Sunday, December 26, 2010

Inpatient or outpatient and the battle to control costs: The truth about the push for electronic medical records?

Electronic health records have been pushed like opiates on a run-down inner city street corner for some years now; yet the evidence does not support the aggressive national push currently underway.

I'd thought wishful thinking, hope, government naivete, industry aggression and lobbying, and other similar factors were a major explanation.

A candid article today, however, in my local newspaper, about the ER of a hospital where I did my residency years ago (pre-EHR), seems to offer the most potent driver behind the current push - real-time money games:

Inpatient or outpatient? The battle to control costs

By Michael Vitez
Inquirer Staff Writer
Sun, Dec. 26, 2010

Randy Klein had a lovely vacation, three weeks in Europe with her husband, Stephen, for their 36th anniversary.

They went to Paris, Rome, Venice, even took a cruise to Monte Carlo. On the last day, they ate oysters in Normandy.

Her stomach started cramping on the airplane. The diarrhea didn't hit, thank God, until she got home, in Rydal, on Oct. 17, but it landed with a fury.

"Doesn't even give you a shot to get to the bathroom," she said.

She went to the emergency room at Abington Memorial Hospital, where they took cultures and she spent the night. She began to feel better and went home the next day.

A few days later, a violent diarrhea slammed her even worse than before. She went back to the ER and soon was on a gurney and hooked to a morphine drip.

Klein, 56, was too sick to know or care, but she was the subject of a conversation taking place down the hall between her ER doctor and an admission review nurse:

Should Klein be admitted to the hospital or treated there but as an outpatient, in what is known as observation?
[That is, "short-stay", or "one-day" fast-tracked admissions - ed.]

This may sound bureaucratic, even benign. But this question - and where it leads - tells a lot about the state of health care today, the tension between hospitals and insurers, the impact on patients.

The tension is strong indeed:

Abington wants to avoid treating Klein as an inpatient, then getting paid only an outpatient rate from the insurer - half as much.

Insurers see themselves as good citizens, responsible parents [I think their principle motivation is, rather, to be good parents to their profits - ed.], doing the difficult job of holding down health-care costs, in part by refusing to pay for what they view [from a distance, post hoc - ed.] as unnecessary care.

Doctors see this as second-guessing by insurers and an erosion of the doctor's role.

[I don't "see it" as second guessing. It *IS* second guessing, on first principles - ed.]

And hospital finance people say these cuts in reimbursement will affect the care of Randy Klein, thousands like her, and eventually all of us.


And some will be injured and die as a result...but it's all for money:

... These skirmishes over reimbursement take place gurney by gurney, patient by patient, like a thousand paper cuts, but the dollars add up.

Abington says it will lose $12 million a year because of this. Hospitals around the state and nation are feeling the same financial pressure.

Observation status, created by Medicare, has existed for years, but was infrequently used by area hospitals until last year, after a crackdown by Medicare auditors.

The idea is basic: If a patient arrives in the emergency room, and it isn't immediately clear whether the patient should be admitted, the patient can be placed in observation - treated in the hospital but as an outpatient.


The statement "treated in the hospital but as an outpatient" shows George Orwell's concepts of language manipulation are alive and well.

... Steve Fisher is one of 40 emergency-room doctors at Abington. He likes to say, "I'm paid to be paranoid."

On Monday, Oct. 25, before he went to see Randy Klein, he saw that she had been in a few days earlier for the same problem, and that immediately raised concern.

The results of cultures taken the previous week showed she had two parasites, campylobacter and giardia, infections one gets from contaminated food and fecally contaminated water. Fisher knew giardia, which he felt was causing her trouble, is rarely life-threatening, but he is paid, as he says, to be paranoid.

On examination, Fisher felt Klein's belly was incredibly tender, and he contemplated a CT scan of her colon, but decided against subjecting her to the radiation.

He didn't think she had a blockage or anything that would need surgery. But considering the extreme inflammation, a rupture was possible, and he was confident she would need subsequent abdominal exams in the hospital, in the days to come.


ER doctors need to be "paranoid" because they ultimately are responsible for outcomes. They also develop a keen sense of judgment towards potential trouble. This patient was admitted for several days, but soon the claim for inpatient care was denied.

Based on a cookbook known as "InterQual", Blue Cross would pay at an observation rate, an outpatient rate, even though Abington provided inpatient care. Read the article or the link above for more on that cookbook.

Now about the denial and the second guessing of doctors:

"Respectfully," [senior medical director at Independence Blue Cross Donald Liss] added, "I'd say, jeez, this is the perfect case for observation. Is she going to respond, get better in six, eight, 12 hours from now and perk up? That's the one where you would want to keep an eye on her, responding to therapy or not."

[How does he know? He was not present. He did not perform an exam. He did not get a "sense" of the patient. - ed.]

Liss wanted to emphasize that "I have a personal interest in the continued existence of Abington. My wife and I delivered our kids there. I live within a mile.


That's very nice, but irrelevant. What is relevant is this:

"We don't intend to tell the ER doc how to practice medicine," he added. "I appreciate the conundrum and challenge that creates at the point of care.

"But unashamedly our job is to be a good steward of the dollars our customers entrust us [such as patients just like Randy Klein? - ed.] to spend on health care."


This is bull. It is a lie. I find this statement offensive and insulting to my intelligence. I am indeed tired of the lying and the spin.

Of course the insurance company representatives are telling the ER doctor how to practice medicine.

Patient disposition decisions are part of an ER physician's practice of medicine. Insurance company interference in those decisions is precisely a matter of telling ER docs how to practice medicine.

