Inpatient Practice Outpatient Practice

Influenza Always Gets The Last Word

I am on this earth because of influenza. This is the 100th year anniversary of the influenza epidemic of 1918 that infected 1/3 of the word’s population and killed 1 out of every 10 people infected. One of those people was my grandmother’s first husband. She was a nurse at a hospital in Durham, North Carolina and after her husband’s death, she met a physician fresh out of medical school, my grandfather. So, if the influenza epidemic had not have occurred, she and my grandfather would never have married and I never would have been born.

All told in 1918, 675,000 Americans died of influenza; that works out to 1 out of every 150 citizens. It was particularly lethal for young persons with the result that the U.S. life expectancy dropped from 49 years to 37 years for men and from 54 years to 42 years for women. The influenza strain that swept the world in 1918 was H1N1, the same strain that caused the 2009 pandemic of influenza that also seemed to preferentially kill young adults.

In 2009, 12,000 people in the United States and a half million people worldwide died of influenza. The problem in 2009 was that the strain of H1N1 that emerged was one that had not circulated in humans for decades – about 1/3 of people over age 65 years had antibodies to it from past infection but few young adults had ever been exposed to H1N1 and thus few young people had any immunity at all. Most years, 80% of influenza deaths are in people over age 65 but in 2009, 80% of deaths were in people under age 65. The H1N1 pandemic was therefore notable not for the total number of deaths (which was actually rather low) but for the fact that most of the deaths occurred in young adults. Even in non-pandemic years, influenza kills thousands of Americans. For example, last year, the CDC estimates that 80,000 Americans died of influenza and its complications, the most deaths in 4 decades.

As of December 22, 2018, the epidemiology of this influenza season (red line in this graph from the CDC) is falling in-between that of the 2016-2017 season and the 2017-2018 season. Most of the influenza being seen this year is once again the influenza A H1N1 strain with a smattering of H3N2 and influenza B. The flu claimed its first celebrity of the season this week when 26-year-old Fox News commentator, Bre Payton, died the day after developing influenza.

Yet still there are people who fear influenza vaccinations and refuse to get a simple and inexpensive flu shot that can save their lives. Here are some of the reasons for not getting a flu shot that I hear from my own patients:

  1. “I always get the flu every time I get a flu shot.” It is impossible to get the flu from a flu shot as there is no live virus in the vaccine. You are no more likely to get the flu from a flu shot as you are to get pregnant from taking a birth control pill. Yet nevertheless, more than half of parents believe that their child can contract the flu from a vaccine.
  2. “I don’t need a flu shot because I never get the flu.” This is like saying that you don’t need to wear a seatbelt because you’ve never been in a car accident. These people probably have had the flu but just didn’t realize it and attributed their symptoms to a cold or other illness. No human in innately immune from influenza. If you inhale a bunch of influenza viruses, then you are going to get the flu.
  3. “I don’t want a flu shot because it causes autism.” Yes, and the earth is flat, unicorns are real, and the tooth fairy plays poker with Elvis and the Easter bunny every Saturday night. Conspiracy theorists love this one. 20 years ago, in 1998, Andrew Wakefield published a paper in the journal, The Lancet, suggesting that the measles, mumps, and rubella vaccine was linked to childhood developmental disturbances. It turned out that Wakefield was funded by attorneys who were suing the vaccine manufacturer for allegedly causing autism. Wakefield was later found guilty of fraud, he lost his license to practice medicine, and the journal retracted his article. But the myth lived on and in 2005, journalist David Kirby published the book Evidence of Harm – Mercury in Vaccines and the Autism Epidemic: A Medical Controversy that alleged that thimerosal in vaccines causes autism. That same year, class action attorney Robert F. Kennedy, Jr. wrote an article in the Huffington Post making the same allegation (presumably setting himself up to win the mother of all class action lawsuits). Celebrities bought into this, most notably actor Charlie Sheen and former Playboy playmate, Jenny McCarthy, who have become the voices of anti-vaccine activism. Most influenza vaccines do not contain any thimerosal (the preservative that contains mercury). Even those that do contain thimerosal have the same amount of mercury as is in about 4 oz of canned tuna HOWEVER, thimerosal is broken down in our bodies as ethylmercury whereas fish contains methylmercury – ethylmercury is relatively harmless compared to methylmercury. The science is very strong: vaccines do not cause autism.
  4. “I don’t need a flu shot because last year I got one and still got the flu.” Yes, it is true that influenza vaccines are not 100% effective in preventing the flu. However, by creating protective antibodies against influenza, your body will be able to fight it off better so that even if you get the flu, it will be a milder case and you will be less likely to die. A study this year by the CDC found that patients who were admitted to the hospital with influenza and had gotten a flu shot spent four fewer days in the hospital, were 37% less likely to be admitted to the ICU, and were 2-5 times less likely to die compared to those patients who had not received a flu shot.
  5. “If I go outside in the cold and wet air, I’ll get the flu whether or not I get a flu shot.” Influenza is not an environmental microorganism, it lives in people and is transmitted by people. You cannot get the flu (or a common cold) by going outside when the temperature is low or when it is raining. In fact, if you spent all of your time outdoors in flu season, you’d be less likely to get influenza than if you are inside a building in close contact with other people who have the flu.
  6. “I always wait until December to get my flu shot so that it will kick in when the flu seasons hits.” Although it is true that antibody levels will peak several weeks after getting an influenza vaccine, a person cannot predict when they are going to be exposed to the virus in any given year. Getting a flu shot on Monday will not do much good if you are exposed to influenza on Wednesday. A person is better off getting the vaccine as early as possible in the flu season, ideally before the end of October. That being said, it is not too late to get vaccinated, even in January or February, as influenza usually continues to circulate in the United States until March or April each year.
  7. “I don’t want to get a flu shot because I might be pregnant.” If I only had one dose of the flu vaccine in my office, I would save it for a pregnant woman. There is no risk to vaccinating pregnant women and in fact, in the H1N1 pandemic of 2009, pregnant women were among those who were most likely to die when infected with the virus.
  8. “I don’t want a flu shot because I might get Guillian-Barré syndrome.” Every year, 3,000 – 6,000 Americans get Guillian-Barré syndrome (GBS) but every year, 10,000,000 – 50,000,000 Americans get influenza. The vast majority of GBS is not related at all to influenza. However, in 1976, the swine flu vaccine did have an increase risk of GBS with the result that one out of every 10,000 people vaccinated developed GBS. Since that time, the increase in GBS has been about 1 case for every 1 million influenza vaccines. The mortality rate of GBS is 2.8% and the mortality rate of influenza is about 0.16%. If you do the math, there are about 150 influenza vaccine-related cases of GBS in the U.S. each year with about 4 of these patients dying. Therefore, you are about 10,000 times more likely to die of influenza if you are not vaccinated than you are to die of GBS if you are vaccinated. As a general rule, I am not a gambler but I’l take the 10,000:1 odds any day.
  9. “I can’t take the flu shot because I’m allergic to eggs.” Because many influenza vaccines are grown in eggs, these vaccines can contain a tiny amount of egg protein. Nevertheless, the CDC recommends that people with egg allergies should still get influenza vaccinations. Patients with anaphylaxis from eggs should be observed in a medical setting after getting a flu shot. However, studies of over 500 patients with anaphylaxis from eggs and who received influenza vaccines found that none of these people developed a serious reaction from the vaccine. People who can eat cooked eggs are very unlikely to have any reaction to influenza vaccines. For those people who are still afraid of the influenza vaccine because of fears of egg allergy, there is a recombinant influenza vaccine (Flublok) that does not contain any egg protein.
  10. “Flu shots are too expensive.” Most insurance plans cover influenza vaccination and if a person without insurance goes to the local pharmacy, that person will pay about $40 to get it out of pocket. On the other hand, we spend about $10 billion per year in the United States on direct costs of flu-related illness and have another $16 billion per year in lost earnings from flu-related illness. That works out to each case of influenza costing about $530. So, instead of looking at the flu shot as costing you $40 each year, look at it as saving you $490 each year.

