Thursday, July 1, 2010
Push or pull?
This post by John H. Schumann, FACP, originally appeared at GlassHospital.
Chances are if you've never been admitted to a hospital, you know someone that has. If that admission was unplanned, you likely waited a long time in the ER before you or your friend/loved one was transported up to the hospital floor.
If hotels ran like hospitals, they'd run themselves out of business. Imagine the desk clerk, instead of giving you your room key (swipe card?), telling you, "I'm sure your room will be ready in the next 2-4 hours, or at change of shift, Mr. and Mrs. Cunningham."
What is it about hospitals and all this waiting?
(Click "more" button below to continue reading.)
For one thing, hotels have the tremendous advantage of their customers planning their departure dates. All the hotel has to do is enforce a "checkout time," after which a guest is threatened with paying for another day's stay--voila!--let the march of checker-outers begin!
Hospitals wish they could do the same thing, but there are major differences. The main difference is that you and I aren't paying directly for the hospital bed--insurance is. So there's no personal incentive to get out quickly.
Also, there are too many moving parts when it comes to executing a checkout (in hospital-speak, a "discharge"). Nurses can't discharge patients from a hospital floor without a doctor's order. Doctors are frequently busy caring for sicker patients, so they sometimes make discharges a lower priority (though this has changed with the focus on efficiency and attention to 'throughput,' getting patients in and out of the hospital as quickly as possible).
To understand why throughput has become such a dominant concept in hospital operations, it helps to understand a bit about the economics:
Since 1984, hospitals in the U.S. are paid for inpatient stays (a hospitalization) under the Diagnosis Related Group system. This was a Medicare innovation. Under the old system (purely "fee-for-service"), the longer someone stayed in the hospital, the more charges the hospital rang up. And the more money the insurance paid. Now you see why politicians sometimes call Medicare a "headless check-writing machine using taxpayer dollars."
The folks running Medicare could see where this was headed--with no incentive to move people along, patients could stay in the hospital indefinitely, until they were, well, better!
How quaint.
Now we admit patients, diagnose them, set them on a treatment plan and discharge them to home or another facility (like a rehabilitation hospital) usually within 72 hours. Hospitals have become patient-churning factories with tight margins.
For the last quarter century, the longer a patient stays in hospital, the longer they stay in the hospital. Typically it results in no higher payment to the hospital (that is, unless there are 'complications' requiring further treatment or that involve alternative diagnoses).
If you have pneumonia, the hospital gets the same payment whether you're there for two days or seven. Suddenly, you can see the logic of the shorter admission.
In such a system, the hospital stands to keep more of what it's paid the faster they can get you out.
The irony is that it's harder to get you out if they can't get you in.
Hospitals have shed beds over the last two decades as they've looked to run closer to capacity. Empty beds don't bring in revenue, so staffing for them is a fixed cost that needs to be ratcheted down if at all possible.
Yet, running closer to capacity strains everyone. It makes the beds scarcer, so it's tougher to get that patient from the ER or the operating room admitted to a bed if all the beds are full.
Plus, there's no incentive for the staff caring for the patients that are currently hospitalized to discharge one patient and bring in the next one. Admitting and discharging patients require inordinate amounts of paperwork on the part of the nursing staff. Caring for the patients that are there is the path of least resistance.
When I worked in administration, I was charged with solving this problem: How could we make the nurses hunger to bring in the new patients faster?
The obvious answer was to provide incentives to help grease the wheels of healing and commerce. But this ran afoul of the collective bargaining agreement with the nurses' union.
I called around to other hospitals, and was surprised to find that this problem exists almost universally. Some places call it "holding" time, some "wait" time, some "time to transfer." Call it what you will.
It means that the patient, the sick one, winds up waiting until a bed is opened, cleaned, and re-assigned. Then the patient has to be transported to the room.
How long should this take?
I called the largest for-profit hospital chain in the country, figuring they must have developed a solution.
The executive with whom I spoke was extremely kind, and willing to share all kinds of information with me about this topic. "Improving patient care is not proprietary information," I was told. I liked this attitude.
Unfortunately, the for-profit world is no better at solving this dilemma than we are.
"Get back to me when you have something that might work!" the for-profit administrator begged me.
John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
Labels: Glass Hospital, guest post, health care cost, hospital costs
posted by John Schumann, M.D. at
8:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert
Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the
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also did his internal medicine training. Certified by the American
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full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
Zackary
Berger
Zackary Berger, MD, ACP Member, is a primary care
doctor and general internist in the Division of General Internal
Medicine at Johns Hopkins. His research interests include
doctor-patient communication, bioethics, and systematic reviews.
CasesBlog
Ves
Dimov, MD, ACP Member, is an allergist/immunologist and Assistant
Professor of Medicine and Pediatrics at the University of Chicago,
where he evaluates and treats both pediatric and adult patients.
David
Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally
renowned authority on nutrition, weight management, and the
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leader in integrative medicine and patient-centered care.
db's
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Robert M. Centor, MD, FACP,
contributes short essays contemplating medicine and the health care
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K. Mavromatis, MD, FACP, provides a conversation about health topics
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Mintz' Blog
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Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid
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FutureDocs
Vineet
Arora, MD, FACP, is Associate Program Director for the Internal
Medicine Residency and Assistant Dean of Scholarship & Discovery
at the Pritzker School of Medicine for the University of Chicago. Her
education and research focus is on resident duty hours, patient
handoffs, medical professionalism, and quality of hospital care. She
is also an academic hospitalist.
Glass
Hospital
John H. Schumann, MD, FACP, provides
transparency on the workings of medical practice and the complexities
of hospital care, illuminates the emotional and cognitive aspects of
caregiving and decision-making from the perspective of an active
primary care physician, and offers behind-the-scenes portraits of
hospital sanctums and the people who inhabit them.
Gut
Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist
at the University of North Carolina School of Medicine, and the
Program Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
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pain.
I'm
dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
hospitalist with an interest in basic and clinical science and
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management, palliative care, patient-physician communication, quality
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Professor
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Just
Oncology
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clinical practice of hematology and medical oncology. His blog is a
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KevinMD
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MD
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Elaine Schattner, MD, ACP Member, shares
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Prescriptions
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Reflections
of a Grady Doctor
Kimberly Manning, MD, FACP,
reflects on the personal side of being a doctor in a community
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Neil Mehta, MBBS, MS, FACP,
is interested in use of technology in education, social media and
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The blog, which has been around in various forms since 2007, offers
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Other blogs of note:
American
Journal of Medicine
Also known as the Green
Journal, the American Journal of Medicine publishes original clinical
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subspecialities, both in academia and community-based practice.
Clinical
Correlations
A collaborative medical blog started
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York University Medical Center's internal medicine residency program.
Faculty, residents and students contribute case studies, mystery
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Interact
MD
Michael Benjamin, MD, ACP member, doesn't accept
industry money so he can create an independent, clinician-reviewed
space on the Internet for physicians to report and comment on the
medical news of the day.
PLoS
Blog
The Public Library of Science's open access
materials include a blog.
White
Coat Rants
One of the most popular anonymous blogs
written by an emergency room physician.
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