of time people have been in the waiting room”.

If you read these words carefully, you can see how it would be easy for hospitals to game the system. If I was the medical director at any of these hospital systems, here’s how I would make my ER wait times look better:

  • HCA Virginia. I would put a physician assistant behind the registration desk so that each patient would be “greeted by a qualified medical professional” as soon as they walked in the door.
  • INOVA Hospitals and Middlesex Hospital. I would have the registration staff “assign a provider” when the patient first registers at the front desk of the ER and then the patient can go wait in the waiting room until an ER bed is available.
  • WakeMed Hospital. I would have each patient go straight from the registration desk to a triage area where a nurse practitioner would check that patient’s vital signs, thus minimizing the time from “check-in to care being initiated by a nurse practitioner”.
  • Mountain States Health Alliance Hospitals. I would build out a 25-bay triage ward where patients would be taken as soon as they register so that they don’t have to wait in the “waiting area”.

So what are the advantages of publicly reporting your emergency department wait times?

  1. It is great advertising. A low posted ER wait time is a great marketing tool to attract insured patients to your hospital.
  2. Motivate your staff. If the doctors and nurses all see a big clock on the ER wall with the current wait time, it gets them motivated to move a little faster.
  3. Better allocation of resources. If the ER wait time is getting excessively high, then the hospital’s nursing director may be able to re-assign nurses from slow units to the ER and the medical director may be able to bring in additional ER doctors to help out or hospitalists to reduce inpatients “boarding” in the ER.
  4. Improve patient satisfaction. If you know that the ER wait time is 90 minutes, you’re less likely to be angry if you sit in the waiting room for 90 minutes than if you were expecting to be seen right away.
  5. Discourage low-acuity patients when the ER is busy. When your ER is full of patients with heart attacks and broken legs, you don’t want to take up precious rooms with a patient who comes in just because he has a cold. Presumably, that patient with a cold will either stay home, go elsewhere, or come back to your ER another time if he sees that he is going to have to wait a long time.
  6. You control the message. As can be seen from the examples above, there are many ways to define “ER wait time” and you can pick the number that makes your ER look best or that best suits your purposes for posting the ER wait time.
  7. Even out the work load among different hospitals. If your hospital is part of a larger health system with multiple hospitals in a single geographic area, then this is a way of insuring that the patient distribution among the different hospitals stays even. This makes staffing easier and improves staff satisfaction. This is particularly the case when office-based physicians have to send a patient to the emergency room – knowing which ER has the shortest wait time can best match the health system’s resources with the health system’s physicians’ needs at any given moment.
  8. Improve timeliness of care in the community. If the EMS squads know that one hospital has an unusually long wait time, then they can re-direct squads to another hospital in the community that is less busy thus ensuring that the entire geographic area’s health needs are being optimized. This has the potential to decrease ER overcrowding and is more proactive than waiting until an ER goes on “divert” status because they can’t take any more patients.

OK, what about the disadvantages of publicly reporting your emergency department wait times?

  1. “Self-triaging” can be dangerous to patients. A patient with a potentially serious condition may choose to stay home rather than go to the ER if the posted wait time is too long.
  2. They are not accurate. The ER wait time is inevitably going to be an average for all patients. However, an ER does not work on a  “first come, first served” basis. A patient with chest pain suspicious for a heart attack is always going to be taken back first, no matter how long the less acute patients have been waiting. So, an average wait time of 30 minutes may mean 0 minutes if you are having a stroke but 60 minutes if you have poison ivy.
  3. Increase stress level of the ER staff. If the doctors and nurses feel like they can’t keep up with the hospital’s wait time goal, (often because of patient surges that they can’t control), then they are at risk for getting burned out.
  4. You may look bad compared to the hospital a few miles away. Particularly if the other hospital chooses a different definition of ER wait time that is more easily achieved than your hospital does.
  5. You may discourage business. ER charges can be very lucrative, particularly for patients paying out of pocket or patients with commercial insurance. You hate to turn away paying customers.
  6. Risk patient satisfaction. If you define your ER wait time as “time to assignment of provider” but it still takes 2 hours before the patient actually sees that provider after the provider is assigned, the patient is going to be pretty unhappy if she expected the wait time to mean the time from walking in the door until a physician lays eyes on her.

So, what is the right answer? Well… there isn’t one. You first have to decide what your hospital’s motivation is for posting ER wait times – is it a marketing tool or a resource allocation tool? Next, you have to decide where you want to post waiting times – you will have vastly different effects (and different audiences) if you publicly post times on-line versus on a sign in the ER lobby versus on the hospital’s non-public website. Lastly, you have to decide how you are going to define your ER wait time.

My recommendation is to start by just reporting your ER wait time internally to hospital staff where you can trend the data and determine how you are going to use it to improve patient flow. Then pick a definition of wait time that is meaningful from an administrative standpoint, such as time from registration to actually being seen a physician/NP/PA in an ER room. Once you are internally comfortable with the information and what it actually means, then make it publicly available.

Publicly posted ER wait times should be a part of overall hospital strategy, not a means of hospital self-flagellation.

March 19, 2017

Outpatient Practice

CG-CAHPS Survey Demystified

The HCAHPS survey is designed to let patients rate their hospital based on their satisfaction with the care provided during an inpatient stay. The CG-CAHPS survey lets patients rate their outpatient doctor or group practice. CG-CAHPS stands for “Clinician and Group Consumer Assessment of Healthcare Providers and Systems”. The information is publicly reported on Medicare’s Physician Compare website. In my case, the CG-CAHPS for all of Ohio State University Department of Internal Medicine outpatient physicians is reported in aggregate. However, internally, we get reports from Press Ganey that allows us to drill down on individual practice sites.

