Admission, Discharge and Readmission Policies - No Better Example Of Business Driven Pseudoscience

One of the recurrent themes of this blog is that the application of science to medicine, especially at the public policy level has plummeted over the past three decades.  That has been directly attributable to the influence of business on all levels of government.  One of the more pervasive themes is that the behavior of health professionals is best accomplished by incentivization.  In other words financially punish physicians to get them to change their behaviors that you don't want or financially reward the behaviors that you want them to produce.  I haven't looked at the scorecard lately, but my guess is that the punishments greatly outweigh the rewards.  Maybe my perspective has been skewed by working for an HMO for many years that considered it a reward if they "held back" part of your salary and then gave it to you if all of the physicians in your group met the desired productivity targets.  I am sure it took the MBAs a while to dream that one up.  The equation seems to be as simple as -  "OK here is what we want the goal to be.  We don't want to pay out any rewards anymore.  Let's just penalize people for not meeting the goal until eventually everyone is compliant with the goal."  There is probably no better example than the Medicare Hospital Readmissions Program.

A recent editorial in JAMA notes that the 2013 readmission rates for Medicare patients is about 18% within 30 days (1).  That is associated with a potential cost of $26 billion.  Since 2010 Congress has levied a 3% of Medicare reimbursement penalty on hospitals who have readmission rates that are considered too high.  The problem is that 80% of hospitals are being penalized are safety-net hospitals or those that have a disproportionate share of low income patients.  Those hospitals are more likely to be penalized all three years since the penalty started  and they are more likely to be the hospitals with the lowest operating margins.  The likelihood of penalty also correlates with the percentage of patients treated who are elderly and live with poverty or disability.  

The authors opine that hospitals should not be penalized "because of the demographic characteristics of their patients."  They point out that the evidence suggests that is exactly what is happening and they conclude:  “Targeting hospitals for penalties, even if indirectly, simply because those hospitals care for more poor people is not good policy”.  They use this as a foundation to build their argument for a proposed policy initiative – The Hospital Readmissions Program Accuracy and Accountability Act of 2014.  It builds in safeguards for hospitals treating patients from a disadvantaged socioeconomic status.   

The obvious problem with the authors’ logic here is that they seem to not realize that discrimination against patients of the lowest socioeconomic status has been institutionalized and occurring for decades.  The people I am referring to are those people with addictions and severe psychiatric problems.  The facts are clear.  For the past 30 years, even though psychiatric disabilities rank as some of the top 10 disabilities by any measure, they get a much smaller fraction of the health care dollar for care.  I have used the example of a middle-aged man or woman being hospitalized through the emergency department for acute chest pain.  I don’t know the fraction of those people who are discharged the next day.  But consider that basic scenario if the evaluation of chest pain turns out to be non-cardiogenic.  In the hospital where I have worked that generally means an evening on telemetry and serial troponins and either a stress echocardiogram the next day or an echocardiogram and a stress test.  Price tag about $25-30,000 for less than 48 hours in the hospital.  On the other hand,  let’s say a person has an exacerbation of an affective psychosis and is not able to function at home or has put themselves at risk.  The will be hospitalized in a very low tech psychiatric unit, the goal of which is to discharge them when they are no longer “dangerous” or to discharge them upon request if they cannot be held involuntarily.  Irrespective of the price tag for this care the best available data I have on the DRG reimbursement for this care is about $4,800 irrespective of length of stay.  The economic incentives all line up to rarely provide them with the discharge resources they require to maintain even a subsistence life style and remain stable enough to stay out of emergency departments or jails.  Furthermore in many cases, states previously charged patients a for a portion of their medication costs per month out of their disability income.  The direct and indirect costs incurred by patients and families with severe mental illness and addictions are a travesty of the highest magnitude.  The rationing mechanisms that have been in place for the past three decades have results in care that is subpar relative to any other medical specialty.  It has created an entire population to patients with chronic illnesses that are discriminated against.  The financing of care for them has set a number of perverse incentives that would seem to be more destabilizing such as an incentive for hospital discharge in order to beat the designated days in the diagnosis related group (DRG) and readmit them if necessary.  If the entire DRG incentivization for admissions and discharges is pseudoscientific sleight-of-hand based on very crude demographic variables - why would we expect readmissions policies to be any different?

The second dimension of this care is just how unscientific care based on demographic factors is in the first place.  I was previously in a practice where “consultants” who had never practiced medicine came in and commented on the “complexity” of our patients.  At the time I was caring for many patients who I knew would never be admitted to other general psychiatric units in any other hospital in the state due to their medical complexity.  The consultants concluded that my patients were no more complex than any other patients in the state even though they could not define the measures they used to make that determination.  Nobody mentioned the inherent conflict of interest when a pro-discharge administration hires consultants that agree with their world view - discharge patients as soon as possible.

