A better POLST (Physician's Orders for Life Sustaining Treatment) and informed consent for resuscitation: can we do this better without "playing God" ?

To resuscitate or not to resuscitate--that is the question. Whether 'tis nobler to beat the heck out of a person on his or her way out in the hope of saving his or her one precious life, or to allow death to proceed at its own pace with expectation of a peaceful passing.

The United States has come a long way in the last 2 decades since 1991 when the Patient Self-Determination Act was instituted. In most hospitals patients are asked what their wishes are regarding resuscitation and many states have instituted POLST (Physician's Orders for Life Sustaining Treatment) forms which spell out which interventions are acceptable to individual patients when they are very sick, things like blood transfusions, antibiotics, feeding by nasogastric or gastric tubes, intubation and ventilation and chest compressions and electrical cardioversion in the event of cardiac arrest. Theoretically we discuss these things with every patient when they come into the hospital, but we don't really do it very well which results in misunderstandings and needless misery.

When the patient is competent to discuss life sustaining treatments the conversation often goes like this:

Doctor: What would you want done if your heart were to stop? Would you want us to do chest compressions and put a tube down your throat so we can support your breathing?

Patient: (thinking, "Why are they asking me this? Am I gonna die? Of course I want them to save me. My heart could stop right now! What about my grandkids?") Sure I'd like that. Just give it a try. But I don't want to be kept alive if I'm a vegetable.

Doctor: (thinking, "I sure don't want to break all of this nice guy's ribs and traumatize his upper airway and, if we did get his heart started again, have him helpless in the ICU while we try to decide whether to put a feeding tube down and send him to a nursing home. With any luck he'll die in his sleep when he's not in the hospital.") OK then. We'll put you down as full code. Just sign here.

I went online to see how other countries do this, and found that there is a great deal of variation. In many middle eastern countries resuscitation is performed on all hospitalized patients in the event of cardiac arrest, regardless of patient or family preference. In Australia there are many different policies which are different in different hospitals, and may or may not involve patient and family participation in decision making. In England the patient is involved in these discussions if he or she is competent, but if not, the doctor makes the decision, and if the family has an opinion this is taken into consideration but   the doctor really has the final say. I read an online discussion about an 86 year old nursing home resident in the UK with heart failure who was admitted to a hospital and suffered a cardiac arrest. He did not have CPR due to a nurse thinking he had a DNR order, which he did not. After the event it was agreed that CPR would not likely have saved him, but it was the discussion after the article that was particularly interesting. About half of the people said that it was terrible that mistakes like this ended in a patient not getting life-saving CPR and that in many cases doctors made these decisions and "played God." The other half were people who said that they had seen CPR on old people and it was brutal and hardly ever worked.

Clearly doctors should not get to or have to "play God." Clearly, also, people who we ask to make these decisions, patients or families, usually don't know what we are really talking about when we ask them to make a decision about resuscitation ("code status.") Physicians are much less likely than our patients to request resuscitation in the event of cardiac arrest. I think our values are pretty much the same as those of our patients, we just know more about what cardiopulmonary resuscitation and its aftermath really look like.

So here is a good solution that preserves the autonomy of the patient while allowing the physician to do his or her job, which is taking care of the patient while following our Hippocratic Oath to "do no harm".

Cardiopulmonary resuscitation (CPR), intubation and ventilation are medical procedures, just like a tonsillectomy or a hip replacement. There are expected risks and benefits. The risks are not insignificant and the magnitude of the expected benefits vary with each patient. If a patient really wants CPR, he or she or a surrogate decision maker should sign a consent form  (well in advance of experiencing a cardiac arrest) which includes risks and benefits. The benefits, of course, would be to live and recover enough to be able to leave the hospital. In the least complex patient, 1 in 5 of those who have a heart event which requires CPR can be expected to survive to hospital discharge. In the most complex, the expectation is 1 in 20 or less.  The risks include, but are not limited to: pain, broken ribs, punctured lungs, trauma to mouth, teeth and upper airway, aspiration pneumonia, loss of brain function, multi-organ failure, prolonged dependence on caregivers including being confined to nursing home, monetary expense, and all the usual complications of prolonged intensive care unit and hospital stays. Also, should we not be successful, loss of the opportunity to die in peace.

Presently our POLST forms say none of that. Different states have different forms, but I have been involved in completing ones in California, Oregon, Idaho and Washington and they share similarities. They start with a check box for CPR (cardiopulmonary resuscitation) or DNR (do not resuscitate, allow natural death.) Then there are other boxes specifying the general level of interventions, including comfort care (giving only treatments that provide comfort without attempt to prolong life), limited interventions (lengthen life, but generally not in an intensive care setting and not using advanced life support techniques) and full treatment (everything, dialysis, ventilator, electrical cardioversion, the works.) Then there may be questions about whether artificial nutrition by IV or tube is acceptable, whether blood products are OK, whether antibiotics should be used. It is really hard for a patient or family to get through all of these questions, and many of them are too complex for a person without healthcare experience to understand. Still, they are a good starting point for discussion.

In general the patients who I talk to just want me, as the doctor, to make the right decisions at the right time that are most likely to get them what they want. Most of them want as much good life as possible, the relief of whatever discomfort or disease brought them in, and to have this done as quickly and economically as possible so they can go home. We have no box for this on the POLST form.

I would propose that we should add this box, up at the top, as an alternative to "CPR" vs "DNR." I would propose that the choice be called "Resuscitation at the discretion of physician, guided by my goals of care." This would allow a nuanced decision about resuscitation--from none at all if the patient had been declining and not responding to treatment and was found unresponsive and pulseless (a situation which almost never results in success) to full resuscitation for a witnessed collapse with ventricular fibrillation in a patient who had a pretty good level of function.

This does, however, require another piece of paper, which I think should be part of any patient's admission to the hospital, and probably part of the chart at the primary care doctor's office. This would be "goals of care." There was an article in the New England Journal of Medicine last year that talked about altering our ideas of success in medical care to reflect how well we helped a patient achieve their goals rather than focusing on specific markers of disease control. Some patients value not being dizzy and not taking a bunch of expensive pills more than they value good blood pressure control, for instance. I think it is important to know, at the time of hospitalization, what a patient really wants. Do they really need to be discharged by a certain date or time? Do they have lousy insurance and need their care to be as thrifty as possible? Do they really value pain control, or sleep at night, or making sure to have a certain meal on time? Do they need quiet, or visitors? Do they want to avoid antibiotics or medications that can cloud their thinking? Do they think that spending time in a nursing home would be OK? Are they hoping to die in the hospital because their burden of disease is becoming intolerable? Do they want to make it home for Christmas or live until a grandbaby is born? We don't ask these questions and we should, or at least somebody should.

