Shell Game

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Are declining rates of inpatient utilization really a marker of success?

One of the things I like the most about the ER is that it is the real “No Spin Zone”.  More accurately, it’s the “No BS Zone”. The dynamics are straight forward. It’s just me and the patient. He’s sick and I’m there to help. It doesn’t matter if he smells like moldy gym socks or if he’s completely broke. It doesn’t matter if he likes me, and it certainly doesn’t matter if I like him. He’s sick – perhaps even very sick – it’s 3am and I’m one of the few human beings in the area who is crazy enough, or care enough, to be awake to take care of him.

So don’t tell me any baloney. “No, that cut on your hand didn’t come from you hitting the wall. The deformed knuckle and jagged cut tell me you hit someone in the mouth. It’s ok. I don’t care about that. Maybe the cop with you does, but I don’t. I just want your hand to heal properly. That’s why I’m here. So just tell me the truth.”


I suspect I’m like most EPs in this regard. We’ve heard all the stories, the excuses, the ruses and subterfuges. We’ve heard the subtexts, the rationalizations, and the diversions, and we just want the truth so we can get down to the business of getting you better. That’s my goal. I like it when you like me. I like it better when you pay your bills. But mainly I want to find out what is wrong with your health and make it better. It’s pretty simple.

Screen Shot 2014-04-07 at 11.01.52 AMSo when a colleague sent me a study about how the new health law was working by helping lower hospital admissions, my first reaction was, “Really? That’s not what it looks like to me.” The study, by a financial consulting firm, was touted to be a “data-rich study to assess whether there is early evidence that progress is being made with the transformation agenda by hospitals and physicians in the greater Chicago area.” If the transformation agenda was taking hold, said the study authors, they would expect to see declining inpatient utilization, beyond the “recession linked factors.”

Let’s start by examining these presuppositions about inpatient utilization. First, were they in fact impacted by the recession? While it is true that during the recession overall health care spending has shown signs of slowing down, this was largely due to changes in the pharmaceutical market. Blockbuster drugs like Lipitor, Plavix, and Singulair went off patent in recent years to be replaced by low cost generics. Almost three quarters of the US prescriptions cost $10 or less in 2012.


The authors seem to reason that, in a recession fewer people have employer provided insurance, and as a result they don’t get admitted to the hospital. But that’s not how it works. When you get sick you go to the ER, whether you’ve got insurance or not. And if you’re really sick, you get admitted to the hospital, whether you’ve got insurance or not. So it’s not the really sick people that a lack of insurance impacts, it’s the marginally sick – the man with a hip that’s bone on bone who doesn’t get his total hip.

So it’s the “suffering but not dying” that aren’t getting admitted when inpatient utilization is down. But aren’t we supposed to relieve suffering? Isn’t that the point? Why are the study authors so pleased about this decline in admissions?

Beyond a decline in inpatient utilization, the study authors want to see more “transformation.” This transformation, according to the study, will be the result of “aggressively increasing intensive medical management.” I wonder if these financial managers really know what that phrase means. It means that the man with the hip that is bone on bone gets more pain pills and a date with surgery several years hence . . . if he gets it at all. “Intensive medical management” sometimes means that if the patient’s CHF is getting worse, just double the Lasix and schedule a follow up appointment in six months instead of one. But what happens when the pain is unbearable or the kidneys start failing and the hypokalemia, or hyperkalemia, results in cardiac problems? That’s right. Send them to the ER. Oh, and don’t admit them. Just let them stay in the observation unit, or the hallway, while the emergency physician corrects their electrolytes. Now that’s aggressive. And it might even mean fewer admissions. But the reality is, did it relieve suffering?

The next indicator of progress toward the transformation agenda that the authors noted was “accountable and risk-based care that is having an attributable statistical impact above and beyond increased medical management.” I had to think about that a little while to really understand what they were saying. Accountable and risk-based care, if I understand it properly, is when the providers, doctors and hospitals, lose money if their patients stay sick and cost too much. Of course, there are myriad ways in which doctors and hospitals waste money. We talk endlessly in these pages of tests and procedures that don’t add to the health of the patient. And to the extent that proper management identifies inappropriate utilization, by doctors and patients, and eliminates or penalizes such, we will all be the better for it. Especially the patients who didn’t need the tests and procedures in the first place.


But cost savings that are admittedly “above and beyond” the effects of aggressive medical management (i.e. more efficient medical care) is really just denial of care. And that goes against the reason I went into medicine. If the patient I’m looking at in the ED would do better, in my opinion, if they were admitted, that’s what I want to do. The problem with having the doctor at risk for a patients over-utilization is that it puts us in an adversarial position. And that is not the position I want to be in. The patient does better, but I get penalized. Or conversely, the patient gets sent home or waits in the hallway, but my administrators reward me. As I said in the beginning, my goal is to get the patient better. It’s really nice that I make a good living off of doing that. But, in fact, that’s not why I do it. In reality, I’m on the patient’s side.

The authors noted that hospital admission rates had been declining steadily over the last decade. But they seemed to point with some pride to the fact that hospitalization for surgery of all types had dropped the most in the elderly category. They pointed to “structural changes – such as increased use of outpatient care” as a possible explanation. So those people who actually needed surgery still got it, but in a different location? In reality, is that an improvement? Can a hospital provide the same service as a Surgi-Center at the same price? If not, why not?

The authors final conclusion was that “doctors and hospitals have started to change the way they care for patients.” If that means that I order fewer tests, and order fewer procedures that do the patient no benefit, then that’s good. But if that means that we have burdened the hospitals with so many regulations that the only efficient place to see patients is in urgent care and surgi-centers and everyone else is managed by the emergency department, we’ve got problems. It may mean fewer hospital admissions overall, but the reality is that it’s just a shell game perpetuated by a few financial managers.


FOUNDER/EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than 30 years, working exclusively night shifts for the past 20 years in emergency departments across the country. During that period, he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

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