At the time of writing this blog post, influenza is already widespread in many states. In the next few weeks, my hospital’s nursing units and ICU will be full of patients with influenza-related illness, and some of them will die. Those patients who survive the ICU are always the first ones to ask for a flu shot the next year. But for those who die, like Bre Payton, influenza always gets the last word.

December 29, 2018

Inpatient Practice

Hospital Workplace Violence

Healthcare workers are more tolerant of violence by patients than almost any other occupations would tolerate violence by customers or clients. In fact, according to OSHA, healthcare workers are more than 4 times more likely to experience workplace violence resulting in days off work than private industry. Patients are the source of workplace injuries (80%), followed by patient family members/friends (12%), students (3%), and co-workers (3%).

However, it is estimated that only 50% – 70% of assaults are reported to managers. A 2014 survey of 3,765 nurses found that 21% had been physically assaulted in the preceding 12-months and more than 50% reported being verbally abused in that time period. A 2011 survey of 7,169 emergency department nurses found that 12% of the nurses had experienced physical violence in the preceding 7 days and 59% had reported verbal abuse during those 7 days. Another 2014 study of 762 nurses found that 92% of emergency department nurses had experienced verbal or physical violence in the preceding year with the most common physical incidence being grabbed (56%), scratched (47%), kicked (41%), pinched (40%), shoved (29%), spat on (34%), slapped (18%), punched (17%), hit by a thrown object (16%), urinated on (13%), or bitten (10%).  A 2002 survey of 72,349 healthcare workers at 142 Veterans Administration hospitals found that 13% had been assaulted in the preceding year. Within healthcare, some jobs are at greater risk than other, for example, psychiatric aides are the most likely to sustain violent injury and are 10-times more likely than the next group, nursing assistants who in turn are 4-times more likely than registered nurses.

So why do we tolerate violence that would not be tolerated in any other industry? There are several reasons:

  1. A sense that it is “just part of the job”.
  2. An unwillingness of healthcare workers to stigmatize their patients when the violence may be a reflection of their underlying disease.
  3. An ethical duty to continue to provide care to a patient, even if the patient’s behavior is poses risk of harm to the healthcare worker.

The most common violent injury sustained by health care workers is being hit, kicked, beaten, or shoved. The next most common injury is from unintentional harm when moving the patient.

Health care violence is also very costly. The direct cost at one hospital system for 30 nurses who required treatment for workplace violence over the course of a year was $94,156 ($78,924 for treatment costs and $15,232 for lost wages). But those direct costs are only the tip of the iceberg of total costs. The indirect costs of caregiver fatigue, burnout, and stress can be enormous as these factors have been associated with increased medical errors, lower patient satisfaction, and higher health care worker turnover. As an example, it costs about $65,000 to replace an RN when separation, lost productivity before a replacement is hired, recruitment, hiring, orientation, and training are all considered.

All told, the American Hospital Association analyzed the financial statements of estimates that community and workplace violence costs U.S. hospitals $2.7 billion per year. If only in-facility violence is considered, the cost is about $1.5 billion ($278 million per hospital). When these costs are broken down, they are 31.6% for security staff and infrastructure, 6.5% for staff training, 3.6% for procedure development, 8.7% for staff turnover, 3.4% for disability, 2.0% for absenteeism, and 1.6% for staff medical care.

A workplace violence prevention program can be effective. The key components are:

  1. Hospital management commitment and worker participation
  2. Worksite analysis and hazard identification
  3. Hazard prevention and control
  4. Safety and health training
  5. Record keeping and program evaluation

More specific interventions to the physical environment that can reduce workplace violence can include:

  1. Security alarms placed in strategic hospital locations
  2. Keypad/badge reader access to patient care areas
  3. Improved lighting
  4. Security cameras
  5. Regular patrols by security personnel
  6. Metal detectors at strategic locations (for example, emergency department entrances)
  7. Panic buttons (including mobile panic buttons)
  8. Prohibition of firearms within the hospital (except by law enforcement officers)
  9. Permit nurses and other healthcare workers to choose whether to display just their first name (rather than first and last names) on their ID badges

Staff training is also important and all staff should be trained in de-escalation techniques so that these techniques can be employed proactively when patients begin using threatening language or show signs of agitation. The Crisis Prevention Institute recommends the following 10 de-escalation tips:

  1. Be empathetic and non-judgmental
  2. Respect personal space
  3. Use non-threatening non-verbal body language
  4. Avoid overreacting
  5. Focus on feelings and encourage patients to talk about those feelings
  6. Ignore challenging questions that can escalate into a power struggle
  7. Set limits with clear, simple, and enforceable limits and consequences
  8. Choose wisely what you insist upon – decide which rules are negotiable and which are not
  9. Allow periods of silence for the patient/visitor to reflect on the situation
  10. Allow time for patients to make decisions

There are a number of organizational factors that can reduce hospital workplace violence. Ensure that staffing is adequate, particularly during meals and visiting hours. Avoid crowded waiting rooms and long waiting times for patients. Community disaster drills are done twice a year in most hospitals. But it is also important to do violence response drills, such as active shooter drills. These can be very effective in creating awareness for alarm locations, security support, escape routes, safe room locations, and emergency communication procedures. Above all, hospital leaders must foster the perception that workplace violence is never OK and that the organization takes workplace violence and its prevention seriously.

When faced with patients or their family/friends who are threatening violence or who are actively violent, healthcare personnel should have a low threshold for calling hospital security or police. Security personnel are generally trained in de-escalation techniques as well as ways to restrain patients without harming them. Most hospitals do not arm security personnel with guns but Tasers are becoming more common to use in those situations where a violent patient or visitor is in danger of harming others or themselves. It is not a crime when a patient who is delirious from sepsis kicks a nurse but when an otherwise alert and oriented patient throws something at that nurse or punches that nurse, it may very well be a crime. Some patients have a history of repeated violence or threats of violence; hospitals cannot always deny those patients emergency care but they can facilitate criminal charges against those patients.

When people are sick, injured, or dying, the emotions of these people and their friends/family can become untethered, resulting in physical or verbal violence directed toward others. Because healthcare workers are especially vulnerable to this physical or verbal violence, our hospitals must take steps to prevent and respond to workplace violence, perhaps more so than any other workplace environment.

December 14, 2018

Inpatient Practice Medical Economics

The 2019 Medicare Readmission Penalty

In September, CMS released the financial penalties that hospitals will pay for excessively high percentages of readmissions within 30 days of discharge. This is an annual event when hospitals get to find out how much their reimbursement from Medicare will be cut the next year. CMS focuses on 6 diagnoses when calculating the readmission penalty:

  1. COPD
  2. Coronary artery bypass surgery
  3. Myocardial infarction
  4. Heart failure
  5. Knee and hip replacement surgery
  6. Pneumonia

CMS looks at readmission data from July 2014 through June 2017. The penalties go into effect October 2018 and continue through September 2019. This year, 3,173 hospitals were evaluated and 2,599 (82%) were penalized. Certain classes of hospitals were exempt from evaluation including children’s hospitals, Veterans hospitals, hospitals in the State of Maryland, psychiatric hospitals, and critical access hospitals.