If a person chooses "CPR" or "RDP" (resuscitation at the discretion of physician) they, or their surrogate, really need to read and sign the informed consent form for resuscitation, because they do need to know what this means.

I hate filling out forms, but if they help focus treatment so it is more appropriate and if they help me understand my patients and communicate with them more effectively, I'm OK with that.

So... bottom line: In order to have patients make better decisions about resuscitation, we need to share more information with them and allow them to depend on our clinical judgement to help them have the outcomes they really want. To do this we should: 1. Add a box to the POLST form that specifies "resuscitation at the discretion of physician" as an alternative to "CPR" or "DNR".  2. Create an informed consent for resuscitation which makes clear expected risks and benefits and have everyone who wants resuscitation sign it. 3. Make sure that patients are asked about their goals of care at the time of admission to the hospital and that physicians read them and honor them as much as is practical. 4. For those unable to complete a POLST form or give informed consent for resuscitation, physicians should make the decision about whether to resuscitate based on most patients' goals of care and good clinical judgement. This is, after all, what we would do for such a patient with any other procedure that we perform in the hospital.

A rant on the hopelessly ill (of course it's not their fault) and how maybe mass media could help

I have been working in the intensive care unit and have been finding it ethically difficult to facilitate the care of the some of the hopelessly and incurably ill patients who rotate through. Many of these patients live in nursing homes that are qualified to manage patients on chronic life support, not just tube feedings or oxygen, but ventilators and tracheostomy tubes. They can live like this for years, with deepening bedsores and pasty disused limbs, foley catheters, rectal tubes or colostomies, with gradually increasing colonization by multidrug resistant organisms. They are brought to the hospital and then the intensive care unit when the bacteria colonizing their endotracheal tubes finally take hold and cause pneumonia or when a catheter in a blood vessel or bladder becomes infected or when one of their vital signs tells their caregivers that some unspecified thing is terribly wrong.

Once a person is on chronic life support, usually nobody talks to them anymore and it is assumed that they will continue as they are until something happens that no force on earth can stop and they finally take their eternal rest. We, as the medical establishment, must continue to use all of the fancy medications and procedures at our disposal to keep them alive. Usually nobody even asks the family anymore if they think that we should stay the course. None of the recipients of this care--family or patient--hear that care like this costs a million dollars a year or more.

Occasionally we can't stand to do the same heroics again or add more complexity and expense for clearly horrible quality of life, and then there are debates with all of the many involved people (and there are MANY involved people with each one of these folks) about medical futility, and what is the value of a life when it has become so very small. These debates are never settled for good, and are new and interesting for every patient, with heated opinion and bitter disagreement and misunderstanding. I spent hours, this week, convincing an ethics consultant that doing chest compressions on a 90 year old non-verbal demented woman with lung cancer and, most importantly, critical aortic stenosis was unconscionable, even though, 7 years earlier, when she could still talk, she had asked to be "full code." I explained that chest compressions do not cause blood to flow through a heart when the aortic valve will no longer open more than a smidgen, and thus the procedure was as futile as removing a non-diseased appendix because a patient requests it.

But it is not necessary to revisit the debates of medical futility, at least not tonight. People with good hearts and good minds, invoking the words of scholars and philosophers, disagree vehemently on what is futile and when a physician's responsibility to do no harm outweighs a patient or family's desire for us to do "everything."

What we really need is prevention. We need to work on the attitude and the economic pressures that lead people to be in advanced care nursing homes and intensive care units when they have no hope of gaining any sort of independence.

Some doctors think a lot about this sort of thing. They suggest that perhaps patients would not ask for million dollar a year heroics in order to lie in beds getting fed through tubes in nursing homes if they, or the family that requests that we continue to treat them, had some sort of financial responsibility. If they had to pay even one tenth of the costs, or one one hundredth of the costs, there would be considerably less of this kind of care. Perhaps it isn't such a bad solution. Even the very richest of people would have to face the question of the value of life support if continuing it meant $100,000 out of pocket costs per year. One might ask if there might be some actual societal value to maintaining a patient on life support when they are never going to be well enough to be off of it, and one might think of Steven Hawking, whose remarkable brain is able to function because his shell of a body is supported in all ways by medical technology. There are undoubtedly other examples, but I can't think of any.

I'm told that the amount of excessive end of life care that I have been seeing this year is nothing compared to how things are done on the east coast of the US, in New York or Boston, at the larger hospitals. There are wards devoted entirely to patients on chronic ventilator support, most of them severely brain damaged. These patients are not paying privately and are not on private insurance but usually have both medicare and medicaid, and are using the same dollars that are pinched tightly when it comes to providing care that might lead to greater independence and function in other recipients.

So--prevention. We need, somehow, to communicate to patients what we know as physicians about the human cost, as well as the very real economic cost, of keeping people alive by artificial means when they become very old or very sick or horribly injured. Americans are on the very edge of the spectrum of world societies in terms of valuing the individual and individual autonomy over the needs of the family or the community. Nevertheless, most people, when asked, will say that they do not want to live so as to become a burden on their family or friends. In a time of crisis, though, it is of great biological value to think only of oneself, and so decisions are frequently made to "do everything" when a person is close to death, which means that they must, after being saved, get really sick many times and eventually only die because we, as caregivers, are not quick or clever enough to save them. This equates to misery and loss of dignity at the end of life.

The end of life for the various people we care for can go different ways in the hospital, depending on the patient's or family's goals of care. If we have heard, quite clearly, that a patient wishes to die in peace when it seems that death is coming, we respond to a drop in blood pressure or high fever or loss of consciousness with clean sheets, soft music, coffee and cookies in the room for family members, pain medications if they are needed, clergy visits if appropriate. If we have not heard that, people rush to the bedside, shake and prod the patient, put in IV catheters, run fluids, perform CT scans, move the patient to an intensive care unit, attach EKG leads, voices are raised, invasive procedures performed. In the first case, the patient will usually die, though definitely not always, and the second case the patient will sometimes die, but may be resuscitated to do it again, hours, days or weeks, and occasionally even years later. Both scenarios have their place, but the first is vastly underutilized.

The cost of the aggressive approach is not inconsiderable. For the day of the decompensation, depending on what actually happened, costs run upwards of $10,000, and the whole hospitalization probably more than $50,000, even if we are unsuccessful. We don't like to think of money as influencing any decisions about life and death, but they are inseparable. Money used at the very end of life is not available for prevention of illnesses in other patients, which interventions cost much less and buy much more happiness and productivity. If our electronic medical records simply told us what each thing we ordered cost, and patients had easy access to that information, behaviors would be much different, and overuse of technology would be less common. We have tripled the use of imaging procedures such as CT scans and MRIs in the last 15 years without any clear improvement in outcomes, and it is likely that reducing our behavior of frivolously doing imaging will probably have no negative effect on our patients' health. Our overuse of antibiotics, especially expensive ones, is fueling an epidemic of drug resistant organisms in our hospitals, so if some financial information made us do this less, it would be great.

