Critical Care Medicine - List
http://www.pitt.edu/~crippen/

The State of Critical Care Medicine in 1998: A critical Care Physician's Opinion.

David Crippen, MD, FCCM

4/19/98

What are my qualifications to make such speculations? I have formal training in two specialties, Board certified in one, fellowship trained in critical care with a certificate of special competency. I have been practicing what we know today as "Critical Care Medicine" for about 12 years. I have seen the beginning and ascent of my specialty and I am witnessing it's evolution from the viewpoint of a working clinician. That's about it. Strictly grass roots stuff.

In the beginning there was ........ us.

We and others perceived a need for intensive monitoring and invasive treatment to reverse multiple organ system failure before it took hold. If patients could be identified early, hemodynamic and ventilatory insufficiencies could be reversed more quickly and easily, nipping expensive and long term complications in the bud. Clearly, this could not happen without specialized patient care units, equipment and personnel.

The first hurdle we faced was acceptance from those previously treating patients in units that bore the name "Intensive Care", but in reality did not provide that service as we understand it. Without the continuous presence of specially trained personnel, any patient admitted to such areas and left to languish did not receive Intensive Care but Expensive Care. I need preach no more to my current choir on this matter. The next hurtle was to convince those who financed the delivery of health care the proposition that ours was a cost effective goal. They would pay more for our services but in the end expensive length of stay and complications would be averted. And this deal seemed attractive to them, at least in it's formative stages.

However, what we didn't make clear was that this deal was directly predicated on patient selection. If we selected the "right" population of patients, we could come through as promised. However, what we didn't tell them was that if we selected the "wrong" population, we would spend more money, propagate longer length of stays and generate stunning high risk/benefit ratios. It was at this point where we actually had a fairly good chance to make it work, but the burden was on us to do so.

And then ........ we gave away the farm.

In fact, we did not reserve the right to select populations of patients most likely to benefit from the delivery of critical care medicine. Anyone with the possibility of getting sick or dying from one heartbeat or ventilation to the next was defined as fair game, even those expected to die or late for the gate. Because of the social nature of the admission process, we were coerced to accept anyone who desired "Critical Care". If we didn't, we were accused of discrimination, a judgment equally as useful to redress bigotry or unfashionable altruism. If they demanded futile life support, we were mandated to provide it until decomposition took place.

In addition, we generously allowed anyone who desired such services to have them because we believe medical care is a right and not a privilege, because we refused to make eugenic and moral decisions about who "deserved" them, and because we had a financial incentive to spend large amounts of other people's money to generate vanishingly small potential benefit. This clearly wasn't part of the original deal but it seemed in our best interest to provide care completely free from the taint of discrimination. We told the reimbursers we could decrease mortality and morbidity while conserving expensive resources and we failed to do it. We created, or stood by and allowed to be created, a health care delivery scheme that spent vast quantities of money on heterogeneous populations of patients in which benefit was not bound to the reality of expenditures. We will pay dearly for that lapse.

Then there was ........... them.

They complained, so we went back to the reimbursers and coerced them to change the rules in mid-game. We sold them the proposition that it was immoral and illegal to discriminate between prospective persons needing our services, and so it was incumbent upon them to pay for all comers in order to support the truly needy ones. The reimbursers grumped, but we had right on our side. Populations of patients either desiring inappropriate "observation" for disorders highly unlikely to require invasive treatment or approaching death from old age demanded their rights to medical care as they desired it. Colonies of patients we "watched" or with multiple organ system failure, able to survive only on some form of continuous titrated support filled our intensive care units and we didn't cry too much because we were rewarded for every incremental hour of indiscriminate care.

The reimbursers figured out quickly we had the potential to break the bank but the social reality was that there was no effective frontal assault against us. To tell burgeoning populations of Medicare patients the system couldn't afford their desires after previously telling them they would be cared for was political anathema. And so it became necessary to ration in such a way as to avoid the appearance of rationing, or to give the impression that someone else was responsible for it.

The first attempt to stem the tide came in the form of rationing by inconvenience and proceduralization. Uncrossed t's and undotted i's were met by disallowment. This ploy worked only as long as hospital bureaucrats were in charge of billing, and it actually worked well as long as hospitals were allowed to cost-shift. Interpretation of DRGs and procedural codes necessary to obtain payment for services were created with built in ambiguity favoring denial of payment. But physicians went back to school again and learned to play the game like a violin. Again reimbursements increased as the game was played more efficiently.