In the past, hospitals that take care of low income patients were penalized more than hospitals that take care of high income patients. For that reason, safety net hospitals and academic hospitals tended to get penalized more highly than other hospitals, in other words, hospitals got penalized for taking care of the poor. CMS overcame some of the limitations of previous years’ penalties by comparing hospitals to other hospitals that have similar patient demographics, rather than comparing all hospitals in the U.S. together. They calculated the number of dual eligible patients (those who have both Medicare and Medicaid) divided by the total number of Medicare patients. Because dual eligible patients are generally lower income than patients with Medicare only, this permitted CMS to compare hospitals that care for similar percentages of low income patients This is an improvement over previous calculations since lower income patients have higher 30-day readmission rates regardless of how good or bad their care was during their initial hospitalization. CMS stratified hospitals into 5 groups based on this calculation. Group 1 had 0-15% dual eligible patients whereas group 5 had 30-100% dual eligible.

The total amount of the penalties for next year is $566,000,000. Hospitals can be penalized a maximum of 3% of their entire Medicare revenues for that fiscal year but nationwide, the average penalty was 0.70%. There are 47 hospitals that incurred the maximum 3% penalty: Texas having the most at 8 hospitals, followed by Louisiana, Missouri, and Kentucky with 4 hospitals each. Here in Central Ohio, our hospitals all did quite well with only minimal penalties:

  1. Dublin Methodist – 0.03%
  2. Ohio State University – 0.06%
  3. Riverside Methodist – 0.17%
  4. Mt. Carmel West – 0.17%
  5. Grant – 0.23%
  6. St. Ann’s – 0.23%
  7. Doctor’s – 0.44%

States that expanded Medicaid have more hospital closures than states that did not expand Medicaid so one might hypothesize that hospitals in Medicaid expansion states would have more financial resources to put into reducing readmissions. So, I spent a few hours with an Excel spreadsheet of the 2019 Medicare penalties for all hospitals in the U.S. and it turns out that there was no difference in the average penalty incurred by hospitals in Medicaid expansion states versus hospitals in non-Medicaid expansion states.

So, overall, next year’s readmission penalties will be more fair than last year’s. But hospitals cannot control everything that a patient does or does not do once they leave the hospital and so the responsibility for fully reducing 30-day readmissions cannot lie solely on the hospitals.

November 24, 2018

Inpatient Practice

Fireproofing Your Physicians Against Burnout

15,000 physicians responded to the annual Medscape Physician Lifestyle Survey. A component of this survey is in the Medscape National Physician Burnout & Depression Report for 2018. Of these 1,500 physicians, 42% reported being burned out. My own specialty of critical care medicine led the way with 48% reporting burnout. Women were more burned out at 48% than men at 38%. Burnout was most common in the 45 – 54 year old age group – this is the age group that normally is the most productive. The most important contributions to burnout were (1) too many bureaucratic tasks, (2) too many hours at work, (3) lack of respect from administrators/colleagues/staff, (4) electronic medical records, and (5) compensation.

Burnout is expensive. When a physician (or nurse) quits, it costs a lot to replace him or her. There is lost productivity while you are waiting for a replacement. There is the cost of recruitment. And then there is the lost productivity while the replacement physician ramps up in productivity. Overall, it costs about $250,000 to replace a physician ($350,00 – $500,000 if that physician is a critical care physician). Then, if you bring a new physician into an environment that is conducive to burnout, then you are just going to lose another physician in short order.

So, how do you fireproof your physicians against burnout? I’ve attended a lot of presentations on burnout and often, they get mired in a lot of psychological generalities, resulting in me drifting off into daydreams about what I’m going to have for dinner and where I’m going to go on my next vacation. Here are some tangible things that we can do to prevent burnout:

