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Hospital Finances Inpatient Practice

Avoid Losing Money On Medical Admissions: 30 Tactics

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

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

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

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

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

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

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

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

August 24, 2021

Categories
Hospital Finances Inpatient Practice

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

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

Never admit a patient between 10 PM and midnight

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The biggest barrier is the length of stay index

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

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

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

It is time to move past the midnight census.

August 20, 2021

Categories
Epidemiology Inpatient Practice

The Next Surge In COVID-19 Hospitalizations

Just when we thought it was safe to go back to the movie theater, to church, and to the grocery store… it looks like we are in for COVID, the sequel. The CDC reported that an outbreak of COVID infections in a town on Cape Cod earlier this month resulted in 469 people becoming infected, of whom 74% had previously been vaccinated. Of these vaccinated persons who developed infection, 79% had symptoms and 4 of them required hospitalization. Disturbingly, vaccinated people who developed COVID-19 had the same viral load detected in their noses as unvaccinated people who developed COVID-19.

This change in the epidemiology of the pandemic is attributed to the Delta variant, a much more contagious strain of the coronavirus that causes COVID-19. Coupling Delta with recent evidence that the SARS-CoV-2 virus is not simply transmitted by droplet spread as originally believed but can also be spread by aerosolization is a warning that we will likely see a resurgence in COVID hospitalizations in the near future. In anticipation of this, the CDC yesterday published recommendations to resume indoor masking for all people (regardless of vaccination status) in areas of the country where there is “substantial or high transmission” of COVID-19. In July 2021, there was a dramatic increase in U.S. counties with high transmission. The three figures below show the change in transmission rates over the past 4 weeks (red is high transmission and orange is substantial transmission):

This data indicates that most U.S. counties are now experiencing high transmission rates. To determine what these trends will mean in the upcoming weeks for U.S. hospitals, we can look at COVID-19 hospitalization trends. The figure below shows the number of new hospitalizations for the entire United States from August 1, 2020 through July 28, 2021. This indicates that the hospitalizations are going up but are not as high as the nationwide peak in January 2021.

Florida was one of the first states to convert from moderate to high transmission over the past month. As such, Florida may be a bellwether for the rest of the country. The figure below shows the same hospitalization data but just for Florida. Hospitalizations in Florida now exceed those of January 2021, when the rest of the country was at peak numbers.

So, if hospitalizations are about to go up, what demographic of patients are likely to be hospitalized? Intuitively, one might think that hospitalizations will be mainly younger people since older Americans are considerably more likely to be vaccinated. The figure below is data from the CDC that shows that in Florida (graph on the right), more younger people are being hospitalized now than in January (yellow line). However, older people still comprise the majority of hospitalizations.

So, what should hospitals do now?

From the Massachusetts outbreak and the Florida data, we can draw several conclusions: (1) the Delta variant is more contagious than earlier variants, (2) vaccinated persons can still get infected and when they do, they have just as high of a viral load as unvaccinated persons, (3) the Delta variant is more likely to be spread by aerosolization rather than simply by droplets, (4) adult hospitalizations are increasing. With those conclusions in mind, here are some tactics that hospitals can take now:

  1. Ensure that all front-line healthcare workers are vaccinated. During the January 2021 surge, many hospitals found that healthcare workers were more likely to get infected by another healthcare worker than by an infected patient. Furthermore, if a hospitalized patient becomes infected from an unvaccinated infected healthcare worker, the hospital could face litigation vulnerability in the future.
  2. Re-institute routine admission SARS-Co-2 testing. Given that more Americans are vaccinated, it is likely that we will begin to see more asymptomatic infections in patients being admitted to the hospital for non-COVID-19 related medical/surgical conditions. These asymptomatic patients can serve as vectors to infect other patients and hospital staff.
  3. Re-institute universal masking. Last winter, nearly all hospitals in the U.S. required patients, visitors, and healthcare workers to wear face masks while in patient care areas and public areas of the hospital. Because of “anti-masking” political pressure, some hospitals have loosened masking requirements in the past few months. These hospitals need to resume universal masking.
  4. Buy more N-95 masks. Given that the Delta variant is so contagious and given that it appears to be more likely to be spread by aerosols than simply by droplets, N-95 masks are likely to be more protective than simple face masks to prevent acquisition of Delta. It is likely that frontline healthcare workers will increasingly demand access to N-95 masks.
  5. Update the surge plan. Last December, hospitals made plans for expanding ICU bed capacity and for increasing the number of non-ICU beds for the January COVID surge of inpatients. It is time to revisit those plans, both for intra-hospital care as well as inter-hospital care.

