The reader might remember how my step-daughter's father was sorely neglected when he had to return to UCSF after an operation for esophageal cancer. (see http://buddshenkin.blogspot.com/2014/04/a-sad-tale-in-teaching-hospital.html). He was poorly treated in the ER where he was delayed for hours and then poorly treated by the resident team on the floor. The attending was in Hong Kong where he responded admirably by telephone to an email from Sara, who is a physician, who was advocating for better care and attention for her father.
I didn't think much more about it, other than to blog about the faults of teaching hospitals. But Sara has brought up another interesting view about the Law Of Unintended Consequences (LUC).
Medicare has tried to incentivize hospitals to do a good job with patients the first time around. In particular, Medicare has wanted them not to neglect patient discharge instructions and coordination, which hospitals have traditionally neglected partially because there has been no money to be made in doing so, and partially because there is no dramatic consequence, either, for the staff and doctors involved. “Out the door and off my plate” has been the traditional attitude. If the patient bounced back, why then, it was another admission that could be charged to Medicare.
The solution Medicare came up with was to inform hospitals that it would refuse payment for a patient readmission within 30 days after discharge. It seems like a simple enough solution, one that would incentivize good and definitive hospital care with an appropriate coda. But Sara observes that while hospitals might save themselves money by doing good discharge planning, if the patient does bounce back to the hospital, the hospital has no incentive to bill for the services delivered, because they won't be paid for. Yes, minimizing the extent of services and discharging the patient as fast as possible is still in the hospital's financial interest, but – importantly in this case where the residents were overloaded with work and Sara's father was neglected – it doesn't matter to the hospital if a staff physician sends in a bill or not, because the hospital won't get paid. It can just be a “resident case.”
Background – for many years teaching hospitals billed for attending physician services whether or not the attending physician actually saw the patient, which was illegal – but if you're a teaching hospital, who cares? Who could or should challenge an institution with such prestige? Well, the US government did so, fined Penn many millions of dollars, and from then on, all the teaching hospitals made sure they had the signature and a note from an attending physician on every patient every day.
But now, with readmissions, all bets are off. They're not going to get paid anyway! So if the attending is in Hong Kong, why get a substitute attending to look at the patient, and to actually care that his sodium is at 128 and plunging? The hospital doesn't really care since payment is not involved. And residents? Ah, residents, our future stars. For now, they're just trying to get through the day, their hours are curtailed by law, and they probably operate in a blame culture, which means that the ultimate bureaucratic virtue is not to be blamed for anything, and the ultimate blame would be to ask an attending to actually help out with patient care, when the attending's priorities are in research and travel, not patient care.
LUC, you are everywhere. Good catch, Sara. She is getting real smart.