  1. Learn to identify it. Every doctor knows that the best way to cure a cancer is to diagnose it in an early stage. The same goes for burnout. But the only way that a medical director is going to recognize burnout early is to interact with the members of the medical staff on a regular basis. That doesn’t mean sitting in your office firing off emails, it means having face to face conversations with each physician. Doctors usually won’t just say, “Hey, I’m burned out”. Instead, they’ll be rude to patients, get angry with the nurses, get behind on their charting, submit their charges to the billing office later, and stop coming to staff meetings.
  2. Make wellness resources available. At the Ohio State University, we have the STAR program (Stress, Trauma, And Resilience) and we also have an Employee Assistance Program. I make sure that our doctors know about these program – with our Employee Assistance Program, physicians (and staff) can meet with counselors without anyone else knowing and at no cost. Wellness programs like these are common in academic medical centers, large hospitals, and governmental hospitals but they are not always available in smaller hospitals or clinics. But almost every hospital has chaplains and social workers who can be utilized for wellness of not just patients, but also doctors.
  3. Look for excuses to pay compliments. Bad things happen in healthcare all of the time. People get sick. Patients die. Families get angry. Medical errors occur. Doctors get sued. We can’t stop all of these things from happening. As physicians, we are faced with life and death decisions every day and we are the often the ones who are most critical of our own medical judgement. This creates a heavy weight on our souls and that weight has to periodically be counter-balanced with some recognition of the good things that we do. When a surgeon comes to the hospital in the middle of the night to operate on a patient with a bowel perforation, send the surgeon and the anesthesiologist an email thanking them. Or if a cardiologist comes in to do a heart cath on a STEMI patient or a gastroenterologist comes in to do an endoscopy on someone with a GI bleed, then thank them the next day. When it comes to being a medical director, compliments are a more powerful tool than money. Ideally, every physician should leave the hospital each day with a sense of accomplishment.
  4. Be willing to be flexible. Maybe the hospitalist who is a new parent wants to reduce their number of shifts for a few months. Maybe the radiologist who is a single parent wants to read x-rays from home on certain days of the week. Maybe your critical care physician wants to be off duty on Friday nights and Saturday to go to Synagogue or be able to have a quiet place with the pager turned off to do Islamic prayers 5 times a day or to be off on Sunday to attend Mass. We all draw great emotional strength from our families, our religions, and our hobbies. Having flexibility with scheduling in order to preserve the ability of our physicians to draw this strength can build resilience.
  5. Yoga (but only for the millennials). There are two ways to get me to run for the door in a committee meeting or workshop: role-playing and yoga. But then, I’m a baby boomer and baby boomers hate doing yoga (or at least doing it in front of one’s peers). But millennials all seem to love yoga and so it can play a fireproofing role for your doctors under age 50. For those of us over age 50, pizza at committee meetings is more effective.
  6. More is not always better. Hospitals and physician group practices are under enormous pressure to increase productivity by seeing more inpatients/ER patients per shift and by scheduling more outpatients per hour. But being a doctor is not like being a mechanical assembly line robot. It is those interpersonal connections that we make with our patients through conversation that build the doctor-patient relationships that makes us feel good about the work that we are doing and drives us to continue on. When doctors feel they don’t have enough time to do a thorough job of caring each patient or enough time to just talk with their patients, then job satisfaction flies out the window. By keeping patient workloads reasonable, the hospital can save money in the long run by reducing physician turnover.
  7. Beware of night shifts. Critical care physicians who work night shifts are more likely to be burned out. These physicians are especially vulnerable because a lot of the usual wellness support resources close up at 5:00 PM. Hospital leaders need to make the effort to stop by the hospital at night to just check in with the night shift physicians and let them know that their work is valued and appreciated. In many physician groups, as physicians get more senior, they do fewer night shifts. I think this is dangerous because it forces younger physicians to do disproportionately more of the night shifts and creates a culture of the night shifts being perceived as something bad, as something less important, and as something to be avoided. The medical director of our emergency department is my age and does night shifts just like any of the other emergency department physicians and I think that is one of the reasons that he is so effective of a leader of his ER doctors.
  8. Women physicians are different than men physicians. That sentence will probably get me into a lot of trouble but nevertheless, women physicians report being burned out much more than men physicians and this is a fact that we cannot ignore. Women also deal with burnout differently. According to the Medscape National Physician Burnout & Depression Report, The most common strategy to fend off burnout for men is exercise but the most common strategy for women is talking with family and friends. Therefore, offering free gym memberships may be effective to fireproof many of your men physicians whereby promoting schedules that are conducive to social functions and family time may be more effective to fireproof many of your women physicians.
  9. Reduce conflict between physicians and nurses. 23% of physicians reported that reduced conflict with nurses/administrators/physicians would lessen their burnout. By promoting interdisciplinary team-based approaches to quality improvement, hospital governance, and nursing unit management, conflict between nurses and physicians can be reduced. But maybe even more important is for medical directors and nursing directors to lead by example; in other words, the medical directors need to publicly show respect and support for the nursing staff and the nursing directors need to publicly show respect and support for the physicians. Over the decades, I’ve too often seen physicians blame the nurses or vice versa when something goes wrong in the hospital. Medical and nursing leaders must rise above the “blame game” and set an example of interdisciplinary respect.
  10. Ensure that non-physician staff are working at the top of their license. What doctors do uniquely best in the hospital is doctoring. But there are a myriad number of other tasks that go into the care of patients that non-doctors can do. Make sure that there are other hospital staff who can line up home healthcare, fill out home oxygen forms, complete FMLA applications, and schedule outpatient appointments. Thirty-four years ago, as an intern, I had to draw all of the blood cultures, do the EKGs, and even transport patients to radiology to get a chest x-ray after 5:00 PM – it is amazing to me that I didn’t go up in flames of burnout back then. Your physicians should spend most of their workday doing physician work.
  11. Make your electronic medical record work for the doctors rather than make the doctors work for the EMR. Electronic medical records were identified as the 4th biggest contribution to burnout in the Medscape survey. It shouldn’t have to be that way because the EMR is just a tool and the purpose of any tool is to make a given task easier to do, whether that tool is a wrench or a garden shovel. Too often, we design our EMRs around meeting governmental regulations and billing requirements first with the physician experience being second. This should really be the other way around and we need to design our EMR software to be as easy to navigate as possible. Hospitals need to put resources into information technology support in the way of 24-hour telephone help lines, periodic EMR optimization education for physicians, and  staff who can do a lot of the basic data entry into the EMR.
  12. Ensure compensation equality. This doesn’t mean that the family physician should make the same salary as the neurosurgeon. But it does mean that there is a compensation plan that is transparent with respect to the rules that go into salary determination. Almost every human being on the planet thinks that they should get paid more for what they do. But most of the time, getting paid more is not as important as knowing that you are getting paid fairly.
  13. Be optimistic. As physician leaders, if we show optimism for the future, it can be infectious. Every doctor has had a department chair, division director, or medical director who seemed like Eeyore from Winnie the Pooh and the Hundred Acre Wood. When physicians know about all of the good things that are happening or are going to happen at the hospital, it can go a long way toward dousing the flames of burnout.
  14. Promote interaction with other physicians. In past years, physicians drank coffee with each other in the physician lounge, ate together in the physician dining room, sat with each other during grand rounds, and spoke face to face about patients as attending and consultant. Now, coffee is usually drank in the nursing stations while staring into a computer monitor, we watch grand rounds remotely over the internet, and consultants leave their recommendations in the electronic medical record. As a consequence, we have less human to human interactions with our colleagues. By having (good quality) coffee and snacks in the physician lounge, doctors will aggregate there. By putting the surgeon’s workroom in the same location as the anesthesiologists’ break room, you can foster communication. Look for ways to create opportunities for physicians to be together in the hospital.
  15. Changes should not come as surprises. Burned out physicians often feel like they are just “another cog in the wheel”. One thing that fosters this feeling is if the physicians feel like the hospital administration is making all of the decisions for the future without involving the physicians. What physician wants to learn from an article in the local newspaper that the hospital is building a new surgical unit or radiation therapy building? By updating and involving the physicians with future plans for the hospital at every step in the planning process, the physicians will feel more engaged – that engagement is one of the chief defenses against burnout.

Burnout among physicians has always been there but it is more prevalent now than ever before and we are more aware of it than ever before. Fortunately, there are tangible things that we can do to make our hospital environments less combustible and thus prevent it.

November 16, 2018

Inpatient Practice

The Cost Of Hospital-Acquired Conditions

This time of the year, all across the country, hospitals are creating scorecards of quality metrics for the upcoming year. But what are the economics of those quality metric choices? It turns out each metric has very different financial implications for the hospital and so there are some metrics that are more cost-effective to achieve than others. Most hospitals focus on hospital-acquired conditions and build their quality goals around reducing these conditions.

Last November, the Agency for Healthcare Research and Quality (AHRQ) published an analysis of the cost of common hospital-acquired conditions. When you study the literature on these costs, you’ll find that there is an enormous range of estimates for each condition in different studies and journal articles. The AHRQ is an agency of the U.S. Department of Health and Human Services and has taken a reasonably thorough and unbiased review of the literature on the cost of these conditions and so their estimates are likely to be at least as accurate as anyone else’s. The findings are summarized in this table, ranked from most expensive to least expensive.

The last cost estimates by the AHRQ was 8 years ago, in 2010 and there has been some fairly substantial changes in the estimates of several of the conditions. Most notably is CAUTI (catheter-associated urinary tract infection) that in 2010 was estimated to incur an additional cost of $1,090 and now is estimated to cost $13,783. Although the cost of most conditions has risen since 2010, the estimated cost of two conditions is now lower than in 2010: the cost of falls is down from $7,888 to $6,694 and the cost of pressure ulcers is down from $18,537 to $14,506.

Improving The Metric Does Not Necessarily Improve The Finances

The first step for a hospital is to accurately track all of these hospital-acquired conditions. The challenge is that for some of these conditions, the “official” definitions by agencies such as the Centers for Disease Control (CDC) are often too broad and can result in defining some patients as having a hospital-acquired condition when the physicians who are actually treating the patients know that their condition is not truly a hospital-acquired condition. For example, failure to document a pre-existing pressure ulcer at the time of hospital admission will count as a hospital-acquired pressure ulcer from a reporting standpoint. Improving the metric by better documenting that pre-existing pressure ulcer does not really save any money.

Thus improving the metric for public reporting purposes will make the Board of Trustees happy and make the public relations department happy but does not necessarily improve the hospital’s financial margin.

Focus On The ICU

The two most expensive hospital-acquired conditions are ventilator-associated pneumonia and CLABSI (central line-associated blood stream infection). Both of these generally occur in the intensive care units. The reasons that these conditions are so expensive is that they significantly increase hospital length of stay (and more specifically/expensively the ICU length of stay), they often result in other complications (such as shock or renal failure), and they cost a lot to treat due to the use of very expensive antibiotics. Simply by reducing 5 cases of these conditions, you can save nearly a quarter of a million dollars a year. Therefore, if the hospital has limited epidemiology resources, it should focus the infection prevention resources on the ICU.