17 years ago, my family was stuck on an island in the outer banks when Hurricane Alex hit. The night before, the main road became covered by a shifting sand dune and the bridge to Hatteras Island had to be closed. A few hours before impact, the local radio announcer said “Hope for the best but prepare for the worst“. That was sound advice in 2004 and it is sound advice again in 2021.

July 31, 2021

Categories
Inpatient Practice

Changing To A Different Hospitalist Group

Hospitalists have gone from rarities to dominating inpatient care in the past 25 years. Currently, there are approximately 50,000 hospitalists in the United States. The term “hospitalist” was first coined by Dr. Robert Wachter and Dr. Lee Goldman in their 1996 article in the New England Journal of Medicine. The young specialty was quick to show financial benefits to hospitals with studies showing improved hospital length of stay and lower costs per admission in patients cared for by hospitalists. Currently there are 3 common hospitalist practice models:

  1. Hospital-employed physicians
  2. Physicians who are part of local primary care or multi-specialty group practices
  3. Physicians employed by regional or national hospitalist companies that contract with numerous hospitals

There are advantages and disadvantages for each of these 3 models and the optimal model will be different for different hospitals. Periodically, hospitals will choose to change to a different hospitalist model or change to a different physician group within a given model. Managing this transition can pose unique challenges to the hospital.

Timing the decision

The decision to change hospitalist models or change to a different hospitalist group requires long-term planning, and should ideally be made 12-18 months before the intended transition date; the larger the hospital, the more time you will need. A small hospital that only needs a few hospitalists can change groups fairly quickly. But if the hospital is looking at changing coverage of a large number of inpatient beds, then the sheer number of new doctors that have to be recruited and hired takes a lot of advanced preparation. For example, to cover 100 beds, the hospital will need somewhere between 20-30 hospitalists, depending on patient acuity and other factors. Because of the high-demand for hospitalists, it can take many months to recruit this large of a number of doctors – there are not many unemployed hospitalists reading the help-wanted classified ads in the newspaper each morning.

Many new hospitalists will be recruited from internal medicine residency programs. Residency programs run on a July through June cycle so residency graduates will be available in July/August each year. These physicians generally start interviewing for hospitalist jobs about 1 year in advance and most residents from the better programs will have signed contracts by October or November of their senior year of residency. If a hospital waits until December to recruit and interview new graduates, there will be very few uncommitted residents left.

When do you let the doctors know?

The initial planning for a hospitalist transition is usually done privately with only a small number of hospital leaders aware of the plan to change to a different hospitalist group or model. This is necessary because as soon as the current hospitalists know that their employment contracts are going to be terminated, they will start looking for a new job. When to make the upcoming transition public depends on the employment contracts that the doctors have. Most physicians will have a 60, 90, or 120 “without cause” termination clause in their contracts. This means that they have to give 60, 90, or 120 days notice if they intend to leave. The day that you tell the doctors that their employment contracts are going to be terminated is the day that they will begin looking for another job.

You want all of your doctors to stay at the hospital until the date of the upcoming hospitalist transition. If you tell them about the transition 180 days before the date and the doctors have a 90 day without cause termination clause in their employment contracts, then you are going to find yourself with no hospitalists in the final weeks or months before the transition. However, you do want to be fair to the physicians who have been providing care to the patients at your hospital – you might want to hire them again in the future plus it is just the right thing to do. It generally takes at least a month for a hospitalist to find and sign a contract for a new job so a good rule of thumb is to let the current doctors know 30 days more than whatever their without cause termination period is in their contracts. So, if they have a  90 day without cause termination clause, let them know that their contracts will be terminated 120 days in advance.

Have a contingency staffing plan

As soon as the contract termination becomes public knowledge, it will be nearly impossible for the existing hospitalist group to hire new physicians – doctors looking for permanent employment do not want to sign up to work for two or three months. Inevitably, there will be some hospitalists in the current group that were planning on leaving, get sick, get called up for military reserve duty, or go on maternity/paternity leave in the months before the transition. So you have to have a reserve of short-term physicians who can fill in the vacancies until the new hospitalist group starts.