Their profits depend on it.


Now for the EHR angle:

... Joanne Mainart and Donna Tobin are nurses and case managers at Abington who review admissions. Mainart was hired for this job a year ago; Tobin joined her in March.

They sit at their own computer in the ER [i.e., with their own access to the EHR - ed.], away from patients, and when they see a black ball beside a patient's name [signifying the insurer may deny an inpatient claim and pay at aforementioned "outpatient inpatient" rates - ed.], their job is to examine medical records and treatments and determine if the patient meets criteria for inpatient admission.

Doctors still make the decision. These nurses only advise. But their mission is to make sure patients get put in the right category - inpatient admission or observation [so the hospital can be paid appropriately - ed.]

Assigning Mainart and Tobin to the ER was Abington's response to the push toward observation.

And this:

... Blue Cross has its own team of utilization review nurses, all of whom, it says, have at least five years experience and have received special training in utilization review.

One of the nurses, working at the Blue Cross offices in Plymouth Meeting, got access to Abington's computers through a secure logon [they can see the EHR too! - ed.] and reviewed the same records Tobin had the previous evening.

[Note the centrality of the computers in this payment "poker game" process - ed.]

The Blue Cross nurse did not feel Klein met InterQual.

[Since nurses cannot unilaterally make these decisions, a physician later reviewed the case and concurred - ed.]


So, there we have it.

Physicians' work is interfered with by EHR's ostensibly put in place to "help them", but in reality a behind-the-scenes cybernetic game of financial chess is going on, worth billions to hospitals and the insurers.

If that is not a compelling driver for EHR technology, I don't know what is.

Unfortunately, it does not benefit patients or doctors clinically (my relative was nearly killed earlier this year by the unintended adverse consequences of an ED EHR system), and it looks like the upper hand financially now lies with the insurers.

Hospitals like Abington estimate they "will lose $12 million a year because of [the denials]." Hospitals around the state and nation are feeling the same financial pressure.

Per Abington Chief of Staff Jack Kelly, a former director of my Residency program there:

John J. Kelly, [now] Abington's chief of staff and top doctor, said: "It actually costs us more money to do observation. You might say that doesn't make any sense."

He said Abington has had to hire more staff and "compress everything" - in other words, try to provide the same care it gives an inpatient but squeeze that into 24 hours of observation.

Kelly also said staff was required to do more documentation "because you're paid by the hour for observation. It's craziness."

"What they're asking us to do sometimes is dangerous, I think," said Kelly, speaking for himself and not the hospital.

"The 'retrospectacope' is the most powerful instrument known to man," he added. [That sounds like vintage Jack - ed.]

"Part of the reason we spend so much of our resources in training physicians is to develop that sense of judgment about who needs what. And we're being second-guessed by everybody strictly on the basis of costs.

"I understand the need to be sensitive to costs, yet they're going to cripple us, the insurers [and] the government."


Note his statement:

"Part of the reason we spend so much of our resources in training physicians is to develop that sense of judgment about who needs what."

I concur with his assessment, and from personal experience. I was one of the physicians he trained.

A plague of our current culture is the permitting of second guessing by people who both lack the expertise of the experts, and/or lack the crucial benefit of direct, concurrent observation of the patient.

In conclusion:

First, it is increasingly apparent that clinical information technology has been hijacked from its inventors and pioneers. It has been morphed from a tool that was supposed to help clinicians in their private doctor-patient relationship, into a cybernetic control mechanism for bureaucrats.

Second, until this culture takes away the power from ill informed bureaucrats, people need to bring a bodyguard (medical advocate) with them to any hospital encounter.

"If you are second-guessed wrong, your patient's dead" seems an apropos motto for this era.

-- SS

6 comments:

Anonymous said...

These people, are, in essence, practicing medicine without a license. The physician reviewer who usually concurs with the observation edict is paid by the insurance carrier.

One bit of information not included is that observation is intended to be "23 hours" max; but if a patient has medical needs demanding more time and stays longer, the hospital is often not paid; and the doctors are "peer reviewed" by "paid volunteer medical staff", if you know what I mean.

As for the HIT systems, current iterations are dangerous to patients' health. We all know that.

Scary, indeed.

Anonymous said...

Do ya think that the stool culture results from the first ER visit were squattin in the EHR silos unbeknownst to anyone for a few days? Just wonderin...

Anonymous said...

These quickie in and outs, better known as hospitalitus interruptus, cause unintended consequences...such as premature and frequent irradiation from CT scans, done to hurry up the rule out and get out process. NY Times may be interested.

Anonymous said...

I think it's obvious that the push for EMRs is motivated primarily by the insurers' wish to have real-time pre-authorization for every single order (inpatient and outpatient) that the doctor writes.

Scot M Silverstein MD said...

Anonymous December 27, 2010 12:58:00 PM EST writes:

I think it's obvious that the push for EMRs is motivated primarily by the insurers' wish to have real-time pre-authorization for every single order (inpatient and outpatient) that the doctor writes.

It is not inconceivable that it could get to that point.

If it does, physicians should refuse to accept liability for orders not "authorized" by their remote overseers as a condition for the physicians' voluntarily lending their hard earned expertise to the care of the sick.

-- SS

Anonymous said...

'physicians should refuse to accept liability for orders not "authorized" by their remote overseers'

That would seem logical, but we've already seen demoralized physicians passively accept full liability when orders for MRIs, drugs, etc. are denied and the patient suffers.

It's very easy for a lawyer to "prove" to a jury of one's "peers" that the lazy physician did not struggle hard enough to get the necessary care for the patient.