Conditions that often happen in a standard medical/surgical nursing unit, such as falls, CAUTIs, and pressure ulcers, are not as costly. As an example, eliminating 3 urinary tract infections saves less money than eliminating 1 central line infection.

Create A Quality Profit And Loss Statement

Reducing hospital-acquired conditions results in “hidden money”. It is money that adds to the hospital’s end of year profit or margin but usually, you don’t realize where it came from. Moreover, the annual hospital capital budget will not reflect these savings. Therefore, in order to show the true value of reducing hospital-acquired conditions, you need a specialized profit and loss statement.

Lets take a hypothetical hospital that had 30 Clostridium difficile infections in 2016. They decide to purchase ultraviolet light-emitting sterilizing machines with an anticipation of reducing their C diff infections by 40%, or to 18 per year. The total projected savings will be $207,120 per year. They buy 3 UV emitting machines at $100,000 each ($300,000 total initial cost) and then depreciate them over 3 years ($100,000 per year depreciated cost). It takes 1 full-time environmental service worker per day to manage the machines and so to run them 1 shift, 7 days a week, 52 weeks a year, you will need to hire 2 FTE EVS workers at $75,000 (salary + benefits). Therefore the total cost will be $175,000 per year. In the final analysis, you will end up spending $175,000 but you end up saving $32,120 because of the reduction in C diff cases.

By creating a quality metric-specific profit and loss statement, you can identify which conditions are going to be financially most lucrative to improve. This allows you to prioritize those quality metrics for the purposes of hospital quality scorecards.

Recognize That There Is A Limit To What You Can Do

No matter how hard you try, sick patients develop complications and you cannot always avoid them. If a patient has unrecognized homozygous Factor V Leiden and then comes in for an elective hip surgery, then normal deep venous thrombosis prophylaxis measures are probably not going to prevent that patient from getting a DVT. So, there comes a limit when the incidence of a hospital-acquired condition becomes so low that putting incrementally more money into trying to reduce it further is neither practical nor possible.

July 13, 2018

Academic Medicine Inpatient Practice

Setting Achievable Hospital Quality Goals

All across the country, hospital quality departments set goals for the upcoming year. For academic medical centers, that fiscal year is starts July 1st. And every year, at every hospital, those goals are set a little higher and hospital leaders get frustrated when a year from now, those goals are not met. The tactic that should be used to avoid all of this frustration is setting realistic goals.

In an academic medical center, there are all sorts of goals that are set for the physicians to achieve:

  1. Quality goals set by the hospital quality department
  2. Productivity goals set by the practice administrators
  3. Educational goals set by the medical school
  4. Efficiency goals set by the hospital finance department
  5. Research goals set by the department chairmen
  6. Citizenship goals set by the medical directors

For the physician with relatively limited time and emotional energy, all of these various goals compete with each other. The hospital finance department gets frustrated when the physician’s efficiency measured by getting all of the hospital discharges completed by mid-morning is affected by the physician doing too much teaching on rounds. The department chairman gets frustrated when the physician’s research output is affected by the physician spending too much time in the hospital trying to meet RVU targets. And the quality department gets frustrated when the physician is spending too much time in citizenship activities such as attending committee meetings and not focusing on spending more time with individual patients in order to improve patient satisfaction scores.

For the physician who is faced with the expectation of achieving a 75th or 90th percentile for all of these various goals, it is overwhelming and not realistically achievable. It is human nature to direct one’s limited time and energy to those goals that are achievable and then effectively ignore those that are not achievable.

As an example, lets say the quality department sets a quality goal that all physicians will do bedside rounds on every patient 3 times a day and the practice administrator sets a productivity goal of 4,000 wRVUs per year. If a physician currently rounds on every patient once a day and had a productivity of 3,500 wRVUs last year, then to both increase the number of daily visits by 2 additional visits with each patient each day AND increase the wRVUs by 500 in the next year, the only way to achieve both goals is for the physician to work more hours every day (the physician has to bill the patient the same amount whether he/she sees that patient 3 times a day or just once a day). From the physician’s standpoint, he/she will have to choose between meeting the quality department’s goal by increasing the number of daily encounters with each patient by 200% or meeting the practice administrator’s productivity goal by increasing the number of patients that the physician sees by 14%. Given these competing demands, most physicians will choose to go after the wRVU goal and ignore the quality goal because the wRVU goal is more achievable.

So, how should we set quality goals?

  1.  Recognize that most physicians cannot be above average in everything. The physician who wins all of the teaching awards get them because he/she is spending a lot of time doing bedside teaching rather than trying to knock the wRVU targets out of the park.
  2. Expect small annual incremental improvements and evelop long-term, aspirational goals. My favorite NFL team, the Cleveland Browns were winless last season at 0-16. Next year, I’m not expecting them to go to the Super Bowl but I’d be happy with 2 wins next season, 5 the following season, and then make the playoffs in 3 years. Setting long-term goals with incremental increases every year over a several year period is more realistic.
  3. Realize that the physicians can’t go it alone. Increasing productivity may require investing in more outpatient exam rooms per doctor, or geographically locating all of a hospitalist’s patients to one nursing station, or staffing up the case management department to facilitate discharge planning. Achieving higher goals requires giving the physicians the tools they need to meet those goals.
  4. Get the right benchmarks. For example, if you are tracking hospital mortality and are at a large tertiary care medical center that has a high percentage of complex, critically ill patients, then using a crude mortality rate will not be useful because your patients are sicker and have a higher expected death rate than those at a smaller community hospital. In this situation, using the mortality index would be a more appropriate way of comparing how well your hospital is doing in patient mortality. The mortality index adjusts the crude mortality rate by the severity of patient illness. For the tertiary care hospital to achieve the same crude mortality rate as a small community hospital or an orthopedic specialty hospital is unrealistic.
  5. The best theoretic result is not always the best achievable result. In an ideal world, there should be zero hospital-acquired central venous catheter infections. However, that is not going to happen, the bacteria always finds a way in the sickest patients and central lines are mainly used in the sickest patients. Therefore, setting a hospital goal of zero central line associated blood stream infections is not realistically achievable and if every year the doctors and nurses feel demoralized because they could not achieve a goal of zero, staff morale will suffer.
  6. Don’t create a storm of goals. There are 300 different merit-based incentive payment system (MIPS) measures. If you hold your physicians responsible for achieving all of these, their heads will be spinning and they will likely just give up. Focus efforts on a limited number of goals that are of highest priority for the hospital. Five or six goals for each physicians is a good target.
  7. Publicize next year’s goals before the start of next year. This seems so common-sense but many hospitals procrastinate on getting goals finalized and then getting those goals publicized to the physicians on time. A hospital that disseminates the annual quality goals 3 months into the year is doomed to failure since by the time the physicians and hospital staff know what their annual goals are, 25% of the year has already gone by. It would be kind of like a head football coach not telling the other coaches and the players what the game plan is until after the first quarter.
  8. Provide timely regular feedback. If one of the hospital’s quality goals is to reduce readmissions for heart failure patients, then report the 30-day readmission rate on a monthly basis, as soon as the data is available. People usually can’t remember what they did differently 6 months ago, let alone a year ago. Regular and timely feedback allows physicians and hospital staff to determine in real time what is working and what is not working and then adjust behavior and practices accordingly.
  9. Achieving a ranking is not achieving a quality goal. I’m probably going to get into trouble for this one because every hospital focuses on the U.S. News and World Report annual ranking of hospitals. Boards of Trustees, CEOs, Deans, and medical directors all define success as “moving up in the ranking”. It is true that in many situations, a higher national ranking by rating groups such as  U.S. News, Leapfrog, etc. do incorporate quality in the determination of ranking. However, the goal of the hospital should be to get the quality right and not just to get the ranking. Medicine is not like NCAA football where the highest ranked team at the end of the season wins. We win when our patients get the best care for their condition possible. The rankings and awards can come later.
  10. But… set goals that are achievable but not too achievable. To be successful in getting NIH research grants, research scientists know that they have to have half of the work already done before they submit a grant so that achieving the goals of the grant (and continuation of funding) is assured. Similarly, it is human nature for hospital leaders to choose goals that they know that they can achieve so that they are assured of looking good at the end of the year. For example, if I, as a medical director, set a quality goal of reducing Clostridium difficile infections by 20% next year and I know that the hospital just purchased an expensive ultraviolet light C diff decontamination system that the literature says reduces C diff rates by 50%, then at the end of the year, my quality goal scorecard is going to look great – it is like benefitting by insider trading.