The easiest solution is to hire locum tenens physicians. These can sometimes be local physicians that the hospital can contract with individually to provide short-term hospitalist coverage but more often, these physicians come through a locum tenens company that maintains a pool of doctors who are available for short-term employment. It is important to plan early with the locum tenens physicians so that you can get them through your hospital’s credentialing process well in advance of when you will need them. If the hospital’s credentials office takes 3 months to complete credentials for new physicians, then you need to identify and get started on credentialing those locum tenens physicians shortly after announcing the hospitalist transition decision. Even if you have to pay a retainer to the locum tenens company, it can be worth it so that you do not find yourself with patients but no doctors to take care of them just before the transition date.

Create a transition workgroup

Key leaders from the hospital, the existing hospitalist group, and the new hospitalist group need to meet regularly. Because there can be animosity between the two hospitalist groups, it may be necessary for the hospital leaders to do most meetings with the hospitalist groups individually. Initially, the workgroup should meet monthly and then in the final 2 months of the hospitalist contract, the meetings should be weekly. These meetings may only take 10 – 15 minutes but it is important to put them on everyone’s calendar to ensure a safe and efficient transition. Specific issues to cover include:

  • How will test results that come back after the transition be handled? This will usually require some way of routing electronic medical record “inbaskets” to the new hospitalists.
  • Who will sign verbal orders after the transition date? Verbal orders have a  habit of showing up in the electronic medical record a day or two after the physician actually gave the verbal order. There needs to be a process in place for getting those orders signed. The same goes for signing discharge summaries, H&Ps, and operative notes.
  • How will death certificates be managed? If a patient dies a couple of days before the transition date, the funeral home will likely send the death certificate over to the hospital after the transition date. A mechanism for signing these in a timely fashion must be agreed upon.
  • How long will the current hospitalists have access to the electronic medical record? The doctors may only need to have access for a couple of weeks to sign verbal orders. However, their billing office may need access for several months to manage late bills and provide documentation of services to insurance companies.
  • Managing patient hand-offs. Ideally, the transition hour should be at the end of a day shift rather than the end of a night shift. The hospitalists who have been managing the patients during the daytime are generally in the best position to answer questions about their care than the night coverage hospitalists. This can result in a smoother transition.
  • What about trainee evaluations? If the current hospitalists have medical students or residents, then work with the appropriate education office to ensure that there is a mechanism for end-of-the-rotation evaluations to be completed after the current hospitalists have left. Trainees are notorious for completing their notes late so there needs to be a mechanism for co-signing these notes after the transition date.
  • Get an equipment inventory. After a period of time, is can be easy to forget whether the hospitalist group or the hospital purchased computers, furniture, phones, journal subscriptions, printers, and fax machines. Make sure everyone knows what stuff stays and what stuff goes.

Meet with the nurses and other physicians

Change can be alarming for doctors and nurses who have been accustomed to one group of hospitalists and one pattern of practice. There must be a mechanism for the hospital to clearly articulate the reasons for the change and reassure the staff that there will not be a reduction in the level of medical care provided by the new hospitalist group. Surgeons who have relied on the hospitalists for inpatient consultative co-management need to be engaged. The emergency department physicians need to be aware of any change in the admitting process with the new hospitalist group. Consultants need to be confident that the new hospitalist group will not reduce the number of consults that they order.

The things you didn’t think about

Different hospitalist groups practice medicine differently and one cannot be simply substituted for another. Consideration need to be made about:

  • Who manages cardiopulmonary arrests? Stroke alerts?  RRTs (rapid response team alerts)? Not all hospitalists have experience managing these situations and may require additional training prior to starting coverage.
  • Who manages bedside procedures such as central venous catheters, lumbar punctures, and intubations? Increasingly, internal medicine residents are not being routinely trained in these procedures. Endotracheal intubation is a particular problem – fewer and fewer hospitalists perform them and so you will need to decide if anesthesiologists, emergency medicine physicians, or respiratory therapists will become responsible for airway management if the old hospitalists performed these but the new hospitalists do not.
  • How will physicians be contacted? Maybe the existing hospitalists prefer to use pagers but the new hospitalists use their cell phones or an app in the electronic medical record. Be sure that it is clear how nurses and other physicians contact the specific hospitalist managing any given patient.
  • Clean up the electronic medical record. Don’t leave an option for a consult or admission to be placed to the old hospitalist group once the new hospitalist group takes over. That order for a consult will not go anywhere and patient care could suffer.