Because taking care of hopeless resuscitation disasters is very emotionally draining, it increases physician and nurse burnout and worsens the quality of care for everyone. I'm torn, much of the time, between the fact that I love working with excellent ICU nurses and discussing physiology with cardiologists and intensivists and the fact that the patients for whom I do this are without hope for recovery and are huge resource sinks. I even like the patients, those who can communicate at all, I just feel terrible about the system that got them there and put them in their impossible situations.

Maybe we, as a society, really do want to support patients with all sorts of life support technology rather than allowing them to die, unless they specifically refuse such treatment. I'm pretty sure there is no clear consensus on the subject. If we do want to do this, we must gracefully accept the fact that there will continue to be more people in this situation lasting even longer and costing even more as our technology improves. This means that we will be spending progressively more health care dollars at the end of life. If we also want to be able to take care of patients who have simple and easily treated conditions, our healthcare spending will rise significantly as a proportion of our national budget, primarily through the Medicare and Medicaid programs.

As silly as it seems, I think the solution may not be in forcing doctors to make more difficult decisions, but in effectively communicating what we know with folks who have very different backgrounds. In Brazil women used to have huge families, lots of children, which was economically very hard on the country as it modernized. When they got television, they started seeing soap operas in which women had only a couple of children, or even none, and had good and interesting lives. They then started having less children. No public health campaign, just a sort of sharing of stories, using the wonders of mass communication. We have these well loved doctor shows, ER, Gray's Anatomy, House, which show how cool it is to be in a hospital having technological medicine happen to you and being resuscitated from death to good normal life. These are the stories that are fun to watch and they are mostly not true. Could it be possible to make a popular TV show that actually shows things as they are and models the choices that those of us in the know would make if it were us our the ones we love who were desperately sick in the hospital? An infomercial even? A music video? Doctors don't particularly excel at this sort of thing but perhaps there's someone out there who will take the challenge.

Healthcare economics and history--how we got here and how we might get out. (Notes for my talk to the League of Women Voters)

Hello and thanks for coming.

I’m going to be talking about what has taken me away from my practice this last year and what I’ve learned about how healthcare is doing and why it’s so expensive. I’m going to talk about what’s going well and not so well and the ways we can have an impact for the better.

In 2011 my friend and nurse practitioner died unexpectedly and my longtime medical partner decided to move far away to take a different job. This left me and my remaining partner to take care of our large practice.  We were both also covering patients in the hospital so had no more room to accept new patients. It  turns out that almost no more outpatient internal medicine physicians are coming out of residencies, so recruiting a new physician was not going to happen. I had also been writing and speaking about healthcare reform for a few years and felt like getting more and new experience would help flesh out my understanding of what was going on. So I left my job and the patients I loved taking care of and, since November 2011,  I have been working as a hospital physician for hospitals in Oregon, Washington, California, Alaska and here at home. I have been studying internal medicine and have recertified with the Board of Specialties. I have learned to do bedside ultrasound and taken a one month fellowship in that at University of California, Irvine medical school. I also took 3 weeks to go to the Republic of Georgia and learn new songs and performed with a trio in Tbilisi. It has been a glorious and sometimes incredibly tiring adventure. I have learned a ton and met lots of interesting people, both patients and caregivers. I have written about 80 articles for my blog, some of which have been re-published by the American College of Physicians and on other websites. I don’t seem to run out of things to say.

The big problem with American healthcare is that we spend too much money on it and for that we offer it to fewer of our citizens than other developed nations. We are only 1 of 2 OECD (Organisation for Economic Co-operation and Development, 34 countries that joined together to promote economic development) countries that do not have some sort of universal healthcare. 17% of Americans at any one time have no health insurance, and many more are underinsured. Canada, for instance, requires access to basic medical care without copay and pays about $1800 per person in healthcare costs to America’s $2800 per person. For our higher healthcare costs, with have a lower life expectancy and a higher infant mortality rate. It is hard to compare countries in this way due to the diversity of our population, but the message is pretty clear. We are paying too much for our healthcare and we are not getting excellent results.

But you could have looked all of that information up on your handheld devices. The real question is why is this true and what can we do about it?

In 1965 a very popular program came into existence. President Lyndon B. Johnson signed Medicare into existence under title 18 of the Social Security Act. Before that time only half of seniors could afford health insurance.  Medicare made sure that older people, often on reduced or fixed incomes, didn’t die of disease because they couldn’t pay for medical care or perish from bankruptcy. Prior to this, elderly people paid the equivalent of $1000 of today’s dollars in a year without a hospitalization and up to $7000 with a hospital stay. This was paid for by family, out of savings and sometimes through charity or public assistance. The average per capita healthcare costs today are over $8600 in the US and over $10,000 for patients 65 and older. Health insurance had become more common even before the inception of Medicare and Medicaid, in the 1940s, but was more like our catastrophic policies are now. With Medicare and Medicaid many more people were insured and insurance was more often comprehensive. Since consumers were no longer exposed to a significant financial disincentive to obtain healthcare, use of services expanded and because it was not the consumer who paid the majority of the bills, costs rose. Because there were deeper pockets, technology blossomed, with more and more expensive treatments and tests. Insurance companies attempted to cut costs by increasing requirement for documentation of appropriateness of care, but this just increased the administrative burden which increased costs further. Higher costs were handed back to the consumer in the form of higher premiums, which made consumers even more eager to get their money’s worth by using health insurance benefits. More and more often insurance was provided by employers which further shielded patients from the costs of healthcare.  In 1965 healthcare spending was about 5% of GNP and today it is nearly 17%. Healthcare is big and getting bigger and it acts like a bureaucracy does with little incentive to downsize or become more efficient.

You may ask how universal health insurance coverage or even a single payer system will help fix this. The answer is that it won’t. Universal healthcare coverage will make sure that everyone at least theoretically has access to healthcare, but it will not in itself reduce costs. A single payer with really good oversight (since bureaucracies do get larger and cost more if left to themselves) could potentially dictate payment levels, but does not tend to motivate elegant solutions and small efficiencies.

So what does expensive healthcare look like from my perspective? I suspect many of you have seen it in action. I have been in hospitals lately which is a pretty good vantage point from which to see high costs, since hospital costs are the largest sector of the healthcare equation. Hospital costs make up about 850 billion of the 2.7+trillion dollars that the US spends on healthcare. Hospitals continue to spend way more resources to take care of patients than are necessary for good care. Although Medicare began in the early 1980s to pay hospitals for patients according to diagnosis rather than how much was done to them, other insurance companies continued to pay “fee for service” which is to say paying for each service that was performed. Doctors not employed by the hospital also are paid according to the volume of services done. Doctors are so used to doing unnecessary tests and procedures from decades of practicing in an environment where neither the patient nor the doctor suffers from excess costs that we feel that this is the only responsible way to practice.