Here are the questions on the GC-CAHPS survey:

  1. If this was a visit for an illness, injury, or condition for care you needed right away, did you get this appointment as soon as you thought you needed it?
    • Yes
    • No
  2. If this was a visit for a check-up or routine care, did you get this appointment as soon as you thought you needed?
    • Yes
    • No
  3. In the last 3 months, if you phoned this provider’s office with a medical question during regular office hours, how often did you get an answer to your medical question that same day?
    • Never
    • Sometimes
    • Usually
    • Always
  4. In the last 3 months if you phoned this providers office with a medical question after regular office hours, how often did you get an answer to your medical question as soon as you needed?
    • Never
    • Sometimes
    • Usually
    • Always
  5. In the last 3 months, if this provider ordered a blood test, x-ray, or other test, how often did someone from this provider’s office follow-up to give you the results?
    • Never
    • Sometimes
    • Usually
    • Always
  6. During this visit, did you see this provider within 15 minutes of your appointment time?
    • Yes
    • No
  7. During this visit, did this provider explain things in a way that was easy to understand?
    • Yes, definitely
    • Yes, somewhat
    • No
  8. During this visit, did the is provider listen carefully to you?
    • Yes, definitely
    • Yes, somewhat
    • No
  9. During this visit, if you talked to this provider about any health questions or concerns, did this provider give you easy to understand information about health questions or concerns?
    • Yes, definitely
    • Yes, somewhat
    • No
  10. During this visit did this provider seem to know the important information about your medical history?
    • Yes, definitely
    • Yes, somewhat
    • No
  11. During this visit, did this provider have your medical records?
    • Yes
    • No
  12. During this visit, did this provider show respect for what you had to say?
    • Yes, definitely
    • Yes, somewhat
    • No
  13. During this visit, did this provider spend enough time with you?
    • Yes, definitely
    • Yes, somewhat
    • No
  14. Using any number from 1 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?
  15. Would you recommend this provider’s office to your family and friends?
    • Yes, definitely
    • Yes, somewhat
    • No
  16. During this visit, were clerks and receptionists at this provider’s office as helpful as you thought they should be?
    • Yes, definitely,
    • Yes, somewhat
    • No
  17. During this visit, did the clerks and receptionists treat you with courtesy and respect?
    • Yes, definitely
    • Yes, somewhat
    • No
  18. In the last 3 months, if you took any prescription medications, how often did you and anyone on your health team talk about all the prescriptions medicines you were taking?
    • Never
    • Sometimes
    • Usually
    • Always

There are additional questions about the patient’s demographics, education level, overall perception of health, and race.

The data is aggregated into different topics and then reported as the percent of patients rating that provider as “top box”. So, for example, in the case of question #17, the top box would be ratings of 9 or 10. Similar to the HCAHPS survey, the CG-CAHPS survey suffers from grade inflation. In our specific clinic location, 93.5% of patients rate us as top box, with either a 9 or 10 overall rating. You can see the average scores at the Agency for Healthcare Research and Quality website where you can see averages by region of the country, physician specialty, type of practice, etc.

Some of the questions can be misleading:

When a patient is seeing a consultant the, questions about whether the provider had your medical records is a reflection of whether the referring physician sent records – if the consultant did not receive records before the patient’s initial visit, they cannot request those records until after the patient has come for the office visit and signed a release form allowing that consultant to request outside records. Therefore, if the referring physician failed to send records, the consultant gets a bad rating for question #11.

Many lab tests can take 2-3 weeks before the results come back. If the GC-CAHPS survey is sent out 2 days after the office visit, the lab test results will not be available and so of course no one from the office will have contacted the patient with the results. You have been set up for failure on question #5.

A specialist is generally not going to talk with the patient about all of their prescription medications every visit. Lets face it, you don’t want your orthopedic surgeon talking with you about the inhalers your pulmonologist prescribed. Similarly, do you really expect your dermatologist, who you are seeing for a mole, to review with you every one of the 25 medications you are taking for heart failure, diabetes, and hypertension? You are going to take a hit on question #18.

Right now, the data is mainly just accumulating and being reported for large group practices (such as the OSU Department of Internal Medicine). I get my own personal patient satisfaction scores internally from our department. However, some health systems now publicly report individual physician scores from the CG-CAHPS (for example, University of Utah). For physicians who are aghast that this information could be made public, search yourself on the internet – you are already being ranked by your patients at websites such as Vitals, Angie’s List, and Healthgrades. That data is unfiltered and subject to error (for example, in Healthgrades, I am listed as a neurologist, not a pulmonologist).

So get ready, you’re being rated just like restaurants on Yelp or hotels on Trip Advisor.

March 14, 2017

Inpatient Practice

HCAHPS Survey Demystified

The HCAHPS survey measures patient satisfaction with inpatient care. It is sent to patients after discharge with instructions to fill it out and mail it in a pre-paid envelope. The results are posted on the Medicare Hospital Compare website where you can see how your hospital performs compared to other hospitals in the same state and other hospitals nationwide. HCAHPS stands for “Hospital Consumer Assessment of Healthcare Providers and Systems”. The survey takes patients an average of 7 minutes to complete. The survey is sent out to a random sample of patients recently discharged from the hospital and can be sent anytime from 2 days to 6 weeks after discharge. The average response rate is usually around 32%. Here are the HCAHPS questions. The first 14 questions are answered by “Never“, “Sometimes“, “Usually“, or “Always“:

  1. During this hospital stay, how often did nurses treat you with courtesy and respect?
  2. During this hospital stay, how often did nurses listen carefully to you?
  3. During this hospital stay, how often did nurses explain things in a way you could understand?
  4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
  5. During this hospital stay, how often did the doctors treat you with courtesy and respect?
  6. During this hospital stay, how often did doctors listen carefully to you?
  7. During the hospital stay, how often did doctors explain things in a way you could understand?
  8. During this hospital stay, how often were your room and bathroom kept clean?
  9. During this hospital stay, how often was the area around your room quiet at night?
  10. During this hospital stay, how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
  11. During this hospital stay, how often was your pain well controlled?
  12. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
  13. Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for?
  14. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?
  15. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
    • Yes
    • No
  16. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
    • Yes
    • No
  17. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?
  18. Would you recommend this hospital to your friends and family?
    • Definitely no
    • Probably no
    • Probably yes
    • Definitely yes
  19. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
    • Strongly disagree
    • Disagree
    • Agree
    • Strongly agree
  20. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
    • Strongly disagree
    • Disagree
    • Agree
    • Strongly agree
  21. When I left the hospital, I clearly understood the purpose for taking each of my medications.
    • Strongly disagree
    • Disagree
    • Agree
    • Strongly agree

There are also some other questions about the patient’s perception of their health, their race, their preferred language, and their education level. You can find the full HCAHPS survey here.