And so as reimbursers learned from their mistakes, their continuing iterations became more dependable, efficient and businesslike. The current model, rationing by retrospective denial is an extremely efficient rationing scheme which has two acknowledged goals:

I) to retrospectively evaluate physician manpower for clinical appropriateness and quality of care,

and

2) deny payment as a negative sanction when quality of care issues are identified.

This system prospectively allows services, then retrospectively denies reimbursement for some after they have been rendered if the third party reimburser decides the service did not adhere to some designated (or undesignated) standard. It's elegance is in its simplicity. It allows reimbursers to decide after critical care has been rendered that it wasn't really necessary after all. Those desiring to challenge such decisions do so at their own expense within a legal oversight system that runs on expensive delay and favors those most likely to endure a war of attrition.

In such a scheme there is no real way to determine whether resources expended will be replenished until after the fact, making prospective planning difficult if not impossible. Care givers are placed in the position of expending resources which may not be repleted on the whims of gatekeepers and murky technicalities. But the general public has been told by the Reimbursers, and the political bodies functioning transparently in their infrastructure that health care is theirs as a right and not a privilege. Therefore, when they arrive for that care, they make no differentiation as to how much it will cost or what the benefit might be. It is simply there and it is their right to have it. Reimbursers and politicians refuse to put themselves in political jeopardy by telling consumers there is a sale, then not showing them the merchandise. It is much safer for them to let someone else feel the heat; someone more vulnerable.

The boat left ........... we weren't on it.

Earlier in the game we probably had the option of delivering patient care in an effectively paternalistic fashion; a benevolent dictatorship if you will. Trained and experienced guardians of resources banks determining disbursement in a fair and equitable fashion dictated by established rules of ethical conduct. We probably could have sold this deal to the system at some point. We chose to be purists, avoiding ethical problems inherent in the distribution of scarce resources. We also chose to run it like a business where we profited by creating a demand and supplying it.

Because we were relatively inexperienced business people, we believed that we could create a business that would serve ourselves and our patients as well and not violate a fundamental business axiom that in the end, business is as business does. Business only has interest in a potential customers benefit if that utility increases business. We prospered by creating demand and supplying it, then believing our own hype delivered to those responsible for picking up the tab. We built a tidy empire not on carefully carved out contracts with reimbursers, but by our interpretation of how such contracts might function in a perfect world. We thought that dressing in suits and going to meetings made us shrewd. We thought that we could beat reimbursers at their own game by meticulous paper gamesmanship. Two equally committed groups but only one holding the money.

We told reimbursers that opening the floodgates of intensive care units to all who desired such services would still conserve resources. Expert care for this population of patients would decrease complications and length of stay more than if the entire population were allowed to languish in non-monitored environments. What we didn't mention was the fact that we were cherry picking in reverse. We were selecting, or allowing to be selected populations of patients with a righteous obligation to die, then allowing them make decisions that extended and prolonged the dying process in a phenomenally expensive fashion. We created that population to be authoritative and self perpetuating, but the reimbursers are balking at paying for it in a fashion we cannot effectively redress. Our own creation threatens to devour us.

Hark ........... the end is near!

In order to avoid rising public discontent reimbursers will have to eventually pay for some form of critical care. Accordingly, it is incumbent on us to define what services we can provide that are reasonable and reimbursable. They will have to make concessions and so will we. There is only one realistic way to make save critical care, and that is to sit down with reimbursers and carve out a deal that no one may like but with which everyone can live. We cannot survive if they continue to find ways to ration by retrospective denial. Somehow, some way they MUST be forced to establish contracts as to what care is reasonable to reimburse and we will have to stop providing care to populations of patients who derive no discernible benefit from it.

When we finally get them to the table, appeals for reimbursement on quality of care issues will NOT enter into the equation because quality of care is unaffordable if consumers are allowed to freely choose it. Quality care to a terminally ill breast cancer patient is the authority to choose a treatment costing US$1,000,000 that will generate only a 1:10 chance of keeping her alive an additional thirty days. Reimbursers cannot afford that kind of quality so they will accept the kind of quality enclosed in restricted cost effective choices expertly marketed as excellence.