So what do we do that is crazy expensive? Much of what I say refers primarily to the big hospitals where I have practiced, which represent American healthcare much more than our local hospital, where we are much more circumspect. What doctors do is to order unnecessary tests, ones which could be avoided by taking a good history from the patient or contacting the patient’s regular doctor for background. Sometimes that is done because the patient is admitted to the hospital after closing time for outpatient clinics or because of lack of time.  We recommend aggressive and technological approaches to diseases where a “wait and see” approach might work just as well. We do this because of a prevailing belief that to do more means that we care more.  We  also worry that if we are conservative with our use of resources our colleagues will fault us or we will look negligent should we end up at the receiving end of a lawsuit. Because of lack of communication between many care providers, hospitalists, specialists, intensive care providers, primary care doctors, patients are often kept alive far longer than they would have wanted, with much poorer quality of life leading to more unstable patients in nursing homes and specialty centers. Some of these patients, those requiring high level chronic support including ventilators and feeding tubes, can cost upwards of a million dollars a year, paid for out of public assistance programs such as Medicaid and Medicare. These patients develop multi-drug resistant infections which are a reservoir for infecting other patients, and become increasingly medically complex, taking physicians attention and time away from care of patients whose prognoses might be better.

There is a lack of elegant solutions to common problems because elegant solutions use less resources and the healthcare system grows larger and more powerful with increased resource utilization. With no limit to the amount of money available to pay for things in the healthcare arena, the solutions become larger and more expensive, rather than simpler and cleverer as they do in so many other sectors.

What are some examples? Every physician longs for a user friendly effective computerized medical record system that has good communication across different locations and levels of care. If you even barely scratch the surface, most physicians could tell you what they want and how it needs to work. They will also tell you that there needs to be one system for the whole country and that every office needs to have it. Instead we have many medical record systems and we can only reliably access information from the hospital in which we are working. Our communication with other physicians responsible for care, if not within the hospital are haphazard and usually by telephone, since we are unable to communicate via the medical record. A universal medical record is a very feasible option but it will not happen as long as large software companies can continue to make enough money through competition with each other by making mutually exclusive products. Our computerized medical records are often owned by large multinational corporations, are very expensive, don’t do what we want them to do and don’t talk to each other. They don’t have to be inexpensive or efficient since deep pockets which extend to everyone’s pockets by secret subterranean tunnels can pay for them.

Stress tests. When I graduated from medical school I learned to perform exercise stress tests in which we had patients exercise hard on a treadmill while we monitored their electrocardiogram to see if their heart would develop abnormalities to suggest a blockage in a coronary artery. This test was very helpful in some cases, but no good for patients who couldn’t exercise and less accurate for women. Imaging of the heart with ultrasound or using chemicals could help to make this kind of a test more accurate. The most accurate pictures were obtained when a nuclear isotope was injected which went to areas of the heart well supplied with blood. Nuclear isotopes, like thallium or technetium, are made in nuclear reactors or cyclotrons, which are big, expensive, few and far between. A third of the nuclear isotopes used in north America are made in a reactor in Chalk River, Ontario, Canada. They are unstable and must be used relatively soon after being made. There is also a special machine for detecting them and doctors must have 2 months of training plus many hours of radiation safety education to be credentialed to interpret the results.  Over the 25 years since I graduated from medical school the nuclear stress tests have all but replaced the standard exercise stress tests. Standard exercise stress tests, even at hospitals, cost around $200 and nuclear stress tests, which also involve a very significant amount of radiation exposure and concomitant cancer risk, cost over $5000. Are there no other less expensive tests that can do the job? Yes, there probably are, but there is no really good incentive to find them since, in the big economic scheme of things, a nuclear stress test pays so many salaries. When you think about it, there are the jobs of all of those people who work in the nuclear power plant, the truck drivers who get the isotope to the hospital,  the people who make the machines that detect the isotope, cardiologists, folks who teach radiation safety—the financial fallout is huge.

We also do too much technological medicine at the end of life, and similar economic pressures contribute to that. Obviously the very sickest patients are the ones who will soon die, and so we naturally pull out all of our very most hi tech medicines, tests and procedures in our patients’ last few usually pretty miserable days, weeks or months of life. To be fair, it is not always clear whether the hi tech offerings will cure a patient and restore them to function, but in many cases at least discussing what we are doing with patients and families might reduce the use of medical technology that prolongs misery. It has become the standard of care to do so much that, in other countries or cultures, would be seen as cutting edge and only used in extreme need. This includes routine use of multiple very expensive antibiotics when infection is only remotely expected and invasive long term IV catheters with risk of blood clots and infection as well as high cost for patients who may not even need intravenous medications, imaging tests from neck to groin for pain complaints which then lead us on wild goose chases due to incidental findings. Exploring humane ways to spend the waning days or more uses very few resources and is reimbursed poorly. Hospitals have palliative care teams which move this process away from the acute care doctor, but this fragments care more and often increases costs. Hospice, both at home and in specific inpatient hospice facilities is big business and associated costs are huge, as we continue to medicalize the process of death.

Third party payers also influence costs by becoming part of our network of communication.  I heard once that administrative costs are half of a hospitals actual expenses. I think that it is impossible to really estimate the burden of billing for services since a significant amount of all of what we do as nurses or doctors, especially in the realm of record keeping, is about getting paid to the highest level for what we do. Legal influences also increase the cost of the care we provide. There are various estimates of the impact of the risk of being sued for malpractice on the medicine we practice. That, too, will be very difficult to estimate, since a large portion of how we think, how we document what we do, how we communicate is influenced by the internal picture of a courtroom with lawyers asking us to justify our actions based on standards of care for our profession.

Costs in hospitals are higher even than they need to be for the admittedly technologically advanced procedures we perform. This is due to the fact that much of what is done in a hospital can’t be billed for, such as the work of social workers and discharge planners, nurses and nurse managers, administrators and janitors. There are uninsured patients who require care and who are unable to pay even a little of their expenses. Hospitals do not usually function very far in the black, so the high costs we pay for care is probably about right, though individual prices for things do not necessarily correlate well with their value. Without the burden of billing and without the perverse incentives of third party payment, though, hospitals could definitely be more efficient and considerably less expensive.

Despite perverse incentives, there are bright spots, movement in the right direction. The American Board of Internal Medicine has started the Choosing Wisely Initiative in which most of the fields of medicine have chosen to unveil the most expensive least effective most commonly performed procedures or tests and marketed that information to both patients and physicians. This includes information about what procedures are appropriate to do for low back pain or chest pain, when antibiotics are helpful, which preventive procedures work and for whom.