The Medicare Hospital Compare website takes these 21 questions and combines some of them into a total of 7 composite topics, 2 individual topics, and 2 global topics that are then reported on the website. The reported topics are:

  1. Nurse communication
  2. Doctor communication
  3. Responsiveness
  4. Pain management
  5. Communication about medications
  6. Discharge information
  7. Care transitions
  8. Cleanliness of hospital environment
  9. Quietness of hospital environment
  10. Hospital rating
  11. Willingness to recommend hospital

One of the problems with the HCAHPS survey is that it suffers from the same phenomenon that high school and college tests suffer from: grade inflation. So, for example, question #17 asks the patient to rate the hospital overall on a scale of 0-10. Medicare divides the answers in to “top box” (9 or 10), “middle box” (7 or 8), and “bottom box” (0-6). A score is calculated from the percent of patients rating the hospital in the top box (in other words, the percent of patients giving the hospital either a 9 or a 10). The average score nationwide is a 72 and the top 5% of hospitals have a score of 87 with the bottom 5% of hospitals having a score of 57. So, if your community is filled with people who think that on a 0-10 scale, 5 is average, your hospital is doomed. On the other hand, if your community is filled with people who think that 8 is average on a 1-10 scale, then you’re in good shape.

The data from all of the questions are then added to a number of other measures of hospital quality, such as mortality and readmission rate, to give a final star rating where hospitals are assigned an overall score of 1-5 stars. In December 2016, the distribution of star ratings for all hospitals in the U.S. is shown in this graph.

Medicare ties HCAHPS scores to hospital reimbursement. This fiscal year, 2% of a hospital’s Medicare payments are tied to HCAHPS so it motivates hospitals to get as high of a score as possible. At our hospital, I get a monthly analysis of our performance on each of the 11 HCAHPS topics and they can vary wildly from one month to another. There are all sorts of strategies used to improve HCAHPS scores including staff education and expansion of specialty services such as pain management services. There is also a lot of speculation about the best time to mail out the surveys – should you wait a few weeks after discharge so that the patient forgets about what the bathroom looked like? Or should you mail the survey out right away, 2 days after discharge before the patent gets their hospital bill?

Regardless, doing well on the HCAHPS survey is not just about improving patient care in your hospital but about improving the patient’s perception of care in your hospital.

March 10, 2017

Medical Education

Paying Doctors To Teach

I am on a committee to provide recommendations to our Dean on how to compensate physicians for teaching. This turns out to be a lot more complicated than it might first appear. One way of approaching it is to calculate the cost to a physician for teaching – from there you can work back to what the physician should be paid for teaching.

Where does the money come from for medical education?

Medical students. Money to teach students comes from the College of Medicine that in turn gets money from several sources: tuition, endowments, “Dean’s tax” on clinical revenues, and government subsidies. In nearly all medical schools, the money from all of these sources is insufficient to pay for all of the hours of teaching by the attending physicians, at least compared to what those physicians could make in their clinical practice for those same hours. Fortunately, the intangible rewards of teaching plus the prestige of being a professor are great enough for many physicians to accept a lower income in order to be a medical school educator… up to a point.

Residents. Money to pay residents’ salaries comes from the hospitals that in turn gets money from federal funds to support GME (graduate medical education) as well as from hospital clinical income and endowments. There are additionally funds from the federal government that come in to support the teaching of residents and these funds can be used to support the teaching efforts of the attending physicians.

Fellows. There is not enough federal GME money to pay the salaries for fellows nor to pay attending physicians to teach fellows. There are 2 types of fellowships: ACGME accredited and non-ACGME accredited. The ACGME accredited fellowships are the standard specialty fellowships, for example, pulmonary fellowship. The non-ACGME accredited fellowships are in highly specialized areas, for example, an interventional pulmonary fellowship (done after a physician has already completed a basic pulmonary fellowship). The funding for ACGME accredited fellowships varies from hospital to hospital – at our medical center, half of the fellows’ salaries for ACGME-accredited fellowships are paid by the hospital and half is paid by the attending physicians in that particular specialty. In turn, the attending physicians get their funding from their own clinical income. Fellows in non-ACGME accredited fellowships are paid entirely by the attending physicians’ clinical income. Fellows in ACGME accredited fellowships cannot bill patients but fellows in non-ACGME accredited fellowships can bill patients and generate at least some clinical income on their own to help support their salaries.

Continuing medical education (CME). This is education for attending physicians who have completed their training but need to stay current in their field. In the past, this was supported by grants and sponsorships from pharmaceutical companies, medical supply companies, and medical device companies. Conflict of interest regulations now limit how much these entities pay for CME. Now, CME is paid for primarily by the individual attending physician being educated or by the hospital. Most of the time, physicians do not get paid to be a CME educator except in situations when they are getting paid an honorarium to give a talk; even then the amount of the honorarium rarely covers all of the teaching physician’s time involved in preparation, travel, etc. The intangible reward for being a CME educator is prestige and local/regional recognition as well as building a referral base.

What is the cost of teaching?

There are 3 major costs to consider in medical education: salary costs of the trainee (for residents and fellows), time costs of the attending physician teaching those trainees, and infrastructure costs for the space and other hospital resources required for teaching trainees. Lets examine each of these further:

  1. Salary costs. Medical students do not cost anything since they are taking out loans in order to pay to be there. Residents make about $52,000 their first year and this increases by about $2,000 for each additional year of training. So if we assume a 3 year residency for salary plus 25% benefits, an average cost of a resident is about $67,500 per year. However, the resident’s salary is going to ultimately be supported by federal GME funds so the attending physicians do not have to cover it. The average ACGME fellow salary + benefits in a 3-year fellowship will be about $75,000 and half of that ($37,500) is paid by the attending physicians, at least at most academic medical centers. The average non-ACGME fellow salary + benefits will be about $80,000 and this will be paid entirely by the attending physicians (plus whatever the non-ACGME fellow can bill for independently).
  2. Time costs. To determine time costs, you have to look at what the physician could have done from a clinical billing standpoint if they were providing patient care by themselves rather than engaging in a particular teaching activity. The most expensive education time cost is in classroom teaching (e.g., pre-clinical medical student classes or resident didactic lectures) because the attending physician is removed entirely from billable patient care during the time that they are lecturing or preparing a lecture. CME education also falls into this category. For attending physicians who are doing clinical education (in the office, hospital, or OR), the time cost varies depending on the level of the trainee. A third year medical student will slow you down the most since the student will need to see the patient independently and then present his/her findings to you before you see the patient. The attending physician will then need to take some time to teach the student about the patient’s disease. Because of Medicare rules on what students are not allowed to document (for billing purposes), the attending physician must then see the patient and re-do most of the history, all of the physical exam, and most of the progress note documentation. Although Medicare does permit a medical student to document the past medical/social/family history, in an era of electronic medical records, this is usually already in the electronic note. A junior resident is generally a break-even as far as the attending physician’s time – they have more experience than a medical student and Medicare permits the attending physician to use most of their progress note documentation for billing purposes. A senior resident or fellow generally adds billing productivity to the attending physician since these trainees can function more independently and at the attending physician has to spend less time with the patient and preparing the progress note on a per billable patient standpoint.
  3. Infrastructure costs. There are two general types of infrastructure costs: office practice costs and hospital costs.
    1. In the office, a typical allocation of examination rooms per doctor is 2 per attending physician/provider. This allows the doctor to be seeing one patient while the nursing staff is rooming the next patient. In certain types of practice, this may increase to 3 or even 4 exam rooms per physician but for the purpose of this analysis, lets assume it is 2 rooms per physician. To maintain clinic efficiency, you have to have additional rooms for trainees since the patients will need to spend more time in each exam room so that the trainee can see the patient first, before the attending physician. Medical students increase the infrastructure cost since they are less efficient in history taking and spend more time with the patient; however, they see relatively few patients so the number of exam rooms taken out of commission by the medical student is relatively few – usually 1. A senior resident or fellow is more efficient but also sees more patients per day and so they may need 2 additional exam rooms. If the physician owns or leases the office, this infrastructure cost goes to the physician; if the hospital owns and operates the office, then the hospital bears the infrastructure cost.
    2. In the hospital, you don’t need to have extra exam rooms or nurses for trainees since each inpatient already has their own room. However, trainees can have addition infrastructure costs in certain areas, particularly the operating room and to a lesser extent, the emergency department. In these areas, trainees add extra time to patient encounters and that extra time adds additional costs. For example, in the operating room, an experienced surgeon may be able to do a cholecystectomy in 30 minutes if he/she is doing it solo with an experienced surgical assistant. But if that surgeon is teaching a resident to do the same procedure, it might take 40 minutes. This adds 10 minutes to the surgeon’s per case time and 10 minutes to the operating room cost (including the cost of the nursing and OR personnel plus the cost of not being able to start another case in that operating room earlier). The surgeon may be able to make that time up by stepping out of the OR while the resident closes the wound and does the operative note dictation but the cost to the hospital of having a teaching OR (as opposed to a non-teaching OR) remains. ACGME fellows are a break-even for the hospital because they have less effect on operative time and permit the attending surgeon to start a second case in a second room sooner. Non-ACGME fellows may actually improve the hospital margin by permitting the attending surgeon to operate in 2 rooms simultaneously, thus increasing the surgical volume.

So, lets put all of this together to see what the net cost of various trainees is to the physician and to the hospital. In the table below, attending physician productivity (RVUs per hour) are reduced with classroom teaching and medical students but increased with residents and fellows. On the other hand, fellows have a cost to the attending physician since the attending physician has to pay part or all of the fellow’s salary. All trainees add additional outpatient infrastructure cost and the more experienced the trainee, the greater the cost because of the number of exam rooms they can cover (thus requiring both more rooms and more office staff). For hospitalized patients, there is no significant infrastructure cost except in the operating room, where these costs are largely borne by the hospital and not the physician.




So, if we look at the net costs of being an educator, we see that it varies depending on whether the trainees are in the physician’s office or in the hospital. Classroom teaching and medical student clinical teaching are the most expensive overall with resident and fellow clinical teaching being close to break-even in the outpatient setting but a net benefit to the attending physician in the inpatient setting.

Obviously, these are generalities and each specialty and each clinical setting will be a little different. Nevertheless, this analysis does demonstrate that there are both productivity costs and productivity gains in medical education.

March 9, 2017


Hospital Finances Inpatient Practice

So, How Should You Pay Hospitalists?

Hospital’s priorities are usually not aligned with how we pay hospitalists. In fact, the two are often in direct conflict with each other. In my last post, I argued that the RVU is not the best measure of productivity for a hospitalist. In this post, I have some ideas of how hospitals can align hospital priorities with the hospitalist’s income.

CMI-Adjusted Census

The first thing we need to do is to get away from the model of a rigid census cap/expectation per hospitalist. In a previous post, I discussed why the work required to take care of 15 patients at one hospital does not equal the amount of work required to take care of 15 patients at another hospital. In fact, a census of 15 patients on one floor of any given hospital is not the same as 15 patients on another floor. Quite simply, this is because the amount of physician work necessary to take care of one patient is not the same as the amount of work necessary to take care of another patient. One way of determining the proper census per hospitalist is to do a CMI-adjusted census (CMI = case mix index). The idea is that the higher the CMI, the sicker the patient and presumably, the more time required by the hospitalist to care for that patient. Let’s look at the CMI of 3 hypothetical hospital services:

Service 1: CMI = 1.30. This service admits general medicine patients but also admits to the ICU.

Service 2: CMI = 1.10. This is service admits non-ICU general medicine patients.

Service 3: CMI = 1.00. This service mainly covers lower acuity medicine patients, generally with single-issue medical problems and about half of patients being observation status patients. They have a short length of stay.

Let’s start with an assumption of 20 patient encounters per hospitalist and then divide the census by the CMI. So, for service #3, we would have 20 ÷ 1.00, which would be 20 patient encounters per hospitalist per day. On the other hand, for service #2, we would have 20 ÷ 1.10 = 18 patient encounters. Service #1 would be 20 ÷ 1.30 = 15 patient encounters. Notice that I used hospital encounters in this analysis and not daily census. Because of the differences in length of stay (and therefore differences in patient turnover) for each of the 3 services, the daily census could be the same for each of the services (eg, 13). Moreover, if you have night coverage hospitalists who are doing admissions to these services at night, the service census at the midnight census tally might be 15 for each of the services. Surgical patients inherently have a higher case mix index because of the surgical procedure so you cannot apply the same analysis for staffing surgical patients as you would with medical patients.

CMI-adjustment does several things to align the hospital and the hospitalists:

  1. It rewards the hospitalist to compulsively document in the chart all of the mundane co-morbidities that affect the CMI score but really don’t affect how the patient gets managed. So, for example, if a patient has a sodium level of 144 (normal 133-143) on admission, the hospitalist is going to ignore it since it is not clinically significant – adding “hypernatremia” to their admission note is extra work and why bother typing in the extra line of text if it is clinically irrelevant? However, since by adding the word “hypernatremia” to their note, the CMI goes up slightly and so the hospitalist is granted a slightly lower census target.
  2. The hospital’s financial margin improves because the higher the CMI, the more the hospital gets paid for that patient admission.
  3. The hospital’s length of stay index improves because the index is determined by the actual length of stay adjusted for the CMI.
  4. The hospital’s mortality index improves because the actual mortality rate is adjusted for the CMI to give the publicly reported mortality index.