Similarly, quality care to a provider is the capacity to CAT scan a long term nursing care patient for the purposes of evaluating an acute exacerbation of long term chronic dementia and get paid for it. Reimbursers can't afford traditional fee for service because of the incentive to create demand in order to provide expensive supply. For that reason, providers will not be allowed to freely determine who will do what and to whom. It will be necessary to control us because we have a long track record of not controlling ourselves. The only way to stop inevitable spiral of more demand, more supply, more demand is to put providers in a position where they have liability rather than incentive to bill for marginal increases in patient load. And they will achieve that goal eventually because in the end they hold the money and therefore have more authority to interpret the rules. It will be necessary for us to become employees in some fashion. How much investiture we will have in that status is yet undefined.

"Meet the new boss ......... same as the old boss!" (The Who)

We will not like becoming employees, but we will get used to it. I hasten to add the fact that employee status in medicine does not necessarily translate to bad patient care or a raw financial deal for physicians. We (in America) are about the only providers left in the world who are allowed to profit from our delivery of care. There are many other health care delivery systems in the world with long track records of delivering high quality health care at a fraction of the price we demand. A prime example which springs to mind is the care Stephen Streat, et al render their patients in New Zealand, and they derive a very comfortable living wage for doing so. What is the difference between them and us?

Stripped of hype and glitz, the difference is simply that they have made a clearly defined deal with their reimbursers to deliver high quality care to a patient population with a high probability of benefiting from it, and the burden of proof for the selection process thereof lies in the contract, not the personal biases of individuals. The only way to consummate such a deal is by sitting down and forging a contract that will give the best possible care for the most participants making the best of the funds available. Outliers are, of course, welcome to use their personal resources to avert such a system if they so choose. That means reimbursers must be given the mandate to say no to some expenditures, and we must be given the mandate to say no to exclude patients desiring services which will not be beneficial. Previously defined social and ethical issues must be ADJUSTED pro actively by negotiation to reflect the realities of scarce resources.

"You gotta fight for your right to .......... parrrrr-ty!" (Beastie Boys)

The end is near. We are hanging a thread. This is no longer the same social or ethical issue it was in the beginning. This is an economic issue that threatens to destroy our ability to provide any care at all. If we are unable or unwilling to accept this painful prescription we are doomed as a specialty. Intensive Care Units filled to the brim with patients having no potential for benefit and reimbursers ratcheting back payment after the fact to hedge on each incremental increase. Future iterations of reimbursement schemes evolving to more effectively insulate them from our offensive maneuvers. Nurses and others selling their souls to unions in a futile effort to maintain parity, further decreasing hospitals cost shifting mobility. Layoffs preceding the specter of hospitals going belly up.

I urge all of you to think very pro actively about this. It is the most important problem of our lives. It MUST be solved and soon. If we are not actively involved, we will be lost.

Robert G. Aucoin (USA):

Well said. I work in an adjunct position in critical care. The problems you see in the adults we see in the kids with the additional hysterics of families/children that is an expansion of what you see with families/parents. We are expanding at an alarming rate with the consolidation and regionalization of care. No one had ventured into the area of "how much is all of this going to cost us?" I just did the budget for PICU. The heavy deliberations were on the salary side and not on the revenue side. We have to cut $800,000 from my budget and still expect to increase our ADC to 9 patients. This in light of hiring not one but two new Pediatric Intensivist, starting a transport service and crank into a new pediatric residency program. Should be a neat hat trick. The house of cards is going to have a hell of a time in this hurricane.

Stephen Streat (New Zealand):

It seems to have certain ring of truth about it. Things are different (but not "better") where rationing has been more explicit and previously accepted by the populace. The economic pressures that we all suffer from under the tyranny of western capitalism exert their effects in different ways and different games.

Here we (the providers) play the "lets pretend this orange is really an apple" game with the Funders who are not prepared to pay what an orange really costs. Government plays the politically correctness of neo-rightist libertarianism to the hilt "lets downsize government, reduce taxes and social security, pay off debt, encourage free enterprise and (here it comes) remind everyone of their need to take responsibility for their personal health care" and underfunds the "funders".