Antibiotics in hospitals are associated with the development of Clostridium Difficile diarrhea which can be disabling and sometimes fatal. Antibiotics for this are sometimes effective but often not. It has been demonstrated for over 50 years that transplantation of healthy stool into the colon of a person with this condition can be curative, but it has been extremely slow to catch on. Hospitals are finally starting to develop protocols for doing this and it is likely to revolutionize the treatment of this disease, using a procedure that, at least theoretically, could cost next to nothing.

The evil drug companies have come up with 3 drugs to replace warfarin (Coumadin) which will probably make the use of injectable anticoagulants with associated hospital stays very rare and, since they don’t require blood test monitoring, make patients with blood clots and atrial fibrillation less dependent on doctors’ offices. This will also reduce the very common complications that warfarin patients have of bleeding or clotting due to varying levels, which is responsible for many hospitalizations and much disability. We have been slow to adopt these medications since we are more comfortable with the very resource intensive use of warfarin, but these new drugs will allow many more patients to be treated for conditions at home rather than in the hospital.

The Affordable Care Act has set up money for various pilot projects that involve delivering care in more efficient ways, including use of midlevel providers such as nurse practitioners and physicians’ assistants, and these people are becoming more important parts of healthcare teams and often do a better job than physicians of monitoring and treating chronic conditions.

I just learned how to do bedside ultrasound and am very excited about its ability to streamline and improve care. Small and affordable ultrasound machines that can live in a pocket allow me, as a physician, to get real time information about the function of internal organs that can help guide appropriate care and can reduce the need for imaging and the delays and costs associated with that. It can also help to focus my test ordering so that the imaging I do order is more appropriate. At the American College of Cardiology a researcher just announced results of a study comparing the use of a handheld ultrasound to physical exam by a cardiologist and found that it was vastly superior in many important ways. This is no surprise to me since I have been using such a machine for over a year and the impact on patient care is huge. Medical students are now learning how to use this technology and though it may take some time for it to diffuse into common use, its time will come.

Alternative therapies that tap into the connection between the mind and the body, and the mind’s ability to promote healing are gaining some respect. Because there is no technology behind this, so it doesn’t make anybody very much money, it has been slow to catch on, but folks like Herb Benson at the Harvard Medical School and Jon Kabat Zinn have been pushing to make mind body medicine take its rightful place among the medical therapies that really work. In our community we have an increasingly popular program of Mindfulness Based Stress reduction which has made a very significant dent in the burden of misery for people with physical pain, anxiety, depression and sleep problems.

Our local hospital continues to look for programs that will allow it to serve the community better. Tiny hospitals like ours don’t make much of an impact on legislation and so novel models of payment such as ACOs (accountable care organizations) which try to reduce costs by coordinating care of patients and having healthcare organizations have financial incentives to be more efficient, do not fit us.  If our hospital, along with representatives of the medical community and community members, had the money all of us spend on the healthcare we get through insurance, we could much more than pay for our medical needs. It would also become financially as well as morally desirable to prevent illness and reduce our need for medical care. This is the idea behind health care cooperatives, organizations such as Kaiser and Group Health in the Northwest, which have been quite successful.  We will soon have a clinic that serves people with poor or no insurance, the CHAS clinic, which will help provide care that will keep people out of the hospital. Their model uses multiple sources of funding to defray costs.

But what can you do about this as an individual and as a voter and community member?

As an individual: have discussions with your physicians about your goals of care.  If a doctor doesn’t know what you want or care about, he or she will likely err on the side of ordering too many tests or consultations or treatments. If your doctor doesn’t want to talk about this, there is a problem. Keep in mind that many doctors do have time constraints, but if they are juggling less data because you asked them not to order that extra test or procedure, they may just have more time for you. Go to the Choosing Wisely website and see what it says about your particular condition. If you have questions based on this, print out the information and bring it to your doctor. Discuss with your doctor what you want at the end of life. Fill out an Idaho POST form or a 5 Wishes form and have it in your chart and in your possession, discuss it with those you love as well.  Live well. Eat good food, lots of vegetables and fruits, fish, local grains and beans, fish, make meat be a treat, not a staple, same with ice cream. Do the things that give you joy, and if exercise isn’t something that gives you joy, go out for a walk regularly anyway. Don’t smoke. Take as few drugs, legal or otherwise, as possible. Stay well so none of what I have talked about needs to apply to you.

As a voter and citizen: try not to make knee jerk Democrat versus Republican judgments about legislation regarding healthcare. Neither party has it right, at least not yet. Read the legislation and think about what it says. Remember that Medicare IS too expensive and that it is not necessarily headed in the right direction, so legislation to change it in some way is not necessarily evil. Question high cost care, even if it’s something that seems sacrosanct, like hospice or preventive services. Get involved in community projects that support good health especially those which bypass or partially bypass the whole healthcare payment machine.  

What does expensive care look like and who are the 1% of patients who use over 22% of health care expenditures?

I have been working almost exclusively in hospitals for the last 17 months and I often get a chance to rub shoulders with the 1%, that is to say the people whose poor health puts them in the position to spend more healthcare dollars than the other 99% of the US population.

At the opening speech of the American College of Physicians annual meeting a few weeks ago Ezekial Emmanuel, an adviser to the US Office of Management and Budget and head of the department of Medical Ethics and Health Policy at the University of Pennsylvania gave some interesting statistics. In the United States, 1% of patients at the highest level of medical spending are responsible for 22% of healthcare costs and the bottom 50% of healthcare utilizers use a little over 3%. I looked at the article, from the Agency for Healthcare Research and Quality, and found that this percentage is relatively stable over many years, and, in fact, the costs are slightly less concentrated in the upper 1% than they were in 1996. Also, and maybe more dramatically, the top 5% of patients consume about half of healthcare costs.

So, after hearing these figures, I paid really good attention to the patients I saw in the hospital, trying to see who was most likely in that top 1%. Patients in the hospital are probably going to be the people who consume the greatest amount of resources, since hospital costs are by far the largest share of US medical expenditures. In 2011, hospital costs were over $850 billion, topping doctor and clinical services at $541 billion and prescription costs at $263 billion. The breakdown of total healthcare costs is pretty interesting and can be found here, at the Center for Medicare Services (CMS.)

The patients at the hospital who use the most resources are people with chronic diseases, the old and sometimes the very old, often poor people on public insurance, either Medicare or Medicaid, and occasionally the outlier who has been extremely unfortunate or spectacularly unwise. They are often obese and many smoke cigarettes, drink excessive alcohol or use damaging illicit drugs. Frequently they have chronic pain and are on regular doses of opiates and other sedating drugs. Many are depressed. These are patients who have been in the hospital for a very long time, usually in and out of the intensive care unit, often with multiple surgical procedures or specialist driven interventions. They have long lists of medications and are likely to have experienced some sort of medical complication due to the complexity of their care.