Outcomes-Based Bonus Plan

Historically, bonus plans were based on productivity. At the end of the day, the productivity that really matters is total cash collections. However, we all know that when performing the same service, you get paid more for a commercially-insured patient than you do for a Medicare patient. You get paid even less for a Medicaid patient and you get paid practically nothing for most uninsured patients. So, the RVU has evolved to be a better measure of physician work effort than cash collections in order to remove the disincentive of taking care of the uninsured and Medicaid patients in the hospital since the hospital has to have someone take care of these patients.

In medicine, we often define true value in the service that we provide by the equation: value = quality ÷ cost. In other words, you can increase your value by increasing your quality or by decreasing your cost. So, what the hospital really wants is for the hospitalist to improve value of healthcare, by either improving quality (particularly in those publicly-reported quality measures on the Medicare Hospital Compare Website) or by improving the hospital’s financial margin. The financial margin in turn, can be improved by either increasing the revenue per patient-day in the hospital or by decreasing the cost per DRG. Therefore, bonuses should be based on some combination of:

  1. Query responsiveness. Hospitals have coding staff that comb inpatient charts looking for those co-morbidities that add up to a higher case-mix index for any given patient. The problem is that even if those co-morbidities appear in the lab results (for example, hypernatremia in the previous discussion) or appear in a non-physician’s note (for example, the dietician who mentions “protein calorie malnutrition” in his/her note), it only counts toward the CMI if a physician (or nurse practitioner or physician assistant) puts it in their note. So, hospitals have evolved a query system where co-morbidites identified by coders are reported to the hospitalist as a query and then the hospitalist decides whether or not it is valid and then addends their note accordingly. This is extra work for the hospitalist and so if they are not incentivized to answer the queries, they are going to ignore the coders and then the CMI ends up being lower.
  2. Patient discharge time. The earlier you get patients out of the hospital, the earlier in the day that bed can be filled by the next patient. However, you don’t need to get all of the patients discharged early in the day – your housekeeping staff can’t clean all of those rooms at the same time. The strategy is to get some of the patients out by 11:00 AM, some more out by 1:00 PM, etc. so that you have a steady flow of discharges throughout the day in order to accommodate the steady stream of patients waiting to be admitted into those beds. So, pick some numbers that work best for your hospital, for example, 20% of discharges by 11:00 AM and 40% of discharges by 1:00 PM.
  3. Mortality index. Because the mortality rates are one of the publicly reported items by Medicare, the hospital wants patients to die anywhere but in the hospital. For those patients who are anticipated to die, transferring a patient to a hospice facility to die is ideal. The danger of using mortality index for hospitalist bonuses is that sometimes, it can work against you from a hospital expense standpoint. For those patients who are clearly going to die in the ICU, the hospitalist could be incentivized to try to keep that patient alive a little longer in order to buff them up just enough to survive the transport to inpatient hospice or to have them die on another hospitalist’s shift so that the death doesn’t count against them. In this situation, earlier withdrawal of life support would have resulted in the hospital not having the expense of those extra days treating the patient in the ICU and the patient (and family) would have been spared making an inevitable unpleasant and uncomfortable death last longer.
  4. 30-day readmission rate. Hospitals get penalized by Medicare if this is too high. The hospital wants all of its rooms to be full, but to be full of patients who were not there in the past month. Hospitalists can often reduce the readmission rate by putting more time and effort into the discharge process (see post on The Most Dangerous Procedure In Medicine).
  5. Lower length of stay. This is a tricky one. If you discharge a patient prematurely, that patient is more likely to be readmitted within 30 days and is more likely to be dissatisfied if they perceive that they were thrown out of the hospital too early. So, length of stay should never be the sole metric for a bonus plan and should only be used when coupled with hospital readmission rates and with patient satisfaction. Also, length of stay lends itself to gaming the system since it is based on the midnight census. So, a patient admitted to the hospital at 11:30 PM already has a 1-day length of stay a half hour later at midnight. In order to improve his length of stay, the hospitalist will procrastinate putting the admission orders in for anyone showing up in the ER in the evening. If that order is placed at 12:01 AM, you just knocked a day off of that patient’s length of stay.
  6. Patient satisfaction. For inpatients, this is measured by the “HCAHPS” survey questions that are reported on the Medicare Hospital Compare Website. Some of these questions are specific to physician practice and can be used in a hospitalist bonus plan; other questions pertain to the patient’s overall perception of the hospital which measures the physician’s performance as a member of a larger team of providers in the hospital.

Billing Benchmarks

You can’t do away with RVUs completely, otherwise, the hospitalist would either not bother to submit their charges for patient encounters or they would bill everyone as a level 1 visit, thus reducing the necessity of all of the painful documentation required to bill higher levels of service. So, there has to be some why to hold the hospitalist accountable for turning in their bills and to insure that they are actually billing for the level of service that they are providing. Most electronic billing programs will allow you to see what the distribution of level 1, 2, and 3 CPT codes for any given physician. This distribution can be compared to internal benchmarks of all of the other hospitalist or to external benchmarks, such as the Vizient benchmark data for academic medical centers.

The Bottom Line

Ultimately, the strategy is to align the hospitalist’s reward system with the financial margin of the hospital. To do this, you need to think beyond hospitalist census caps and RVUs.

March 7, 2017

Hospital Finances Inpatient Practice

You Can’t Pay Hospitalists By The RVU

Every year about this time, hospitalists begin their contract negotiation with hospitals for the upcoming fiscal year. I’ve been on both sides of the negotiation table over the past 20 years. As with any negotiation, to be really successful, one party needs to not only know what the other party really wants but they need to know what it is they, themselves, really want. All too often, because we know neither what the other side wants nor what it is that we really want, we fall back on negotiating about money. The problem is that money is often not the most important thing that either side values.

