Mr. D is an 80-year-old gentleman who is treated in the hospital for congestive heart failure (CHF) with a question of pneumonia. He is deemed de-conditioned secondary to his medical illness and is sent to an extended care facility. He returns from the extended care facility 18 hours later with fever and shortness of breath. The emergency department (ED) attending speaks to the primary care attending who took care of him during his previous admission; the primary care physician now wants the patient on the hospitalist service.
Does this scenario sound familiar? We have all dealt with such requests during our hospitalist careers and have wondered what the potential repercussions might be.
There is a danger—always present—that the hospitalist service will be used as a receptacle for undesirable patients. The word undesirable is used loosely here to include complicated patients, patients who keep returning to the hospital with recurrent problems, patients with no insurance or poor insurance coverage, and, of course, problematic patients with problematic families.
Complicated Patients, Complicated Consequences
In the scenario described above, the patient comes back with the same diagnoses but now winds up on the hospitalist service. From an ethical perspective alone this seems objectionable. What about the legal ramifications of such a situation? Two different admissions with the same diagnoses occur within a short time frame, but different physician groups are involved in caring for the patient. Additionally, such scenarios often cause patient dissatisfaction and even hostility. Surely it doesn’t make the patient happy to hear that the primary care physician no longer wants the patient on her service.
The hospitalist service usually deals with more complicated patients than the average physician. Often, the primary physicians, who have more constraints on their time, want hospitalists to take care of the more complicated patients. This becomes a problem when a patient who was on a physician’s service is readmitted. Naturally, the primary doctors are frustrated with the recurrent admissions. A case could be made to admit to the hospitalist service when the readmitting diagnosis is different from the previous discharge diagnosis, but when the discharge and readmission diagnoses are the same, the jury is hung.
Loss of Revenue
To many physicians’ minds, a readmission occurs less than 24 hours after the previous discharge; to others, however, a readmission means something else. For example, Medicaid, considers a readmission one that occurs within fewer than seven days of the previous admission. This situation brings about an automatic readmission review, and the readmission is denied if it is perceived that the patient discharge was not appropriate or was premature.
In the case of Mr. D, the hospitalists might end up getting a denial—and suffering a loss of revenue—for a readmission that had nothing to do with them. Hospitalists are seldom cognizant of such repercussions because we are programmed to perform patient care without contemplating the financial implications.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) collects data for their core measures program. A part of this effort also involves reporting the readmission rate within 14 days—both for the same diagnosis and for a different one.
Looking again at the case of Mr. D, the core measures would have included estimation of ejection fraction, use of angiotensin-converting enzyme inhibitors, and appropriateness and timing of antibiotics in pneumonia. The hospitalists, who had no control of these indices on the first admission, might have been penalized if these particular measures were not carried out and their omission contributed to the patient’s readmission.
Another potential point of contention is the practice of admitting patients to the hospitalist service once the resident teaching service is capped. This is institution-specific. In cases where the entire resident overflow is admitted to the hospitalist service, patients seldom go back to the teaching service because ED doctors label them as belonging to the hospitalist service. Many of these patients either have no insurance (or have Medicaid); in addition, they often have multiple health problems, and noncompliance runs rife. Because unscheduled readmissions are viewed negatively under current guidelines, patients who are handed off in this manner can cause resulting penalties for the hospitalists who end up serving them.
Extended Care Readmissions
Patients with established primary care physicians often go to extended-care facilities where there is another physician of record. At readmission, the new attending is recorded as the patient’s physician. The prior primary attending might have wanted to follow the patient during the readmission. Unfortunately, the ED physician will typically call the newly assigned attending because that is the name that appears on the transfer note. If, at this time, the new attending decides to admit the patient to the hospitalist service, a misunderstanding may ensue. The original primary care attending may view this as an attempt on the part of the hospitalist service to appropriate patients, though the decision to admit to the hospitalist service is seldom made by the hospitalist.
The pitfalls of these practices are accentuated when the readmission occurs within a relatively short time frame. Another downside may arise if the new attending, who knows little of the patient’s history, orders another extensive inpatient workup. This example highlights a potential, and avoidable, cause of spiraling healthcare costs.
The Hospitalist’s Role
We practice in a milieu of increasing scrutiny. Pay for performance is gaining momentum and acceptance. Two years from now, non-compliance with specific indicators, such as readmission rates, will be met with financial penalties. Hospitals complain of decreasing reimbursements. Unscheduled readmissions to the hospital continue to be a source of lost revenue and patient dissatisfaction.
The hospitalist plays a central role in the management of the patient from a medical standpoint. Rules of admission to the hospitalist service vary widely amongst different institutions. Often, depending on patient load and available staffing, these rules are in flux even within institutions. Procedures run the gamut from the so-called “closed system,” in which only specific physicians can admit patients to the hospitalist service, to the “open system,” in which everyone is welcome, on a voluntary basis, to admit to the hospitalist service. The potential pitfalls of the open system will become more and more apparent in the years to come, and many of us will be forced to rethink our models of healthcare delivery. TH
Dr. Chabria is a hospitalist at Waterbury Hospital, Conn., and a clinical instructor at Yale University School of Medicine, New Haven, Conn.