It is very hard to care for the 1%. They have had so many tests that it takes extremely keen data management skills to make sure that all of the incidental abnormalities are followed up and that procedures that have already been done are not repeated. Their medication lists are hard to follow, and rationale for care is difficult to tease out from medical records. They are often frustrated and jaded with caregivers because they have seen so many mistakes and heard so many contradictory explanations and plans from their many specialists and rotating hospitalists. Some of them will never be well, but nobody will take the time to explain this, and even if a doctor did take the time, the patient finds it difficult to trust that they know what's going on.

The 1% have had just about everything done to them. In some cases this means that they no longer want anything medical for the rest of their lives. More often, though, they have been through hell and it doesn't seem so bad, and so they would do it again. I see this pretty often with patients on renal dialysis. Out of a total Medicare budget of over $522.8 billion dollars in 2010, $32.9 billion was spent on patients with endstage renal disease (ESRD), who made up a little over 1% of the Medicare insured population. Patients with ESRD do not have enough kidney function to survive without regular dialysis, usually 3 times weekly. For most of these patients this means several hours at a dialysis center where their blood is circulated through a series of filters which act as an artificial kidney. Fluid is removed, electrolytes are adjusted and toxins are filtered out. Sometimes medications such as antibiotics or blood cell stimulants are administered. Patients on dialysis are dependent on machines for life support, though they can walk around between sessions and do regular person things. Usually, to be on dialysis, a person has been sick a long time, and the kidneys are not the only organs that have suffered, so most patients with ESRD are at least a little bit sick all the time. Most are disabled from work, and the majority are not able to pursue an active life.

Other patients in the 1% are the old and very old, people over the age of 80, often with multiple chronic medical problems, at least one of which decompensates and lands them in the hospital. As a hospitalist, I often have the opportunity to talk to these patients or their family members about goals of care. Sometimes I find that they want a reasonable attempt to cure the problem at hand with the expectation of being able to return to home or nursing home with about the same level of function as before they got sick, and that they understand that it is also possible that an illness that is so bad that it lands them in the hospital might also be fatal or lead to an unacceptable level of disability. We then address the question of "code status", whether they would want to have chest compressions and be on a ventilator should vital functions cease, and I explain that, in a person such as they, none of this is likely to be effective in bringing them back to life. The actual percentage of success for CPR in this population is about 5%. The downside of CPR, I will explain, is that it means that they will not have a peaceful death, and often it will be painful and traumatic. It is hard to have this talk, because it makes the poor patient imagine their death, hardly the comfort I would prefer to be offering. Some patients have already thought it through, and even before the discussion is under way they tell me that they have had a good life and when their time comes they would like to be allowed to depart in peace. Some will hear the whole discussion and say "I think I'd like you to just give it a try and if it doesn't work, don't have me live forever on machines like a vegetable." This is then translated into a very simple medical order, "full code", and the patient will then get just about every medical procedure available that might even remotely lengthen their life until such time that any observer would consider that they are just being kept alive on machines like a vegetable, at which time life support is gently discontinued. The process of getting to comfort care from cardiac resuscitation can be quick, but more often involves an agonizing period in which a loved one is festooned with tubes and wires, pale, miserable, helpless and confused.  "Full code" for the patient with multiple medical problems is a terrible thing.

Another 1% patient is the drug abuser or alcoholic, usually also a smoker. Some of these patients have pretty amazing stories. They have lived on the edge of the world for so long that being in the hospital is not necessarily any more dramatic than the rest of their lives. They develop blood stream infections, skin and muscle abscesses, AIDS and its complications, hepatitis C and its complications, cirrhosis of the liver with massive bellies and stick-like arms and legs. They come in to the hospital on multiple occasions, so sick we think they must die, and then recover, only to go out and do it all again. They want everything done, have no money or insurance to pay for it, and often leave against medical advice before we are even done treating them. Wow.

A smaller proportion of super healthcare utilizers have cancer, despite the fact that they lived well and are still young. They have genetic diseases such as cystic fibrosis, have organ transplants or bone marrow transplants or are babies born too early. Or they were hit by a car and developed multi-organ failure. Or they were bitten by a rodent with the plague and developed shock and had their limbs amputated. Or something else horrible happened that we could all stay up nights worrying about.

So what does it all mean and what should we do about it? Clearly a healthcare dollar buys much more happiness in the bottom 50% of Americans who make up only 3% of all healthcare spending. For these folks, their pneumonia is cured by an oral antibiotic or their broken arm is set and splinted or their head laceration is sewn up or they receive effective contraception or other preventive services which keep them on their feet, happy and functional. For the very sickest, a healthcare dollar buys close to nothing, no joy, no productivity, maybe one saline flush after the dose of antibiotic goes in.

I truly don't know what to do about it. It is not right that folks who persist in self abuse use resources over and over while the working poor can't even afford basic healthcare. But it is also not up to me to police the choices that people make about how to live their lives. It is not right that huge amounts of money are spent to minimally lengthen the lives of the very old. Most of the very old with whom I have had this conversation agree heartily on that point. It is not right that physicians continue to advise very expensive technological care for patients near the end of life, especially since research shows (at least with lung cancer) that a palliative care approach both lengthens life for those patients and improves its quality. I think that "full code" should not be the default assumption in patients for whom the likelihood of it being effective is very low. I think that it is up to us, as physicians, to figure out some way to educate our patients about this. Perhaps we need an advertising campaign to "Live well, die in peace," complete with a very accurate depiction of resuscitation versus a comfort care approach at the end of life. We need to change  our payment structures so that it doesn't benefit us, as doctors or hospitals, to make patients dependent upon us. We need to have an accurate idea of costs and feel comfortable bringing them into discussions with our patients. Primary care doctors need to have the time and expertise to discuss resuscitation with patients (who know and trust them) as they age and develop chronic medical problems. We all need to take more time to think about the what these many tests and treatments we prescribe are really good for and be a little more focused about applying them. If we reduce the complexity of the care we provide, we will free up time and energy to actually sit and listen to our patients, a much neglected but often magically effective treatment strategy.

How to learn bedside (point of care) ultrasound: tips for the interested internist

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was 3 days long and cost a little under $700 and changed my life forever and made me a better doctor.

Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.  Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret the images takes time and is inaccessible. The American Academy of Chest Physicians (ACCP) is the professional organization that represents critical care and pulmonary doctors, and their journal, Chest, has recently adopted ultrasound education via an online section called the Ultrasound Corner. The editorial by Seth Koenig MD accurately describes the power of the technique in critically ill patients, and the educational offerings of the ACCP for intensivists.