Your quality metrics will take a hit

During the last month of the old hospitalist group, the doctors will be less motivated to help the hospital with things that matter to the hospital. Anticipate that the inpatient length of stay will go up, hour of discharge will be later in the day, patient satisfaction will go down, and quality events will increase. This will be particularly true if the hospital has to rely on a lot of locum tenens hospitalists in the last weeks before the transition. It is very similar to college students getting “senioritis” in the months just before graduation. You can partly preserve performance on these various quality metrics by developing a bonus plan to pay the physicians for their performance in the last couple of months of their contract.

Be collegial

When a hospital changes to a different hospitalist group or model, the current hospitalists are going to feel betrayed and devalued. The end of their employment at the hospital means the end of friendships with nurses, other physicians, and hospital staff. It may mean that they have to sell their houses and move to a new community. It may mean that they will be out of work for a few months while seeking a new job. It likely means an end to a job that they really liked and were passionate about.

These physicians need to be treated as the professionals that they are. Meet with them regularly. Volunteer to provide job references. Provide them access to continuing medical education such as hospital grand rounds for a few months. And most importantly, explain to them that it was a business decision and not because they are bad doctors. Who knows, you might want to hire that physician or hospitalist group again in the future.

There will often be non-compete clauses in their employment contracts so the hospital or new hospitalist group may not be able to hire them. For those hospitalists who are superstars, it may be worth trying to negotiate a buy-out for the non-compete contracts. It costs a surprisingly large sum of money to hire a new hospitalist when you consider paying for a search firm as well as interviewing, credentialing, and orienting the new hospitalist. You may have to pay moving expenses or medical school loan repayments. When all of these are considered, it may be cheaper to pay a $25,000 or $50,000 buy-out for a current hospitalist than to hire a new hospitalist.

Managing change is one of the main things that hospital leaders do and it can be time-intensive as well as emotionally draining. But by planning in advance and giving attention to detail, changing from one hospitalist model or group to another can happen smoothly and offer new opportunities for the hospital.

November 7, 2020

Categories
Emergency Department Inpatient Practice Intensive Care Unit

With COVID-19, Hope For The Best But Prepare For The Worst

In August 2004, my family was vacationing on the North Carolina Outer Banks. I had been following Tropical Storm Alex as it came north from the Caribbean toward the island that we were staying on. On August 3rd, it was looking like the storm was going to head out over the Atlantic the next afternoon and miss Cape Hatteras. Not wanting to take any chances, I decided to get up early the next morning, pack up the kids, and head inland for the day, just to be sure. When I woke up at 5 AM, the first thing I heard on TV was that overnight, the storm had picked up wind speed, was moving across the ocean faster than expected, and had turned inland – directly toward our rental house in the town in Salvo. The second thing that I heard was that there was that storms overnight had caused sand and water to block the only road on the island leading to the bridge to mainland. The news announcer said to all of the people now stuck on Hatteras Island “Hope for the best but prepare for the worst.”

Having 4 children, my wife and I were used to buying in bulk and since this was at the beginning of our planned 2-week vacation, we were already pretty well stocked with food and supplies. We filled up all of the bathtubs with water for bathing and filled up as many bottles as we could find with drinking water.

By the time the storm hit us, Alex was now a level 2 hurricane. The eye wall passed over our rental house and as the wind changed direction with the passage of the eye, we moved all of the kids from a bedroom in one corner of the house to bedrooms in other corners. As the power went out, the wind sounded like a freight train and I watched as siding and parts of roofs were torn off of houses around us. A 2×4 board flew through the air like a missile across the street. Picnic tables, bicycles, and and lawn furniture were flung a hundred yards like toys. The roads all turned into rivers. Meanwhile, we played games with the kids and fed them Cheerios to keep them distracted.

It seemed like the end of the world and I wanted to be almost anywhere other than where we were.