In another scenario and on a committee, I asked if the demographic determined characteristics and time lines for treating community acquired pneumonia led to any differences in mortality or complications – and nobody knew.  The original Big Data approach in medicine looked at HEDIS variables.  Any practicing physician knows this is an incredibly crude approach that in many cases is meaningless.  There is no better example than saying that treating acute and chronic psychosis in a few days makes no difference in outcomes, when nobody knows the best treatment approach and practically no hospital screens for functional or cognitive capacity - two well known areas of psychiatric disability.  In the outpatient sphere, it is the equivalent of saying that 10 or 20 minutes three or four times a year with an emphasis on medications that are not likely being taken by the patient can possibly affect their real life outcome.

In the case of patients with addictions the treatment is more dire.  When a person using heroin, alcohol, and excessive amounts of benzodiazepines cannot get admitted for detoxification or they cannot get admitted for residential treatment, society and its representative governments at all levels are saying that this is a situation where we can ignore conditions that are clearly life-threatening and in many cases fatal.  We can ignore them because businesses and governments say that this is a collection of disabling and life-threatening diseases that we can ignore so that they can either make money or divert money to treat more socially acceptable life-threatening and disabling diseases.  

This is all a clear pattern of discrimination that not only affects the elderly but anyone with a psychiatric disability or addiction.  If the authors want to do something about that – I say let’s start by reversing over 30 years of discrimination against those with psychiatric and substance use problems that is clearly based on socioeconomics especially the lack of a vocal political constituency, very poor research based on demographic variables rather than complexity, and a lack of innovative research based on poor resource allocation.

George Dawson, MD, DFAPA

References:

1: Boozary AS, Manchin J 3rd, Wicker RF. The Medicare Hospital Readmissions Reduction Program: Time for Reform. JAMA. 2015 Jul 28;314(4):347-8. doi: 10.1001/jama.2015.6507. PubMed PMID: 26219049.

Attribution:

Photo by Mark Buckawicki (Own work) [CC0], via Wikimedia Commons.

The Drive To Do Good Work When No One Is Looking

Himmelstein and Woolhandler have hit it out of the park again.  This time in a seemingly modest letter to the editor in the weeks JAMA.  Although their main point was the perversity of pay-for-performance incentives in the final paragraph they make this observation:

"We fear that pay-for-performance incentives will undermine the mindset required for good physician practice (ie, the drive to do good work even when no one is looking)." (p.304)

This is a quote that everyone should pay attention to because the so-called financial incentives that have been with us for years are highly problematic and have not contributed a thing to the quality of medical practice.  The first consideration is whether or not what Himmelstein and Woolhandler say is true?  It has  clear validity.  Physicians are trained to do the right thing in terms of individual patient care.  That involves dedication and adhering to professional standards like continuity of care.  Physicians as a group are driven people.  They will work past the point of exhaustion especially f they feel that they need to follow up a certain problem for a certain patient.  Many primary care physicians are working 24/7 in order to keep up on paperwork, labs, prescriptions, and test results.  It is not possible to "call it a night" if there is a critical lab value that needs to be evaluated or a patient that needs to be informed.  There are plenty of decisions in medicine that have a high inherent degree of uncertainty and that can lead to sleepless nights searching for an answer.  The electronic health record (EHR) has increased that burden.  I have colleagues that tell me that every morning when they walk into clinic they may have as many as 200 lab results waiting for them in the EHR.  If they do not have assistance with triage, they have to personally view these results and do something about them.  They may also have to respond to direct e-mails if they are affiliated with a plan that allows patients to directly e-mail their physician.  That is before they begin seeing a full schedule of patients and seeing urgent problems that day.  Responsibility to the patient is what drives this process not trivial financial rewards and penalties based on illogical outcome measures.

Why all of the confusion?  I think the problem can be analyzed at several levels.  At the antiphysician level there are obvious forces in play that want to coopt the professionalism of physicians and make it seem like without a business and government bureaucracy that physicians would be out of control.  In other words the public needs the government and big business to control physicians.  This was the essential rhetoric that led to the managed care era in the first place.  Physicians were greedy, did too many procedures for financial gain, and needed to be managed by a large and expensive business administration.  The managed care theory completely ignores two basic facts.  The most obvious fact is that three decades of managed care has not controlled health care inflation or increased health care access as promised.  That is compounded by the fact that many of these companies currently own all of the means of production including the doctors, hospitals, labs, and MRI scanners.  But nobody has accused them of being greedy.  The second fact is that independent review of the problem from the 1990s showed that the political theory that physicians were engaged in massive overutilization was so inaccurate that they closed the government review program down.  How often does a government program get shut down?