So, first of all, why might an internist want to learn bedside ultrasound and how might it be merged effortlessly into patient care? When I see a patient now, instead of taking their pulse and placing my stethoscope on their chest and back, hearing the vague taps and clunks and bubbles and whooshes of the internal organs I have come to trust are in there, I open the ultrasound machine that lives in my white coat, squeeze a little gel from a tube I keep warm in my pocket, and the patient and I look at heart, lungs, liver, spleen, kidneys and bladder. Most of them, those not blind or in a coma, think this is incredibly cool. At the end of this exam, which takes all of 5 minutes if I am thorough, I know whether their heart squeezes normally, whether there is excess fluid in the lungs or pericardial sack, whether there is fluid in the belly, whether the kidneys are blocked and whether the bladder is emptying normally. Sometimes I also see things like gallstones or tumors or blood clots. I can often evaluate whether the patient is dehydrated by looking at the inferior vena cava, the vein that returns blood from the lower body to the heart.

If a patient loses consciousness, like one of them just did today, I can quickly rule out a major heart attack as the cause of the problem. My little machine is not quite as sensitive as the huge expensive ultrasound machines, but it is pretty good and I can usually be sure about the answers to the questions that are most vital to treating my patients immediately.  If a patient has chest pain and my ultrasound of their heart is good, I can be much more confident about whether the chest pain is due to a heart attack. Several times since I have been doing this, I have found an unexpectedly poorly functioning heart in a patient whose story of chest pain was not particularly convincing for coronary artery disease and was able to advocate for quick or aggressive treatment which expedited treatment and saved heart muscle. The ability to evaluate bladder size is powerful. The ability to rule out hydronephrosis (urine backed up in the kidneys) allows me to avoid excessive imaging in patients who have a change in their kidney function. We often see patients with big bellies who may or may not have excess fluid due to cancer or liver failure or heart failure, and it is so very convenient to be able to make the distinction between fat and fluid without waiting for an imaging procedure to be done.

But how does a person learn how? I took 3 emergency ultrasound CME classes with live models and hands on instruction, one on line ACCP class in critical care ultrasound and bought the pocket Vscan ultrasound from GE which I use at least once on just about every patient, friend and family member. The dog has barely escaped due to excess fur. I then took a mini ultrasound fellowship with the department of emergency ultrasound at UC Irvine under the direction of Chris Fox MD. This involved 4 weeks of scanning in the ER, going over saved scans, teaching medical students and studying online material. It was kind of expensive: $5000 for the fellowship and 4 weeks off of work in a place where I had to stay at a hotel. But I am way better at it than I was, I know what the protocols are and can do ultrasound of things that internists don't usually examine that way, including eyeballs and uteruses and testicles and thyroids and skin structures. My Vscan doesn't have a linear transducer, so I haven't been able to improve as fast at procedures that need shallow scanning, such as blood vessels, muscles and joints. I'm thinking that I will need to have access to a machine that I can use whenever I want, so I will probably buy an ultrasound machine with a linear transducer from China where the technology costs about 1/10th what it does here.

There are other ways to learn bedside ultrasound, including year long fellowships, which are usually based in emergency rooms. There is a program at Harvard that lasts 5 or 10 days that involves participating in scanning at the radiology department, and reviewing many scans every day. I would love to do that. The limitation of learning ultrasound techniques from real ultrasonographers and radiologists is that they do a more thorough exam than we usually have time for, and the perfect protocol for quickly determining relevant information in an internal medicine patient is not the same as what an ultrasonographer does when we order specific tests. The ACCP has excellent courses with live patient scanning, which are apparently quite expensive. I would also love to take one of these. There are many for-profit groups that offer training as well. It's not hard to find a course that will get a person started, but it does take many hours of practice and the ability to review scans with experts in order to feel comfortable. If our hospitals or clinics decided to embrace bedside ultrasound, and radiologists bought into it (and I actually think they would) we could really benefit from the teaching of our radiology technicians and MD radiologists.

It continues to astonish me how much more effective I am as a doctor with an ultrasound than I was as a doctor without one. I make diagnoses I wouldn't have thought of, save patients radiation and hospital days and quickly have information I need to focus treatment. I understand why my busy colleagues haven't embraced this technology yet, but when they do they are going to love it!

Attending the Annual Meeting of the American College of Physicians in San Francisco 2013: becoming a fellow

The American College of Physicians is an organization of internal medicine doctors, about 133,000 of us, which had its inception in 1915 with the aim of promoting the science and practice of medicine. It is the second largest doctors’ group in the United States, and has members and chapters  throughout the world.  The college has representation in the American Medical Association and influences government health policy.  

The ACP had its annual meeting this year in San Francisco, which is a wonderful place. It was located at the Moscone Center, a big convention hall with gorgeous architecture, and the weather was spectacular. It was right near Chinatown, so I didn't have to eat the overpriced pastries and coffee from the convention vendors, or sell my soul to the devil by eating what the industry sponsors supplied in the hall of evil advertisers. 

I went this year because I was receiving my fellowship in the college. If an internist has been doing medicine for long enough and has distinguished him or herself in some way, in my case by learning and teaching, he or she can be awarded a fellowship in the American College of Physicians. It is necessary that the physician in question be a member of the college, which is a yearly commitment of $525 for me, since I am out of school more than 8 years. It is then necessary to pay an additional $150 for fellowship initiation and have two present fellows write letters of recommendation. There are various categories of being distinguished that one can fall into, which are outlined in the Advancing to Fellowship section of the ACP site. I'm not entirely sure that it means anything, really, but I thought that it would help me to express to people who I wanted to work with in the medical world that I am not a bozo. After being advanced to fellowship, I now can put four more letters after my name: after MD comes FACP, which does look kind of nice.

There were 3000 new fellows this year, 500 of whom went to the ACP meeting, wore graduation gowns and caps and were recognized at the convocation ceremony. Also a much smaller group of doctors received Masters recognition, and quite a few received specific awards for things like research and teaching and service. I usually prefer not to go to ceremonies because they are tedious, and this was a little tedious but also wonderful in some ways. I realized as I watched the folks getting the Masters recognition that these were the grand old men and women of medicine and that their life stories were probably fascinating and filled with sacrifice and dedication and hard work. Also the president of the college, who struck me as a person who would not give a good talk, gave a very good talk. Dr. David Bronson has been involved in all of this ACP business for years, but distinguished himself in preventive medicine at the Cleveland Clinic as an internist. He pulled no punches in his speech, which I will not paraphrase since I would certainly not say it as well. What I heard, though, was that we, as part of the American healthcare system, are responsible for how expensive and ineffective it has become and we need to pull together and fix it, and it will take a long time and a lot of work. He also recognized that many of us are already doing that work and that it is important. He gave lots of details, which I probably have deep in my gray matter somewhere and showed a brief film which reminded me to be as empathic as humanly possible, and we filed out. We returned our regalia and were then done. 