But by afternoon, the wind died down, the clouds cleared, and the sun came out. All of a sudden, it was just another beautiful day on the Outer Banks. Over the next 3 days, the power returned, the flood waters subsided, and the sand was cleared from the roads. The bridge re-opened and the people staying in Salvo came out and cheered when one of the first vehicles that crossed the bridge to the island was a Budweiser truck.

COVID-19 is a lot like Hurricane Alex. The patient surge is coming and we can’t just wish it away. Just as the news announcer said on TV in the morning of August 4, 2004, we should hope for the best but prepare for the worst. But also like Hurricane Alex, the COVID-19 surge is going to pass; the clouds and pandemic storm is going to eventually subside; and life will be back to normal once more.

April 1, 2020

Categories
Inpatient Practice Intensive Care Unit

Reducing Hospital Employee Exposures To COVID-19 Patients

Having patients with COVID-19 in the hospital can be disturbing to the doctors, nurses, and respiratory therapists who take care of them. The good news is that isolation procedures work and proper use of personal protective equipment can dramatically reduce the chance of getting healthcare workers infected. Even though that risk is low, there are certain simple steps you can take that will reduce the risk even further. By taking these steps, you not only reduce healthcare worker exposures but you can also conserve personal protective equipment (masks, gowns, gloves). Here are a few:

  1. Use the right personal protective equipment (PPE) and be sure that it is used correctly.
  2. Minimize blood draws. If you don’t need daily labs, don’t send the nurses in to draw them. When you do get labs, try to cluster all of the lab tests that you need in a single phlebotomy.
  3. To anticoagulant a patient, use oral apixaban, oral rivaroxaban, or subcutaneous enoxaparin instead of a heparin drip. The problem with heparin drips is that you have to do frequent PTT blood tests. Other anticoagulants do not require testing.
  4. Use a sliding scale of subcutaneous insulin rather than an insulin drip. Insulin drips require the nurse to check the patient’s blood glucose every 1-2 hours whereas the SQ insulin sliding scale may only need to be done every 6 hours.
  5. Synchronize medications. Ordering a Q6 hour medication plus a Q8 hour medication means that a nurse has to go into a patient room 7 times a day. If that Q6 hour medication can be stretched out to be given Q8 hours, then a nurse only has to enter a patient’s room 3 times a day. Even better, use medications that only have to be given once a day whenever possible. This is particularly true of empiric antibiotics where there may be multiple equally appropriate antibiotic choices – some that have to be given 3 or 4 times a day and some that only have to be administered once a day.
  6. Use meter dose inhalers instead of nebulizer treatments. Nebulizers can result in aerolsolization of viral particles, at least in theory. Meter dose inhalers for bronchodilator treatments reduce the amount of time that a respiratory therapist has to be in a room to deliver a bronchodilator treatment.
  7. Have patients self-administer meter dose inhalers (or nebulizer treatments). The respiratory therapist can often observe the patient from a door window or a video monitor to ensure that the patient uses proper technique.
  8. Minimize the rounding team. If bedside rounds normally consist of the attending physician, a nurse, a resident, and a physician assistant, then reduce that to just the attending physician and just once a day.
  9. Don’t use physical and occupational therapy if you don’t need it. Frequently, admission order sets will include PT and OT for nearly every admission. Only order it if you really need it.
  10. Don’t order tests that you don’t need. “Routine” daily chest x-rays are usually unnecessary.
  11. Don’t order tests that can be done later. If a chest x-ray shows a suspicious pulmonary nodule and a chest CT is recommended for confirmation, that CT can wait a few weeks.
  12. Empiric treatment is OK. If a patient has epigastric pain, rather than ordering an endoscopy right away, give the patient some empiric omeprazole to minimize procedures.
  13. Utilize inpatient telemedicine for consults. There are two ways to do this, by a regular telemedicine visit or by an eVisit.
    1. CPT 99451 is for an eVisit and reimburses at 1.04 RVUs. There has to be an order for the consult and the consultant has to put a note in the medical record. The consultant must document his/her time and it must be > 5 minutes. This is a way to get reimbursed for the so-called “curbside consult”. An example would be “What follow up should occur for the incidental 5 mm pulmonary nodule that was seen on my patient’s CT scan?”
    2. CPT G0425 (30 minutes ), G0426 (50 minutes), and G0427 (70 minutes) are for initial inpatient telemedicine consults. For follow up inpatient consult visits, use CPT G0406 (15 minutes ), Go407 (25 minutes), and G0408 (35 minutes). These codes are based on the amount of time communicating with the patient
  14. Can you run your pumps outside of the patient’s door? continuous infusion pumps are forever alarming or needing infusion rates to be frequently adjusted. If the infusion pumps can be placed outside of a door with the tubing running under the door then the pumps can be adjusted without the nurse having to enter the room.
  15. Eliminate visitors. Visitors can bring COVID with them and many visitors have often had close contact with COVID patients before they were admitted, making them especially high risk. By eliminating visitors, there are fewer members of the public in patient care areas who can infect hospital staff. Furthermore, there are fewer times that the patient’s door is opened and no additional personal protective equipment consumed by the visitors.
  16. Be sure that the healthcare personnel are getting enough rest. When a nurse, RT, or physician works too long of a shift or too many shifts, fatigue can set in and with fatigue brings mistakes. Mistakes with isolation procedures can create infection risks.