The assault on the professionalism of physicians reached new heights in the 1990s when the federal government under the Clinton administration decided that fraud conducted by physicians was also a major driver of health care inflation.  Armed with billing codes and guns, it was an era where FBI agents were trained to enter offices, get the records and determine of the documentation matched the billing code.  There were several high profile cases where the Department of Justice decided that "fraud" had occurred.  The fraud they were referring to in one of the landmark cases was attending physicians not writing an extensive enough note in addition to whatever note the resident physician wrote.  That led to about two decades of excessive and unnecessary documentation.  Right up until the point that the federal government could grant this power to managed care companies and give them the power to deny payment and demand reimbursement back based on their interpretation of whether the documentation supported the service provided.

Throughout all of this heavy handed political intervention physicians have continued to do the right thing and maintain their professionalism but the rhetoric has taken a heavy toll.  It is not unusual for a person to enter a health facility owned by a managed care company and see some credos from the physician code of conduct plastered on the walls in an elevator.  When that happens the company is generally sending a clear message: "It is only because of us that medical professionals behave in a professional manner."  Nothing is farther from the truth.  There is no carrot or stick that keeps a neurosurgery residents on call in a hospital every day and night for a year at a time.  There is no carrot or stick that keeps psychiatrists treating aggressive patients who continually threaten and may try to assault them.  There is no carrot or stick that keeps physicians going to the point of exhaustion and to the point that they realize that they are clearly spending much more time caring for other people than their own families.  A typical response from people with those scenarios is either: "You don't have to do that." or "You don't have to work that hard."  Physicians currently waste 20-30% of their time on bureaucratic nonsense dreamt up by people who themselves do not provide direct patient care.  In the time left they are expected to see more patients and do more documentation than physicians have ever had to do at any point in history.

I don't mean to suggest that there are not people in all walks of life who do the right thing at work.  As I am typing this I recall my father describing one of his coworkers sometime back in the 1960s.  My father was a railroad engineer.  He drove locomotives of both the diesel and steam variety.  The railroad world in those days was a parallel universe that I would occasionally get a glimpse of.  Massive buildings smelling of diesel fuel storing massive, loud, pulsating diesel locomotives.  They just let them run 24 hours a day.  My father and a group of his railroad colleagues were rebuilding the porch on our house one day and they were all talking very positively about a car knocker who worked for the same railroad.  A car knocker is a rail car repairman.  They keep trains rolling.  All of my father's co workers and my father all praised this person because at work he always seemed to do the right thing.  The quality that they seemed to admire the most was that he would always attend to part of the task even when he lacked a certain skill that required him to pass part of the job on.  That was apparently a rare trait and that was my first observation of the quality of doing good work and how it was widely admired on its own merit.  No financial reward or employee of the week parking spot.  Just the mostly hidden admiration of your coworkers.

To me the most perverse aspect of physician "incentives" is that they are already earned by physicians.  In the managed care world, groups of physicians are subjected to a "holdback" of anywhere from 5-15% of their gross billing.  The idea is that unless the entire department makes the productivity expectation (an arbitrary number set by an administrator) the money is lost.  If the financial target is made money "awarded" was already earned.  There are no bonuses only penalties.  A lot of the incentives for reporting various measurements or complying with the next bureaucratic hoop are in the 1-2% range.  That is important only for the bean counters described in the letter.  Make no mistake about it - they will exert whatever pressure they can on physicians to "make" that 1 or 2%.  And make no mistake about it - twenty years that bean counter job would not have existed.

And there still would have been physicians in hospitals all night long trying to do the right thing and not caring who knows about it.

George Dawson, MD, DFAPA

Himmelstein DU, Woolhandler S. Physician payment incentives to improve care quality. JAMA. 2014 Jan 15;311(3):304. doi: 10.1001/jama.2013.284475. PubMed PMID: 24430325.

Additional Clinical Note 1:  Some health care settings have really taken the incentive programs to an absurd level.  Mandatory pep rallys for the employees, employee of the week or month awards and the expectation that everyone generates a huge amount of false enthusiasm for these rewards.  At the same time the confidential 360 degree performance review is the latest tool that administrators can use against physicians.  In this exercise a panel of anonymous multidisciplinary coworkers rate physicians on a number of non-medical standards (like how well they support corporate standards).  The performance review is basically a combination of subjective impressions that have very little to do with the physicians medical competence.  It is all part of the corporate beauty contest that is passed off as medical quality.  Most managed care companies seem to not know the meaning of the word.

Additional Clinical Note 2:  Governments and managed care companies are never at a loss for measuring things that are completely irrelevant to the provision of quality medical care.  The best example is patient satisfaction surveys.  If you are ever handed one as you leave the hospital or clinic the first question to ask yourself is whether the questions seem familiar.  If they do it is because your were scripted.  That means that the person you just talked with covered a number of bullet points corresponding to your survey.  It is designed to maximize the score on that satisfaction survey.  These results are often linked with incentives.  But nobody ever talks about the fact that you could have received the best care in the world and may not been able to complete a survey when you left the hospital.