What the hospital really wants:

  1. A positive financial margin at the end of the year. This is what the Board of Trustees really cares about and you can improve the margin in two ways: increase your revenue or decrease your expenses. But sometimes spending a little more on one expense item/department can greatly reduce the expense of another item/department. This becomes very difficult because large hospitals are often administratively compartmentalized and each compartment is held individually accountable for its financial bottom line and often for the hospital to make money overall, one compartment has to lose money. If the hospitalist is trying to see as many patients as possible and pump out as much in billings, then this may or may not be in alignment with the hospital margin. By paying a little more for the hospitalist, the hospital can often save more money if the extra amount of time that the hospitalist can now spend on the patient translates into a shorter stay and less expensive testing.
  2. Higher patient satisfaction. This is one of the publicly reported measures that hospitals are judged and compared to each other on the Medicare Hospital Compare website. If the hospitalist is primarily motivated by patient volume, what the patient thinks about the hospitalist (or the hospital) becomes relatively unimportant. RVUs are a quantity contest, not a popularity contest.
  3. Shorter length of stay. A shorter length of stay results in a more positive financial margin. If you can get a patient out of the hospital one day earlier, then that patient doesn’t consume expensive hospital resources (medications, lab tests, nursing time, meals, etc.) and, more importantly, you can get another paying patient in that room quicker. If the hospitalist’s goal is to maximize RVUs, then it can be paradoxically better for that hospitalist to keep the patient in the hospital one more day because that extra day in the hospital will involve relatively little time on the hospitalist’s part thus resulting in earning low-effort RVUs.
  4. Lower readmission rates. The hospital is penalized if 30-day readmission rates are excessively high. The hospitalist is rewarded if the 30-day readmission rate is high: it not only means more RVUs, but you can copy most of your previous history and physical exam making the admission quick with more low-effort RVUs. One of the key drivers in whether a patient gets readmitted shortly after discharge is the amount of time and effort spent in the discharge process. If the hospitalist has the time it takes to personally speak with the patient’s primary care physician, do a careful medication reconciliation, and ensure that all post-hospital tests and appointments are scheduled, that patient is less likely to be readmitted. The problem is that the hospitalist is going to get paid the same amount in RVUs whether or not they go to all of that extra effort to ensure a good discharge.
  5. Patients being discharged from the hospital earlier in the day. From the hospital’s perspective, an earlier discharge hour means that another patient can fill that bed earlier from either the ER or the OR and so patients don’t have to wait as long in the post-op recovery room or in the ER to get a bed. From the hospitalist’s standpoint, getting those patients out earlier in the day means that he/she will have to work a lot more intensely early in the morning and if paid by the RVU, you end up with the same amount of money in your pocket whether you discharge that patient at 10:00 AM or 4:00 PM and it is a lot easier to take your time and get the patient out at 4:00.
  6. Higher case mix index. The higher the case mix index (a measure of the severity of disease of the patient), the more the hospital gets paid. The case mix index also affects the publicly reported mortality index  (mortality rate adjusted for case mix index). So, the hospital wants a higher case mix index and the only way to do this for non-surgical admissions is for the physician to document all of the little co-mobidities that the patient had on admission (such as hypomagnesemia, malnutrition, etc.). When paid by the RVU, the hospitalist is not motivated to go to the extra effort to document all of these co-morbidities because he/she is going to be paid the same and ferreting out all of these (often obscure and unimportant) findings takes extra time and effort.
  7. Patients moved out the ER to the floor rapidly. The hospital has to report the amount of time the patient spends in the ER waiting for a bed and needs to keep that number as low as possible to avoid public embarrassment. Furthermore, the quicker the hospital can get that patient out of the ER, the sooner another patient can be placed into that ER room. To do this, the hospitalist needs to see the patient and write orders on the patient so that the patient can move from the ER to the nursing unit. The hospitalist who is paid by the RVU could not care less how quickly the patient gets out of the ED since they get paid the same, regardless.
  8. Avoidance of unnecessary expensive tests and treatments. For the hospital, fewer tests on inpatients equates to a higher financial margin. The hospitalist paid by the RVU could not care less.
  9. Lower mortality index. Neither the hospital nor the hospitalist wants to have one of their patients die. But patients are going to die, regardless. Most of the patients who die in our hospital are “DNR-CC” or “DNR-CCA”, meaning that they are anticipated to die and have elected to not be resuscitated when their heart and lungs stop working. There are two ways to lower your mortality index: (1) increase your case mix index by documenting all of the obscure co-morbidities or (2) get the patient to die somewhere other than in your hospital, most commonly at an inpatient hospice facility. For most of these patients, dying at home is neither practical nor desired by the family. If a DNR patient dies in your hospital, it is included in the hospital’s mortality rate but if that same patient dies at a separate inpatient hospice, the death doesn’t count against the hospital’s mortality rate. Once again, the mortality index is publicly reported on the Medicare Hospital Compare website. For the hospitalist paid by the RVU, arranging the transfer of a dying patient to a hospice facility takes a lot of work and it is easier to just care for that patient in the hospital until they die; plus, the hospitalist can bill for a few more days of inpatient care.
  10. Avoidance of complications. Healthcare associated infections and surgical complications are publicly reported on the Medicare Hospital Compare website so the hospital wants to keep the numbers down. Even more importantly, hospital complications are costly and can lower the hospital’s financial margin. For the hospitalist, the RVU pays the same, with or without complications. In fact, if a patient has a complication, the hospitalist can bill a higher level of service thus generating more RVUs.
  11. A sufficient number of doctors to provide care to the patients at any given time. The hospital wants to optimize patient throughput whereas the hospitalist paid by the RVU wants to optimize patient volume. There comes a point, however, where too high of patient volume results in reduced patient throughput. For more explanation, see the post on The Starling Curve of Physician Productivity.