March 31, 2020

Categories
Electronic Medical Records Inpatient Practice

Are Verbal Orders A Patient Safety Concern?

Hospitals have a love-hate relationship with verbal orders. On the one hand, they can expedite care to the patient and can save physicians time. On the other hand, they can increase medical errors. Some groups believe strongly that the goal should be to have zero verbal orders whereas others believe that there should be no barriers to verbal orders. Electronic medical records have reduced the use of verbal orders in some situations but promoted the use of verbal orders in others.

The Joint Commission, the Leapfrog Group, the Institute of Medicine, and the Institute for Safe Medical Practice have all called for reducing or eliminating verbal orders. Nursing groups often see verbal orders as dangerous because of the risk that a verbal order error will place nurses in a position of liability. The Health Systems Management Society that determines best practices in hospital medical record keeping has set a goal that verbal orders should be < 10% of a hospital’s total inpatient orders and < 5% of a hospital’s total outpatient orders.  The literature is rife with anecdotes of the nurse who thought a doctor said to give a patient 10 mg of Viagra when the doctor actually said to give 10 mg of Allegra. The reality is that verbal orders can both improve patient safety and worsen patient safety.

Electronic medical records have reduced verbal orders

Much of the literature on verbal orders is from a pre-electronic medical record era. 15 years ago, most hospital orders were written in the patient’s paper chart that was kept in a nursing station. For a physician to place an order, that physician had to go to the nursing station hand write the order. If the doctor was out of the hospital or was on a different floor of the hospital, then entering an order was not possible and verbal orders proliferated. A bad phone connection, a doctor with a foreign accent, or a lot of background noise in the nursing station helped to foster mistakes. Although physicians had to eventually sign those orders, signing often didn’t happen until weeks after the patient was discharged when the patient’s chart was flagged by the medical record department as containing an unsigned order. Every physician who practiced in the 1990’s can remember weekly trips to the medical record department where each physician would have a stack of discharged patient charts requiring signatures.

Pharmacy orders were a particular problem. In the by-gone era of the physician’s prescription pad, a hand written prescription was given to patients at the time of an office visit or when being discharged from the hospital. But if that patient called in with an acute illness or needed a prescription refill, then the doctor had to call the pharmacy to give the pharmacist a verbal order for a medication. On nights that I was on-call, I would almost always have to phone in a verbal prescription to a pharmacy for a patient needing an antibiotic or an asthma inhaler; the options were either a hand-written prescription or a verbal order.

With the advent of electronic medical records, a physician no longer had to be physically in a specific nursing station to place an order. Doctors could now access the patient’s chart from a computer located anywhere and can even place orders from an app on their phone. I have not hand-written a prescription on a prescription pad in years. Even when I am on call, I find it easier and faster to send in a prescription by computer or by an app on my phone than to call a pharmacy (and be put on hold for several minutes). It is now easier than ever before to place an order electronically and this has reduced the need for verbal orders.

When verbal orders are a good thing

There are times when a physician simply cannot safely place an order in the electronic medical record. For example, the surgeon who is scrubbed in the middle of an operation cannot break scrub to place an order for the nurse to give the patient a fluid bolus. The family physician who is at a restaurant having dinner and gets a call from a patient with bronchitis cannot easily walk away from the restaurant, drive home, get on a computer to access the electronic medical record, and then send an electronic order for an antibiotic to the patient’s pharmacy. When a physician is driving to work in the morning is called from the ICU about a patient who is seizing, that patient needs to receive a dose of lorazepam immediately and not 15 minutes later when the doctor has access to a computer to place the order.