But that wasn't the most interesting part of the annual meeting. The "Scientific Sessions" (actually just lectures by experts) were excellent, covering all of the major high points in internal medicine practice. Some of the talks dealt with things like giving a talk that isn't boring and providing effective leadership, not being wasteful of our patients resources and avoiding errors of miscommunication. It was possible to attend only a small fraction of these, and then, if one was really motivated, shell out more money (the conference itself was pretty expensive) for recordings of all of the sessions. I was impressed with most of the speakers who had really prepared and presented subjects that they appeared to find fascinating in a way that was engaging. I learned a great deal and expect to learn more when my CDs of the rest of the meeting arrive. 

Naturally I was disappointed in the fact that bedside ultrasound, which is clearly transformative for internists, had very little air time in the meeting. There was one workshop in bedside ultrasound of the heart and abdomen, and that was so popular that the waiting list had over 100 people on it. I didn't go, since I have now had enough bedside ultrasound training that I could probably teach it, but it is clear to me that internists are aware of the importance of this and only lack time and teachers at this point. In talks about things like assessing patients with chest pain or sepsis, bedside ultrasound was not even mentioned, which didn't surprise me, but it would have been good to see that these influential folks were moving in the right direction. General Electric, which makes the pocket ultrasound machine that I use, and that internists would find most convenient in their practice, exhibited only one product, a radio tracer, analog of cocaine, which deposits itself in the brain in such a way as to differentiate benign essential tremor from Parkinson's disease, which is hardly transformative, and probably mostly superfluous. 

I probably won't go to the ACP meeting next year, since it is in Orlando, Florida, which is pretty far off of my usual stomping grounds. Still, I am happy about the general direction that the ACP is taking, with real leadership in turning medicine into a leaner and more effective service. 

Hospital readmissions: what exactly is the deal with this?

Medicare has been costing the government a scary amount of money for many years, and the very popular program, established in 1965 under President Lyndon Johnson to pay for health care for seniors, has undergone many changes since its inception. Because the government funded program was a very deep pocket from which the sick could pay hospitals and doctors, it influenced the cost of medicine and the volume of health care in a pretty profound way.

In 1983 Medicare began to pay hospitals for care of patients in a way that was felt to be likely to reduce unnecessary and expensive care. This was the Inpatient Prospective Payment System, the IPPS.  Instead of paying a hospital for everything that was done to a particular patient, which would potentially encourage higher costs and higher utilization of services, Medicare began to pay hospitals a certain amount for each kind of sickness. These categories of sickness were called Diagnostic Related Groups (DRGs). If a patient had a particularly bad pneumonia, the hospital would get a certain amount of money, encouraging them to treat the patient as quickly and cheaply as possible. Doctors were still paid according to how much they did, but hospitals received a bundled payment for stuff such as bags of IV fluid and antibiotics and CT scans. Many hospitals closed, and the ones that survived learned to discharge patients earlier, use less expensive resources, use the DRGs that paid the most (as much as they could without defrauding the government) and also shifted some of the costs to patients who were insured by private companies.

There was concern that hospitals could game the system by discharging a patient, potentially too early for the patient to really make it at home, and then readmit the patient to the hospital and get paid again. And, indeed, that does happen. As physicians we were (and are) strongly encouraged to get our patients out of the hospital at the first reasonable moment, and the constant nagging and puppy eyes of the discharge planners would often make us send patients home before we felt it was wise to do so.

In 2011 Medicare announced that it would pay hospitals less for taking care of patients if records showed that the hospitals had too many readmissions of Medicare insured patients within 30 days of discharge. This is really quite a random number, based loosely on how long it takes the moon to orbit the earth (actually 27.3 days.) It was thought that, if a patient came into a hospital, got fixed up properly and was discharged, that patient should stay well for slightly longer than it takes the moon to go around the earth. So if that patient came back to the hospital before the moon made it entirely around the earth, it was likely that some mistake or carelessness had been committed. Equally randomly, it seems to me, they decided to look at just three diagnoses, heart failure, myocardial infarction and pneumonia, to start with.

I'm all for punishing hospitals for convincing me to discharge patients early against my better judgement, but that is not what is happening, in my recent experience.

I have taken care of several patients, readmitted before 30 days had passed, in the last few weeks. Their stories are varied, but don't really represent poor care. The JAMA (Journal of the AMA) has occasionally visited the concept of hospital readmissions, and some of the articles are excellent, exploring the idea that readmissions don't necessarily represent dangerous care and that they are indicative of a population of patients who don't have adequate access to good medical care outside of the hospital (look at this article for a good discussion, though you only get the first page because JAMA is proprietary.)

So I'd like to look at some of the examples to see if there is a pattern.

1. 50 year old man with alcoholic cirrhosis who lives on the street and has just recently been diagnosed. He has no insurance and no regular doctor, and though we give him an appointment to see a doctor after each discharge, he never makes it to these appointments, sometimes because he gets sick with massive ascites before he can get there.

2. 88 year old woman, discharged after a long battle with pneumonia to her home and pets, returns to the hospital weak and short of breath. She appears to have worsening chronic lung disease on further evaluation and be too weak to return home. It was still worth a try!

3. 29 year old woman, uninsured and with very bad luck and 2 forms of cancer, discharged to assisted living, returns in a day, short of breath and anxious. She has been too anxious to actually take her anxiety medications, and hasn't yet seen her oncologist back for treatment of both cancers which are still quite active.

4. 60 year old man with dialysis dependent kidney disease who was very grouchy and obstructive in the hospital, returns after a day in a nursing home because he is grouchy and obstructive.

5. 87 year old woman with end-stage kidney disease, also on dialysis, has been in the hospital approximately once per lunar orbit for 18 months for problems such as pneumonia and urinary tract infection, admitted with shortness of breath and a large collection of fluid in both lungs.

I'm thinking that a really great and very motivated outpatient doctor who goes the distance and visits patients in their homes and treats patients for free and lets the homeless ones crash on her couch could have averted all of these readmissions. I'm also thinking that this particular doctor is not just a dying breed but virtually nonexistent. In the absence of this doctor of whom legends are written and ballads are sung, a good hospital will continue to be a (very expensive) refuge. The costs to those patients who have no insurance in this group is huge, but they have no resources and will never pay, and the hospital knows this and stays afloat in some other way. It's hard to know what to do with our well established cultural belief that everyone needs dialysis at the end of life unless they vigorously oppose it, which is what results in frequent readmissions of patients with end-stage kidney disease. Clearly the fact that a hospital is usually the only place that a person with no resources whatsoever can get good medical care will continue to drive frequent readmissions of this group of people.