What the hospitalist really wants:

  1. To feel that they are valued as professionals. The hospitalist invested 11 years of post-high school education to become a hospitalist and they want to be recognized for that effort. What the hospital often thinks it needs is a warm body with the initials M.D. or D.O. One advantage that our hospital has in the local market is that all of our hospitalists get an OSU faculty appointment, even if it is an unpaid appointment. Being able to say that you are an Assistant Professor at the Ohio State University is enormously valued.
  2. Adequate work-life balance. Physicians of the baby boomer generation went into medicine with the expectation that they were going to work very long hours and have very few days off. Most hospitalists are in the millennial generation and trained in an era of ACGME-legislated duty hour limits and emphasis on life outside of work. Baby boomer doctors have no problem carrying their pagers 24-hours a day and being called on their days off work. Millennial doctors want to turn their pagers off when they leave the hospital and not turn them on again until their next shift.
  3. To have sufficient time during the day to do their job well. Physicians are professionals and they want to take pride in a job done thorough and a job done well. To do that, they have to have enough time that they don’t have to cut corners in patient care. Insufficient time to do one’s job leads to burn-out.
  4. A reasonable salary. Notice that I didn’t say the highest salary. Most hospitalists are not choosing a job because it pays the best but because it is the best place for them to work. In fact, if a hospitalist is choosing a job purely based on salary, you probably don’t want that hospitalist in your hospital. A hospital with a terrible “churn and burn” environment with excessive hospitalist work loads and high turnover will have to pay more to attract a hospitalist than a hospital where the hospitalists feel valued and treated as professionals.
  5. To heal patients’ disease and suffering. Lets face it, college students who decide to go to medical school are intelligent… really intelligent. And to get into medical school, they’ve got to be hard working… really hard working. They are going to spend 4 years racking up $180,000 in medical school debt then get paid a little more than minimum wage as a resident for 3 years. With their intelligence and work ethic, they could have gone into engineering or IT and made more money over the course of a lifetime than a doctor. The reason that they went into medicine in the first place was a desire to heal and help.
  6. A collegial work environment. Most hospitalists want to work in a team of like-minded physicians and they want to work with people who they know will back them up if they have a family emergency or they get sick. They want to know that when they have 3 patients crashing at the same time, that one of their partners is going to come over to help out without being asked. They also want to work with consultants who are going to partner with them in the care of their patients.

There isn’t a lot of overlap between these two lists. So, what we usually do is fall back on things that we can understand and easily quantitate, like the number of patients a hospitalists sees per day, the number of shifts per year, salary, and RVUs (Relative Value Units) billed. But by doing this, neither side really gets what they want and both sides end up being less satisfied than they could be. What is the solution? I have some ideas and I’ll outline them in the next post.

March 4, 2017


Emergency Department Intensive Care Unit

What Do You Do If You Can’t Intubate The Patient?

At our larger, tertiary care, University Hospital, we have a “difficult airway team” with an experienced anesthesiologist with a surgeon for back-up available in the hospital 24-hours a day. At University Hospital East, we don’t have a difficult airway team in the hospital at night and the anesthesiologist and surgeon have to be called in from home when a difficult-to-intubate patient develops respiratory failure. In the operating room, the percentage of patients with a difficult airway is 1-4% but in the ICU or ER, it is as high as 20%. So what can the hospitalist or emergency room doctor do to ventilate the patient for the 20 minutes it takes before help arrives? 15 years ago… not much. But now, we have a lot of devices that we can use when an endotracheal tube cannot be placed. Here are some of the more common ones:

  1. The video laryngoscope. One of the first of these to come to market was the Glidescope®. Similar devices include the McGrath, the King Vision®, the IntuBrite®, the APA™, the C-MAC®, and the Marshall Video Laryngoscope®. These laryngoscopes have largely replaced the rigid steel Macintosh and Miller laryngoscopes in many hospitals. They are easier to use and improve intubation success for less-experienced physicians. Many EMS units now carry them in their emergency squads. In our hospital, we have Glidscopes available in our ICU, OR, and ER. We still use standard laryngoscopes in our intubation kits that are in our crash carts but the respiratory therapists can get a Glidescope to the bedside on very short notice. They have been shown to double the likelihood of a successful intubation on the first pass of the endotracheal tube and can reduce the time of intubation to one-third the time it takes with a standard laryngoscope. Watch a video of how to use the Glidescope here.
  2. The bougie. Think of this as a guide wire for an endotracheal tube. Many times, when looking at an airway with a laryngoscope, you can see part of the vocal cords but not enough to confidently pass an endotracheal tube. Or, you may be able to get a good look at the vocal cords but as soon as you introduce the endotracheal tube, you obliterate your view. The bougie can solve this problem by being being small and semi-rigid. Also, it is colored blue so it is easy to see the tip of it, even if the is a lot of blood, fluid, or floppy laryngeal tissues covering up the vocal cords. Once you pass the bougie into the trachea, you then simply slide an endotracheal tube over the bougie and into the airway. If you can’t slide an endotracheal tube over the bougie, you can put an adaptor on the end of it and at least blow oxygen through it. Watch a video of how to use a bougie to facilitate intubation here.
  3. The laryngeal mask airway (LMA). These are very simple to insert and in fact, anesthesiologists will often use them during short duration surgeries to ventilate patients in the operating room. They require little skill to place and can ventilate patients sufficiently until you can get someone with advanced airway skills into the hospital to place an endotracheal tube. The LMA consists of an elliptical inflatable cuff that is inserted into the mouth (after lubricating it) and over the top of the tongue, along the hard palate until you meet resistance. You then inflate the cuff. In the middle of the cuff, is an opening that leads to the ventilation tube. When the cuff is inflated, it occludes the esophagus so that air coming out of the port can only go one way – down through the vocal cords into the trachea. They do need to be secured, particularly when transporting a patient, because if they migrate out of the mouth, air may not go into the trachea properly. Watch a video of insertion of an LMA here.
  4. The Combitube. This is somewhat similar to the King airway (see below). It is a fool-proof tube that you place into the mouth so that it can either go into the esophagus or the trachea – it will usually go into the esophagus. Either way, you can ventilate the patient. Inside the Combitube, there are two tubes – one with an opening at the distal tip of the tube and one with an opening on the side of the tube about a third of the way back from the distal tip. There are two balloons on the Combitube – one at the tip and one about half way back from the tip. So, if the tube goes into the esophagus, then you blow both the proximal and the distal balloon up and ventilate through holes on the side of the Combitube. The distal balloon prevents air from going into the stomach and the proximal balloon prevents air from going back out of the mouth. If the Combitube ends up going into the trachea, then you can ventilate the patient through the distal tip of the tube. If you are not sure where the tube is, you can use an end-tidal CO2 detector connected to each of the two ports of the Combitube to determine if you are in the esophagus or the trachea. Watch a video of how to place a Combitube here.
  5. The King airway. This looks a lot like a Combitube but it is designed to only go into the esophagus. Although there is a hole at the distal tip, it is only there in order to pass an NG/OG tube through it into the stomach and not designed to ventilate through it. Ventilation is through the side ports. Like the Combitube, the ventilation holes in the King airway are on the side of the tube, in between the two balloons. In a study of 27 emergency medical responders comparing the King airway to the Combitube, the King airway insertion time was 24 seconds and the Combitube insertion time was 38 seconds; the King airway was perceived by the responders to be easier to place and was preferred over the Combitube by 26/27 of the participants. Watch a video of how to place a King airway here.
  6. The nasal intubation. OK, so this is not exactly a new device. This is an old-school approach that I was taught to use for difficult airways back in the early 80’s, before LMAs, King airways, and Glidescopes were invented. You simply liberally lubricate a small (#7 or #6) endotracheal tube and insert it into the nares like you would a nasogastric tube. A little neosynephrine in the nose will open things up and make passage of the tube easier. Once the endotracheal tube makes the curve in the back of the pharynx, you listen over the end of the tube (or, better yet, place an end-tidal CO2 monitor on the end of the tube). If you position the patient’s head in the “sniffing position” (as opposed to bending the neck forward like you would when inserting a nasogastric tube) then you will have more success getting the tube to go into the trachea instead of the esophagus. Insert following the breath sounds (or end-tidal CO2 waveform) until you are in the trachea. This is a particularly useful approach when you can’t open the patient’s mouth fully to insert an endotracheal tube orally and can also be useful in the patient with angioedema. Watch a video of how to place a nasotracheal tube here.