The hospitals’ ultimate goal is to match the healthcare resources of the hospital to the healthcare needs of the community in a way that maximally benefits the patients. In most situations, a hospital cannot change overnight to perfectly match these needs and the alignment of hospital resources with community healthcare needs is a long-term journey. Setting achievable quality goals is a critical part of this journey.

July 11, 2018


Hospital Finances Inpatient Practice

Avoiding The “Observation Status” Trap For Surgical Admissions

Some surgical procedures require a patient to be in what is called “inpatient status” or else Medicare will not pay for the surgery. These are so-called Medicare inpatient only procedures. But Medicare specifies that many other surgeries can only be done as an outpatient, unless there are extenuating circumstances. In my last post, I discussed how surgeries done as an outpatient or “observation status” result in the cost of hospitalization being transferred to the patient rather than being paid for by Medicare or insurance companies. The differences are summarized in the table below:

From this table, you can see that Medicare (or the commercial insurance company) is highly motivated to have patients classified as being in outpatient or observation status since Medicare will not have to cover as much of the cost of hospitalization. Instead, either the patient has to cover the rest of the costs or the hospital just does not get paid for those costs. For surgical procedures such as a knee replacement, this has enormous implications for the patient: first, the patient is going to have a huge out of pocket cost and second, the patient is not able to go to a nursing facility for rehabilitation after the surgery. Knee replacement surgery was considered an inpatient surgical procedure in the past but now, it is considered an outpatient procedure unless there are other conditions that would require it to be done as an inpatient.

For patients who are otherwise healthy, it is very possible for the knee replacement to be done as an outpatient with perhaps a 1-night stay in the hospital for observation. These patients will have to pay more out of pocket but can still be cared for safely without being formally admitted to the hospital. But for other patients, particularly those with compounding medical conditions, it is unsafe to perform knee replacement as an outpatient and instead, these patients should be admitted to the hospital. The problem is that Medicare requires the decision about whether the surgery will be done as an outpatient or inpatient procedure to be made before the surgery, or at the latest, before the patient leaves the operating room. And if the surgeon decides that the surgery needs to be done as an inpatient and then Medicare audits the patient’s medical record after the fact and determines that the surgery could have been done as an outpatient, then Medicare can deny the charges and the hospital takes a huge financial loss on that surgery. In order to justify a surgery being done as an inpatient versus an outpatient, the surgeon and the hospital have two layers of defense: (1) the pre-admission testing evaluation and (2) the hospital’s “physician advisors”.

The pre-admission testing evaluation is typically done by an internist or anesthesiologist. Increasingly, nurse practitioners or physician assistants are employed in this setting, generally with back-up by a physician. Patients are sent to the pre-admission testing area after the decision to perform a surgery (such as a knee replacement) so that all of the patient’s medical conditions can be identified and post-operative complications can be anticipated. Some medical problems will be determined to be “optimized” and not pose a barrier to doing surgery, other medical problems will be determined to require subspecialty consultation for optimization before surgery, and other medical problems may be determined to be dangerous enough that surgery cannot be safely performed. This preoperative medical evaluation is beneficial to the surgeon who is often not trained or as experienced in the management of complex chronic medical conditions and is beneficial to the patient by making their care safer. During the pre-admission testing process, medical conditions may be identified that would make performing the surgery as an outpatient unsafe and documenting these co-morbid conditions can justify doing the surgery as an inpatient. Some of the more important to identify include:

  1. Known or suspected obstructive sleep apnea. These patients can develop worsened apnea after surgery due to the effects of opioid medications used to control post-operative pain. In some situations, this can be life-threatening. These patients often need to stay in the hospital for more than just one night for telemetry and/or oxygen saturation monitoring while sleeping. Often they may also require non-invasive ventilation (eg, BiPAP) in the post-operative period.
  2. Heart failure. These patients can worsen due to the effects of intravenous fluids used during surgery and anesthesia and often need titration of diuretics in the post-operative period requiring them to be in the hospital for more than 1 night.
  3. COPD. There are several reasons why patients with chronic obstructive pulmonary disease may need to spend more than 1 night in the hospital after surgery: they may require additional bronchodilators due to post-operative bronchospasm, they may require “pulmonary toilet” and incentive spirometry by a respiratory therapist, and they can develop potentially life-threatening carbon dioxide retention from opioid medications used to control post-operative pain.
  4. Diabetes. If a patient has difficult to control diabetes (for example, a pre-operative hemoglobin A1C of > 8.5) or requires insulin to control their diabetes, there can be wide swings in their blood sugar levels post-operatively due to going all day without eating on the day of surgery, having nausea/vomiting after surgery, or having their blood sugars fluctuate due to the physiologic stress of the surgery.
  5. Morbid obesity. These patients often have reduced mobility and may require additional physical therapy before they can be safely discharged home.
  6. Old age. Older patients are often more susceptible to medications and need lower doses and more careful dose titration after surgery. This can often require additional days in the hospital. There is not a fixed age before which the risk is low and above which the risk suddenly goes up but a 90-year old is at higher risk than an 80-year old who in turn is at higher risk than a 70-year old.
  7. Chronic kidney disease. These patients can require longer hospitalization because medication doses may need to be more carefully adjusted, they are more prone to fluid retention from the fluids given during surgery, and they are at higher risk of their kidney function worsening due to surgery or medications. This is especially true for patients on dialysis.
  8. Chronic liver disease. These patients are analogous to the patients with chronic kidney disease.
  9. Previous complications from anesthesia. If patients had post-operative complications from anesthesia in the past, they are at risk for having them in the future and this can result in longer hospital stays.
  10. Risks for excessive bleeding. This could be because of the requirement for long-term anticoagulation or because the patient has a disease that results in easy bleeding.
  11. Anemia. Even the best surgeon will have some blood loss during surgery and if a patient has baseline anemia, then they are at higher risk for requiring post-operative blood transfusion which can prolong the hospital stay. Anemia is an independent risk factor for re-admission to the hospital.
  12. Infection. If there is pre-existing infection (such as an infected joint), then the patient may require additional time in the hospital in order to receive antibiotics and to ensure that sepsis does not develop.
  13. Cognitive dysfunction. Patients with previous stroke, a history of “sundowning” when in the hospital, dementia, or other causes of impaired memory are more likely to have worsening of their memory problems after anesthesia and after medications used to control post-operative pain. Premature discharge to home can put the patient at risk of harm if their mental function is not given sufficient time to return to baseline.
  14. Fall risk. Patients with neuromuscular disease, vertigo, visual impairment, or significant arthritis in other joints often require additional physical therapy before they can be safely discharged home.
  15. Inadequate social support. Patients who live alone or in a residence where navigating stairs on a daily basis is necessary also often need additional physical therapy before they can be safely discharged home.