The reality is that most hospital locations have to use verbal orders some of the time in order to ensure timely care of patients. But there are some areas where a higher percentage of verbal orders (> 10% of the total) is more necessary than other areas:

  1. Operating rooms
  2. Intensive care units
  3. Cardiac catheterization labs
  4. Endoscopy labs
  5. Dialysis units
  6. Cardiac echo labs
  7. Emergency departments
  8. Radiology areas
  9. Patient emergencies anywhere in the hospital

When verbal orders are a bad thing

Although electronic medical records are ubiquitous today, most hospitals have only adopted them in the past 10 years. Consequently, there are many physicians who are still unfamiliar with the use of electronic medical records. Probably every hospital in the country has that doctor who still has not figured out how to place an order in the electronic medical record and gives all of his/her orders as verbal orders to a nurse. As younger, more computer literate physicians replace older, less computer literate physicians, this will be less of a problem in the future.

It can take time for a physician to enter orders in the computer and having someone else do it for you can improve your efficiency and allow you to spend more time actually talking to the patient. Consequently, many physicians like having a nurse that they can dictate orders to follow them around in the clinic or during hospital rounds, entering those orders into the computer as the doctor goes from one room to the next. This is an expensive use of a nurse and most physicians in small private group practices realize that it is financially untenable. However, hospitals have to court certain specialties, particularly surgical specialties, to keep them from moving their practice to another hospital in town. So, hospitals are often willing to provide an order scribe to the surgeon who brings a lot of high value surgical procedures to the hospital’s operating room. They know that they stand to make more from the surgeries than they will lose in the cost of the nurse to do order entry. The hospital can stand to ignore the hospitalist who says “Let me give verbal orders or I will leave” but cannot ignore the joint replacement surgeon or neurosurgeon who says the same thing.

There are situations when orders are generally not emergent and the risk of a medical error from an incorrect verbal order is just too great:

  1. Chemotherapy orders
  2. “Do not resuscitate” orders
  3. Orders for narcotics when the nurse/pharmacist cannot confirm that the person calling in the order is actually the doctor

Minimizing the risks of verbal orders

Given that the use of verbal orders is beneficial to patient care in certain situations and essential to patient care in others, complete elimination of verbal orders is neither practical nor possible. However, there are certain steps that the hospital can take to reduce the chances of verbal order errors:

  1. Use “read-back” of the order by the nurse or pharmacist so that the physician can confirm that what he/she actually said was what the nurse or pharmacist heard.
  2. Avoid using abbreviations. “QID” can sound too much like “QD” on the phone. Saying “K” for potassium can be confused for vitamin K.
  3. Beware of “sound alike” medications. It is easy to mistake “Tramadol” for “Toradol” or “clonidine” for “Klonopin”.
  4. Keep the noise down. A lot of people talking loudly in the nursing station makes it harder for the nurse taking a verbal order to hear that order correctly.
  5. Beware of accents. Regional American accents, foreign accents, and speech impediments can make it difficult for the nurse or pharmacist to understand the doctor accurately.
  6. If it doesn’t make sense, confirm it. If the ER physician tells a nurse to do a pregnancy test on the patient in bay 5 and the nurse walks in to find that the patient in bay 5 is a 70-year old named Joesph Smith, then it is best to double check with the doctor before asking for a urine sample.

Despite what some would have us believe, verbal orders are not inherently evil. However, they can create vulnerability from both a patient safety and medical-legal standpoint. Hospitals do need to regularly monitor for judicious use of verbal orders.

February 22, 2020

Categories
Emergency Department Inpatient Practice Outpatient Practice

Suicide Risk Assessment

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

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

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

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

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

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

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

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

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

There are other risk factors to consider as well:

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

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

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

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

November 9, 2019

Categories
Inpatient Practice Medical Economics

The Confusion About Medicare’s Two 3-Day Rules

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

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

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

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

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

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

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

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

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

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

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

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

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

July 13, 2019

Categories
Hospital Finances Inpatient Practice

Every Hospital With More Than 150 Beds Should Be A Trauma Center

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

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

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

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

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

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

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

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

June 16, 2019