The whole idea of using any of these techniques is to be able to ventilate the patient as quickly as possible. So when should they be used in the hospital? First, if the physician is not trained or proficient in performing endotracheal intubation with a standard laryngoscope – there is just too much that can go wrong such as placing the endotracheal tube in the esophagus or causing airway trauma that can create difficulty even for the skilled operator who performs an attempt later. Second, if the physician cannot get the patient intubated quickly using a standard laryngoscope – my rule is that if it takes 3 tries, you need to go to another option. If all else fails, then the cricothyroidotomy is the procedure of last resort. The last time I did one of these was on a dog during an Advanced Trauma Life Support course in 1983 and I hope that I never have to do one again.

If you are on call by yourself in the hospital at night, make sure you know what is available because when you are responding to a cardiorespiratory arrest and you encounter a difficult airway, you’re not going to have time to go to a computer and search the internet for advice.

February 28, 2017

Intensive Care Unit

2,3-DPG Is A Wonderful Thing

Yesterday, I responded to a code blue in one of the procedural areas of our hospital. The patient had severe hypoxemia due to flash pulmonary edema from combined systolic + diastolic heart failure and then had an IV dye load that tipped him over into pulmonary edema. He had a previous tracheostomy and still had a residual stoma that had not entirely closed. We put an endotracheal tube into the stoma until we could obtain a large enough tracheostomy tube to fit his tracheal diameter. Despite mechanical ventilation with 100% oxygen and a very high level of PEEP (positive end-expiratory pressure), his oxygen saturation stayed in the 70’s and 80’s for at least a half hour.

If that had happened to me, I would likely have severe anoxic brain injury. Yesterday, we had 4 patients in our ICU with severe anoxic brain damage that had been admitted after suffering cardiorespiratory arrests. But the patient who coded yesterday is waking up just fine this morning. So why do some patients get anoxic brain injury from prolonged hypoxemia and others seem to get by without any brain damage? I think it comes down to the wonders of 2,3-DPG.

2,3-diphosphoglycerate (2,3-DPG) is a chemical normally present in relatively small amounts in red blood cells. Its job is to change how oxygen binds to hemoglobin in order to make oxygen fall off of hemoglobin more easily so that when a red blood cell passes through vital organs (like the brain), more oxygen can be released by that red blood cell. Normally, a red blood cell will release about 25% of its oxygen as it passes through tissues; it then goes to the lungs and re-loads with oxygen. 2,3-DPG makes the red blood cell release more oxygen. This is particularly important in people who are traveling to high altitude (e.g., mountain climbers) and people who chronically are hypoxemic (e.g., patients with untreated sleep apnea). A normal person will have an oxygen saturation of nearly 100% as blood leaves the lungs; the red blood cells will release about 25% of its oxygen in the tissues so that the oxygen saturation is about 75% when that venous blood returns to the lungs. If you are at high altitude, your arterial blood’s oxygen saturation may only be 80% and if the red blood cells can only release oxygen down to a saturation of 75% as they pass through the tissues, then there isn’t much oxygen being released and the tissues can be starved for oxygen. 2,3-DPG allows the red blood cells to release oxygen down to a saturation that is much lower than 75%, say 60%, so that enough oxygen is being off-loaded into the tissues to keep them functioning normally. From a physiologic standpoint, we call this a “right shift of the oxyhemoglobin dissociation curve”.

One of my heroes is Lonnie Thompson. He is an OSU Professor of Earth Sciences. He is arguably one of the most renowned faculty members at the Ohio State University and his research involving high-altitude glacial ice core samples has led him to spend more time at extreme altitude than any other human in history. 2,3-DPG is one of the main reasons he can do it.

My patient yesterday most likely had non-human high levels of 2,3-DPG that allowed him to come through a period of prolonged hypoxemia unscathed. And that got me wondering. What if I could bottle 2,3-DPG and put it in a syringe? Who would I give it to? Here is who I would give an amp of 2,3-DPG if I could:

  1. Everyone in a cardiopulmonary arrest. I would change the ACLS algorithms to push 2,3-DPG even before giving epinephrine every time cardiopulmonary resuscitation was required.
  2. Patients with unstable angina. If a coronary artery was partially blocked, wouldn’t it be great if you could off-load every last oxygen molecule from the red blood cells that did get through to the myocardium?
  3. Jehovah’s Witnesses undergoing surgery. It is every surgeon nightmare who operates on a Jehovah’s Witness – that there will be unforeseen bleeding in a patient that you can’t give blood transfusions to. An infusion of 2,3-DPG would allow you to get more out of what little blood the patient has left.
  4. Patients in shock. Ultimately, shock is an imbalance between oxygen consumption and oxygen delivery. Currently, when a patient is in shock, we try to improve oxygen delivery by giving vasopressor medications to increase the blood pressure. I think we’d be far more successful if we could increase tissue oxygen delivery if we gave an IV infusion of 2,3-DPG.
  5. Mountain climbers. If everyone who climbs mountains had Lonnie Thompson-levels of 2,3-DPG, we wouldn’t have to worry about altitude sickness anymore.

It is going to take someone a lot smarter than me to figure out how to make 2,3-DPG into a marketable pharmaceutical. But for now, I’m just really glad that the patient yesterday had a lot more of it than a normal person.

February 24, 2017