I guess it is time to start a new series, on bean counters. I am fully aware of the need for fiscal responsibility on the part of health care providers and insurance companies, so please don't take what comes as an invitation for profligate spending. But there are times when, in the name of saving money, places lose their moral compass and engage in behavior that is cruel to patients and families and is often wasteful, to boot.
Here's one, with names left off. A long-term patient was sent to us from a rehab hospital belonging to another health care system. After an appropriate stay in our ICU, we sought to send this ventilator-dependent patient back to the facility from which s/he had come. The facility refused, saying that they would not accept the patient because s/he had used up the annual Medicare allotment for in-patient stays. When we inquired further, we learned that they were trying to put pressure on the family to come up with a cash payment to offset this reduction in government payments.
Eventually, we were able to shame the rehab hospital into taking back this patient, but we were required to board the patient in our ICU for an extra six days.
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18 comments:
It's not just bean counters. This is another rather mild example of administrative evil. It's fairly pervasive when administrative goals do not match ethical goals.
The need to find some truly heinous evil person behind a problem interferes with the need to correct the behavior of basically good people who are participating in administrative evil. It's a different form of discouraging people from disclosing and correcting errors.
Thank you for addressing the bean counter situation. I'll look forward to reading more on the topic too.
I think the PBS movie, "Money Driven Medicine" did a good job on portraying how some of this happens with show a "day in the life" with physicians helping patients make decision on their healthcare, based on "what is covered" and the doctors simply stating I just want to practice medicine and help heal.
I understand that cost enters the picture from all arenas today, but we somehow need to find the right balance here so patients and doctors can be guided to the right decision making processes. This is certainly a "hot topic" today and it seems to be getting hotter all the time as well.
As humans we just don't always fit the formulas used to help determine what care we receive and as the algorithms get more complex and difficult to interpret, so goes the care we receive too at times. If we can find a way to strike a balance here, we will all benefit tremendously.
Excellent example of what happens every day in hospitals and physician offices. We are a safety net hospital, and as I have posted on this blog before, the pressure that we get from doctors and hospitals outside of our service to send us uninsured patients is tremendous.
Tax exempt hospitals really have no justification for such behavior (much less taxable ones). However, I am a bit sympathetic to the physician in private practice who is asked to care for a patient where he/she may recieve no remuneration. I have always thought the idea of giving physicians a tax credit on their S or C corporation in exchange for treating some level of uninsured was an idea worth looking into.
As a hospital based case manager, we work with this situation on a daily basis. Many of the long term acute care hospital's "cherry pick" who they will and won't take by payor and by expense.
In addition are own Mass Medicaid system is currently backed up to October for review forms. When they don't key in the form, they terminate the coverage for those patient's even though they've sent the form in timely and thus they back up in the acute cares unable to access services at home. Hospital's shouldn't have to bear the burden of the state's lack of staff and budget cuts!!
Paul - Are you implying that BIDMC does not manage discharge planning based on LOS guidelines? Aren't your case/discharge planners tasked with managing to the authorized number of days?
We manage patients according to their medical needs.
I was the case manager following the patient and I can tell you how personally painful I found the entire process. Though this case is probably the most egregious I've encountered, on many other occasions I have had facilities delay transfer in more subtle ways when it has benefited them financially.
Let me first understand the situation. The patient had used up the yearly Medicare rehabilitation days? If so, the patient was at a "custodial care" level, but with high acuity needs? And, Medicare does not commonly pay for "custodial care". So, someone has to pay for it. The hospital was paid on a DRG basis so there was no income to cover the ongoing cost. What is the problem with the patient's financial guarantor being responsible for providing the cost of ongoing custodial care? Am I missing something? Was the patient in a "Medicaid pending" situation?
In response to 76 degrees' comment: I am a physician involved in this case. The issue here is not one of payment, but rather of ehthical business practices (or lack thereof). Discussing the financial details of this case would put the privacy of those involved at risk, so the following information will have to suffice: the patient had exhausted their Medicare benefits and had become, essentially, self-insured. The rehab hospital refused to accept the patient back until a payment source could be ensured. In my mind, this is "dumping" an unisured/underinsured patient, which is a deplorable practice. Unfortunately, this happens all too often these days (see the post by the person who works at a safety net hospital, above). That commenter also makes a distinction between physician practices which would be financially burdened by caring for too many uninsured/underinsured patients and hospitals, which, given the comparative size of their budgets, have no justification to do this. I understand the distinction, though I will argue that once you have entered into a physician-patient relationship, you have a responsibility to care for that patient regardless of payment source. In my mind, hospitals are not exempt from this responsibility. What makes this particular case even more eggregious is the size and resources of the network which owns the rehab hospital in question.
My questions are probably less sophisticated versions of what 76 degrees in SD asked, but here goes:
Could a vent-dependent patient really undergo any kind of useful rehab? Was the rehab hospital an appropriate setting for this patient? Would a nursing home be the better placement for this patient? Just asking for my edification, really.
Many thanks for the blog.
Excellent questions. In Massachusetts, nursing homes do not take patients on mechanical ventilators. These patients are typically cared for in LTACs (Long-Term Acute Care Hospitals), which the "rehab" hospital in question is. You would be surprised how many of these "ventilator-dependent" patients are weaned successfully off the ventilator in the se LTACs. Grant you, it typically takes months or even years, and many patients are never able to be weaned completely off mechanical ventilators. Some patients are able to go home on mechanical ventialtors, given adequate resources and family support. Still, the places that are best at weaning these long-term patients off vents or sending them home on vents, are these LTACs.
Also, vent-dependent patients can absolutely undergo useful rehab. Christopher Reeve is one well-known example, though spinal cord injury is only one of many diagnoses where rehabilitation can make a real difference and can allow patients to lead fulfilling lives outside of a hospital or nursing home despite needing mechanical ventilation.
Of course you and your doctors are not guilty of sending very sick patients out of the hospital when your profit margin is threatened. People in glass houses shouldn't throw stones.
That's not at all true.
Great thread. It appears that the patient had already exhausted her 100 rehab days and needed a 60 day interruption to receive another bucket of days. The hospital stay was a convenient way for the rehab hospital to force the issue of payment. I wonder what they would have done if the patient had remained in their facility when the rehab days were exhausted. Are they obligated to keep her or can they evict her if she is unable to pay? The Medicaid eligible sounds like the prudent approach. Did she legitimately require hospitalization? Was the attending rehab physician a party to this?
This entire exchange of comments is an excellent illustration of how screwed up our health (or, as some say, sick) care "system" is, both in reality and in perception. Very sad on all sides.
nonlocal
I appreciate the additional information and understand the privacy issues. We physicians continue to care for patients even when they lose their insurance and we work out financial issues on an individual basis. And hospitals do end up "holding the bag" on "cash" patients. But, it could be several orders of magnitude difference between hospitals or physicians not being paid, and a "custodial care facility" not being paid for what could be a close to unending financial loss over many years. Patients leave hospitals; physicians go home, but SNFs can end up having high costs for very very long stays of extremely medically complex patients. I think I understand their dilemma.
You don't think that Medicare refusing to pay the bills for this patient's needed benefits is a slightly larger issue? If this patient comes back and sits there for months the hospital just ate over six figures worth of unpaid costs. I'm not sure the system as currently constituted is going to keep hospitals that make a practice of letting that happen afloat. Race to the bottom.
Dear Anon 2:34,
Yes, there is the bigger issue that you cite. Perhaps Congress will fix that some day. Yeah, right . . .
In the meantime, I think nonlocal states it well.
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