Before the hospital sends the final bill to Medicare for a surgery, such as a knee replacement, the hospital will want an additional level of assurance that the patient did, in fact, need to be an inpatient rather than an outpatient. This is especially true if the order for inpatient admission was made at the time of the surgery but the patient ended up only spending 1 night in the hospital post-operatively. These 1-night inpatient hospital stays are a red flag for Medicare auditors and they are at high risk of being subsequently denied by Medicare, resulting in a huge financial loss for the hospital. This is where the role of the “physician advisor” comes in. The physician advisor will typically review the chart either after the surgery but before the patient is discharged or (more commonly) after the patient is discharged. The physician advisor then becomes a (theoretically) impartial third party who can confirm that the patient did indeed need to be an inpatient. The physician advisor then reports back to the hospital billing department (and usually also to the surgeon) whether he/she agrees with the inpatient designation. In event of a Medicare audit, the documentation by the physician advisor can help the hospital defend the decision to make the patient an inpatient rather than being in outpatient or observation status. As a physician advisor myself, here are some of the things I look for:

  1. Were there pre-operative conditions that would require the surgeon to anticipate that the patient would likely need to be an inpatient? This equates to the anticipation that the patient would need to be in the hospital for at least 2 nights after surgery. The two places to most easily find this documentation is in the surgeon’s history and physical examination or in the pre-admission testing evaluation. Often the pre-admission testing evaluation will have additional details about the co-existent medical problems that can help to justify inpatient status for the surgical procedure.
  2. Were there complications at the time of surgery that would have required the patient to be an inpatient? This could take the form of intraoperative cardiac arrhythmia, witnessed sleep apnea that was previously not diagnosed, excessive bleeding, etc. The surgeon’s operative note and the anesthesiologist’s note often have this type of documentation.
  3. Did the patient recover more quickly than expected? In a presentation by our Medicare carrier’s Medical Director, the phrase that we, as physician advisors, were told to use in this situation is: “The patient had unexpectedly rapid recovery”. This is particularly relevant to those patients who had an inpatient order but only spent 1 night in the hospital after surgery. In the opinion documented by the physician advisor for the hospital’s billing office, this phrase is a key component.

Outpatient knee replacement surgery can create a lot of unhappiness. The patient is unhappy because he/she has to pay a lot more out of pocket. The hospital is unhappy because they won’t get paid as much. The patient may be unhappy because he/she is not able to go to a SNF for additional rehabilitation after hospitalization. And the surgeon is unhappy because his/her patient is unhappy.

The strategy to avoid all of this unhappiness is to appropriately designate those patients as being inpatient who justifiably should have their surgery performed as an inpatient. Although this adds additional layers of administrative cost and additional pre-operative consultation visits, it can be worth it to the patient, the surgeon, and the hospital.

June 8, 2018

Inpatient Practice Medical Economics

The High Cost Of Observation Status

Medicare and commercial insurance companies love observation status. When a patient has to be hospitalized but only for “less than 2 midnights hospital stay”, then that patient is classified as being in observation status rather than admitted to the hospital. This classification means that the patient is technically an outpatient and not an inpatient and therefore the cost to Medicare is considerably less. Medicare uses this as a way to control the high cost of health care. But is it really less expensive when you look at the big picture?

To understand observation status, you have to understand the difference between Medicare Part A and Part B:

  1. Part A – covers inpatient care, skilled nursing care, home health care, and hospice care. Part A has no co-pay.
  2. Part B – covers outpatient medical and surgical care, emergency department care, durable medical equipment, and physician charges. Part B has a 20% co-pay.

So, if a person is in observation status, then Medicare Part A does not cover the bills, instead, Part B does. From the patient’s standpoint, this is a critical distinction because if that patient is considered an inpatient, then Part A covers the inpatient charges, including medication costs, with no co-pay. On the other hand, if that patient is considered to be in observation status (i.e., an outpatient), then Part B covers it but the patient is billed a co-pay and importantly, the patient is also billed the medication costs.

If you read the Medicare website, it sounds like the decision about whether a patient is considered as observation or inpatient is the hospital’s decision but this really could not be farther from the truth. The Medicare website states: Your hospital status (whether the hospital considers you an “inpatient” or “outpatient”) affects how much you pay for hospital services. But the hospital is not really the one making the decision about inpatient or outpatient. Medicare has very strict rules about what they consider to be criteria for inpatient status versus observation status. If the hospital believes that the patient should be inpatient status, and bills Medicare Part A, then Medicare can audit that patient’s chart and if they determine that the patient should have really been in observation status by their definition, then Medicare will ask for the Part A money back and in some cases can even fine the hospital for “fraudulent” billing. Moreover, if the patient has already been discharged then the hospital cannot bill the patient for their Part B co-pay or for the cost of the medications that the patient received due to the “MOON” regulations. In other words, if the hospital bills the patient as an inpatient but Medicare does not agree, then the hospital loses a boatload of money on that patient. Therefore, the hospital really, really wants that patient to be in inpatient status and not in observation status but risks not getting paid at all if Medicare disagrees with the inpatient status decision.

Another key difference between observation status and inpatient status is that there is a weird rule in Medicare that a patient has to be an inpatient for 3 days before being discharged to a skilled nursing facility for Medicare to pay for that nursing home charge. If the patient is in observation status, then the hospital cannot discharge the patient to a nursing home and instead has to discharge the patient to their regular home.

The reason Medicare and commercial insurance companies like observation status so much is because they don’t have to pay the hospital as much. But the costs do not go away, they are just transferred to the patient, instead. Many patients are shocked when they were sick enough that they needed to be hospitalized but then get an enormous bill for a 20% co-pay for all of their costs plus a bill for all of the medications that they received when they were in the hospital. These additional co-pays and medication bills require additional layers of administrative costs on the part of the hospital in order to bill and collect and can also be both costly and confusing to the patient.

So, from the patient’s perspective and from the hospital’s perspective. it is better to be an inpatient than to be in observation status. But from Medicare and insurance companies’ perspective, it is better to be in observation status than inpatient status. This has resulted in the hospitals becoming a battle ground for deciding who is an inpatient and who is in observation status.

The most recent victim of this battle is the knee replacement. in the past, knee replacement surgery was considered an inpatient procedure but recently, Medicare has classified knee replacement as an outpatient surgery. But almost no one goes home the same day that they have a knee replacement – those patients need physical therapy, need to recover from general anesthesia, and need to have their pain managed. The result is that almost all patients spend at least one night in the hospital after a knee replacement.

