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Nonsensical mandates

December 2013

Published in the December 2013 issue of Today’s Hospitalist

ROBERT WACHTER, MD, closed the 2013 Society of Hospital Medicine annual meeting by identifying cost and waste reduction as the new planks of hospitalists’ value proposition. But as the first-year results from Medicare’s ACO program have demonstrated, lowering health care costs will prove more difficult than improving the quality of care.

To achieve significant cost savings, most physicians will have to change their approach to treating patients, but that promises to be an uphill battle. In a study published this summer in the Journal of the American Medical Association, 64% of physicians reported believing that the major responsibility for cutting costs lies somewhere else than with them. They instead identified as likely culprits trial lawyers, health insurers, hospitals and health systems, pharmaceutical and device manufacturers, and patients.

To reduce health care costs right, hospital administrators will have to be adept at extracting cost and utilization data that are timely and accurate, map end-to-end processes, isolate root causes, invest in core-skill improvement, and engage physicians. Unfortunately, we have scant evidence that administrators possess such capabilities.

In July, American Medical News confirmed that while hospital CFOs report more collaboration with physicians in an effort to improve care coordination, only 20% reported being “very prepared” with the necessary infrastructure to support outcomes-based management and quality. Only 15% claimed to be very prepared to analyze and communicate physician-specific data, while 14% said they were very prepared to manage case coordination. Only 7% reported being very prepared in terms of population health management.

Many of the remaining unprepared hospital administrators “who have a typical shelf life in hospital jobs of between 18 and 24 months “are pushing the panic button instead. To hastily shore up declining profit margins, they are resorting to indiscriminate cost-cutting and exerting relentless pressure on hospitalists to cut corners.

Sound familiar? Here are some nonsensical mandates (NM) hospitalists often face from administrators and a level-headed response (LR) to each:

NM: A daily census of 16-18 is too low. Hospitalists must see 24-25 patients.
LR: Hospitalists seeing 24-25 patients, given a case mix index of 1.6, is not conducive to high-quality care, patient safety, patient satisfaction or physician retention.

NM: Hospitalists must finish their rounds before noon.
LR: While it is reasonable to expect hospitalists to see sicker patients first, they cannot be expected to finish a full day’s work in half a day.

NM: Hospitalists must finish all discharge orders by 11 a.m. to make beds available. And if hospitalists aren’t reporting to work by 6 a.m. to start discharges, we need to add a time clock for them.
LR: Many discharges require nursing follow-up, case manager involvement, consultant/ surgeon clearance, and hospice, SNF, acute rehab, or durable medical goods coordination. Overwork, poor processes and staffed bed shortages are far bigger impediments, not the time that hospitalists start working in the morning.

NM: Hospitalists are refusing admissions. They must admit all patients, even those who are primarily surgical patients.
LR: Treating patients who have a primarily surgical diagnosis is outside hospitalists’ scope of practice, hospital privileges and malpractice coverage. If specialists are available, they should admit; if they are not available, you need to investigate as to why. Plus, Medicare may consider medically unnecessary hospitalist services over and above the surgical global fee to be inappropriate.

NM: Hospitalists must reduce the gap between average length of stay (ALOS) and geometric mean length of stay (GMLOS).
LR: Mathematically, GMLOS is designed to minimize the impact of outliers, so it will of course always be smaller than ALOS. By not removing the outliers from ALOS, you are comparing apples and oranges “especially when the hospital can qualify for additional payments for high-cost outlier cases.

NM: Hospitalists’ patient satisfaction scores must be on par with those of the surgeons.
LR: The differences in scores between surgeons and medicine physicians exist, not because surgeons are better physicians, but because patients admitted electively are known to be more satisfied than those with an acute illness who come through the ED. For an apples-to-apples comparison, make sure you evaluate similar populations “and remember that medical and surgical patients aren’t the same.

NM: A nurse practitioner (NP) should be on the night shift instead of a physician because NPs are more cost-effective.
LR: Night shifts are difficult enough for a well-trained, experienced hospitalist. Having an NP admit 12-15 complex patients at night while cross-covering as many as 90 patients would be dangerous in terms of patient safety, patient satisfaction and malpractice liability. Those problems will not be offset by insignificant cost savings. Regardless, a hospitalist would need to be on call at night for backup anyway.

NM: Hospitalists must write a ‘D’ by the patient’s name on the white board at the nurse’s station when the discharge order is written.
LR: Other than wasting hospitalists’ time on clerical tasks, it makes a mockery of electronic health records and HIPAA.

I could easily go on with more mandates about core measures, observation status, readmissions, medical records, meeting attendance and other important day-to-day hospitalist activities, but you get the picture.

As Mark Twain said, “You can’t depend on your eyes when your imagination is out of focus.” These and other myopic mandates “no matter how forcefully made under the guise of efficiency and cost reduction “will not reduce health care costs while improving quality. Instead, they will drive up long-term costs as a result of physician burnout, substandard care and increased liability.

Abhay Padgaonkar is a management and health care consultant, author and speaker. He is the president of Innovative Solutions Consulting LLC and blogs at innovativeThinking. He advises clients of all sizes on challenges related to performance improvement and can be reached via e-mail at abhay@pobox.com.