But Medicare will allow for a knee replacement surgery to be billed as an inpatient if the physicians and the hospital can document extenuating circumstances why that particular patient needs to be an inpatient (in other words, why that patient is expected to spend more than 2 midnights in the hospital). These extenuating circumstances are usually co-morbid medical diseases, like sleep apnea, heart failure, insulin-dependent diabetes, etc. But the catch is that these conditions need to be documented in the patient’s chart before surgery because Medicare rules require the decision about whether an order for inpatient admission to be made before or at the time of surgery. This generally means that the patient has to go to a “pre-admission testing evaluation” by a physician, nurse practitioner, or physician assistant where these medical illnesses can be laid out in a way that justifies the surgery taking place as an inpatient procedure.

Furthermore, the hospital has to employ a “physician advisor” who can then review the chart and confirm that the patient actually meets the requirements for inpatient status. The physician advisor must then document his/her opinion about whether the patient really needed to be an inpatient or not and also document their reasoning why so that the hospital has documentation to submit to Medicare auditors in the event that the patient’s admission is denied by Medicare. Many smaller hospitals cannot afford to have a group of their own physicians who are trained in the nuances of inpatient versus observation status and be on-hand for 24 hour decision-making so they will contract with an external physician advisor company such as EHR (Executive Health Resources) who they will pay to have physicians who can review the patient’s chart and offer a determination about whether or not the patient should be inpatient or observation status.

In the final analysis, Medicare and insurance companies pay less for observation status, the hospital has to add an expensive layer of administrative costs, and the patient is personally responsible for more of the costs. The net effect is more total societal costs to deliver health care but lower costs directly paid by Medicare.

So, does observation status reduce healthcare costs? The sad answer is no. It actually adds administrative costs and transfers those costs back to the patient or to the hospital.

June 3, 2018

Emergency Department Inpatient Practice

When It Comes To Opioid Overdose, Be A Pupil Of The Pupils

Last week in Kearney, Nebraska, the state patrol seized 120 pounds of fentanyl during a routine traffic stop. Let me put that in perspective. I use fentanyl to sedate patients undergoing bronchoscopy and 120 pounds of fentanyl would be enough to do a half a million bronchoscopies.

Fentanyl is about 25-50 times stronger than heroin and typically gets into the United States through the regular mail from producers in places like China where it can be ordered on-line over the internet. Like most American cities, Columbus has been flooded with fentanyl and its cousin, carfentanil, which is about 100 times more potent than fentanyl and is often mixed in with other drugs, such as heroin. The result is that the potency of street drugs is often unpredictable and it is easier than ever before to overdose. In fact, here in Columbus, we average 1-2 overdose deaths per day. Nationwide, about 64,000 Americans die of drug overdose every year. That’s more than the number of Americans who died in the entire 20 years of the Vietnam War. It is the 8th leading cause of death in the United States. Many people who overdose on opioids die before anyone can help them but increasingly, our first responders and emergency departments encounter patients when they are unconscious but still alive.

But overdoses don’t just happen in the streets, they increasingly happen in our hospitals. When my pager goes off with a message: “Code blue, outside the front entrance to the hospital” or “Code blue, room XXX, visitor”, then more times than not, it will be an opioid overdose, often with a needle still in the person’s arm.

Given the ubiquity of opioid overdose, it is now necessary for all physicians to be able to rapidly assess an unresponsive person and determine if they likely took an overdose of an opioid because if so, then immediate administration of the drug naloxone can be life-saving. One of the most important clues is to look at the pupils.

In an overdose, the pupils will be tiny and constricted. Although there are other conditions that can cause pinpoint pupils (Horner’s syndrome, cerebral hemorrhage, prescription eye drops, etc.), opioid overdose is at the top of the list, particularly if both pupils are constricted equally. Normal-sized pupils do not entirely rule out opioid overdose because if a person is simultaneously taking another drug that can cause pupil dilation, then the pupils may appear normal in size.

On the other hand, if an unconscious person has dilated pupils, then think about alcohol intoxication. Other things that can cause dilated pupils include prescription medications (decongestants, antihistamines, anti-epileptic drugs, tricyclic antidepressants, Sinemet, etc.), certain street drugs (amphetamines, cocaine, LSD), cerebral edema, or previous eye injury.

The reason that rapid diagnosis of opioid overdose is so important is that intranasal naloxone can save the person’s life. Naloxone can be administered to the nose in two ways – either a pre-prepared intranasal device containing naloxone (sold under the brand name Narcan) or by attaching a spray adaptor to the end of a syringe containing naloxone. The former is more expensive but more convenient, the latter is less expensive but less convenient.

So, when faced with an unexpectedly unconscious and or not-breathing patient, be a pupil of the pupils.

May 30, 2018

Inpatient Practice

The Cost Of Measuring Quality

Quality is expensive. In the United States, we spend about $40,000 per physician just to report on quality measures. That’ $15.4 billion per year. A study by Dr. Catherine MacLean and colleagues found that of the 86 MIPPS/QPP measures (Merit-based Incentive Payment System/Quality Payment Program) that were relevant to general internal medicine, 35% were not valid and 28% were of uncertain validity. In other words the measures fell into the categories of either “sounds good but no data” or “sounds good but the data refutes it”.

When we define value in medicine, we often use the equation: value = (quality ÷ cost). Therefore, to assess value, you have to be able to measure both quality and cost. Measuring cost is relatively easy but measuring quality is not. So, we’ve put in place a number of measurable markers of quality, or at least what we think are markers of quality.

This week, I met with the Medical Director of one of the Medicare Carriers and I asked him about Dr. MacLean’s study. What he told me was that Medicare created the MIPPS/QPP measures based on recommendations by the various physician professional societies. So then, who do physicians have to blame for all of these measures? The answer is… ourselves. It was our professional societies that created these measures. As the comic strip character Pogo once said: “We have met the enemy and they is us.”

The problem is that measuring quality is not cheap. A recent study published in Health Affairs estimates that United States physician practices spend $15.1 billion to report quality every year. In all, physicians and their staff spend 15.1 hours per physician per week on quality. This includes collecting data, recording it in the medical record, and transmitting it to regulatory agencies. When broken down further, physicians spend 2.6 hours per week and their staff spend 12.5 hours per week managing quality data. In all, this works out to $40,000 per physician per year.

The cost of hospital quality measure management has not been estimated in the medical literature but it has got to be very high. Most hospitals have multiple full-time staff members devoted to collection and reporting of quality measures, everything from CLABSI rates (central line-associated blood stream infections), to mortality indices, to emergency department wait times, and to patient satisfaction.

One of the reasons for the explosion in the reporting of quality measures is the electronic medical record. In the past, auditing thousands of paper charts in physician offices to determine how many patients in the practice had a hemoglobin A-1-C measured or how many patients got a flu shot each year was simply not possible. With the advent of electronic medical records, we now have a much easier way of auditing our physician practice for markers of quality. Things that could be easily tabulated from the electronic medical record have become prime targets to become quality measures whereas those things that cannot be easily searched for and tabulated in the electronic medical record have been passed over as quality measures. So, instead of asking ourselves: “What really reflects the best quality of health care?”, we have instead asked ourselves: “What data can we get out of our electronic medical record might reflect quality?”. Consequently, we have limited our quality measures to those things that can be searched for in the electronic medical record. Although many of these searchable markers do reflect quality, many of the best indicators of quality cannot be searched for using computer analysis of the electronic medical record.

If we as a society are going to spend this much money measuring quality, we have to be sure that what we are measuring is valid. In order to improve American healthcare and ensure that Americans are getting true value in their health care, we have to be able to measure components of healthcare delivery that truly reflect quality. However, we cannot afford to measure things that do not really reflect true quality of medical care.

May 20, 2018