The hospitals play the "negative incentive for achievement" game - "Congratulations on your increased productivity, we are reducing the size of your available resource commensurate with your demonstrated ability to work even more efficiently - we are pretending to ignore any invisible downside to this in terms of reduced access to services". One of the Commonwealth (=nothing in common, no wealth) legacies of Thatcherite policies is that we (especially in NZ) have all to some extent been infiltrated by this insidious and repugnant glib doublespeak.

At the sharp end we just carry on trying to do with what we have, put out fires and try to aim for the stars. Family, friends, strong collegial links, good fishing and the occasional brandy help a lot.

David Crippen (USA):

Recent history: Patient X with a large stroke, hemiparesis, aphasia, blood pressure wildlyout of control maintained on continuous infusion of nicardipine, lethargy from brain swelling, no gag, intubated to protect his airway. Did better as the swelling subsided and his blood pressure settled down on meds through a nasal-duodenal feeding tube. Extubated expectantly Tuesday and skirted the treetops for 24 hours. Every time I walked by the bed I got the urge to re-tube him but he hung on so I waited him out. Wednesday, his airway was improved but he still had a lot of secretions and required constant suctioning. I got him out of bed in a special folding chair contraption that goes from a stretcher to a sofa and back again. Continued lethargic but weakly followed commands. Slowly improved.

The social worker informed me Thursday morning that the medical gatekeeper for the HMO involved had downgraded his reimbursement to "skilled nursing care" from "Acute ICU care". This was done after a selection of lab parameters and patient condition parameters were phones into him at his desk in another part of the city. His blood gas seemed normal, he was extubated and out of bed in a chair. These parameters were fitted into a template that predicted that the patient no longer needed "intensive care" and was now a candidate for "skilled nursing care". I was never contacted and the person issuing this order never saw the patient. Therefore, we were welcome to give him "intensive care" in the ICU if we so chosed, but they would only pay for "skilled nursing care".

Now, the clinical reality was that the patient's "normal" numbers were maintained at the expense of numerous compensation factors that could crumble at any time and if they did so in a non monitored environment, the patient would crump between heartbeats or between ventilations and would never be detected by floor nursing staff. He remained extubated only because of continuous skilled nursing and respiratory care. He was out of bed only because of a special chair and people with the skill to use it. These parameters were "normal" because the patient was maintained in a unit staffed by experts in nursing, respiratory therapy, and so on. Their chance of remaining "normal" outside such environment was extremely problematic.

So, we are being reimbursed for the same services the hospital ward provides because the patient has "normalized", even that normalization occurred at the expense of 24 hour constant, skilled and expensive presence. "Normal" is as "normal" does, so "normal" is reimbursable the same way for all comers.

There is a happy ending to this particular story because I got On the phone to this physician and tactfully explained that the parameters he had accessed were not indicative of a true situation. After our discussion, he did authorize another day of ICU care. He seemed sensitive to my argument but I do not think he is representative of the current ilk of gatekeepers who are actively looking for any kind of statistical evidence that patient DO NOT NEED ICU CARE, then dropping the reimbursement without discussing it with those in charge of the patient's care. Now, as if I didn't have enough problems, I get to call bureaucrats on the phone and plead for enough resources to maintain sick and unstable patients and the burden is on me to prove my argument against statistical evidence to the contrary.

Anonymous (Germany):

How timely your manifesto. . I have the joy of reviewing all the DEATH charts for the hospital each month. Of course there are some cases not handled well, but more disturbing are the huge number of elderly patients with end-stage disease given the opportunity to die with a tube in their mouth by their kindly family practitioner or dialysis doc (Mississippi has the highest incidence of renal disease in the world and there is NO age limit on dialysis). I have reviewed charts of 94 year olds who develop post-op renal failure after hip surgery who get dialyzed, Swaned, dopamined, intubated, etc. while the physicians carefully monitor their demise with stacks of reports of very expensive laboratory tests, daily, of course.

When I mentioned to the committee that I was going to report on all cases I thought "futile" care, they (the physicians) weren't too happy. Of course, the administrators all pricked up their ears. One young family doc said to me (a practicing anesthesiologist and a "saw the future" intensivist), "You just don't understand. I have to do everything the family wants." I replied, "No you don't." We got into a heated discussion and I went home grumbling to my husband, "What the fuck are they teaching these kids in medical school?" "Doesn't anybody teach them how (really) to be a doctor?"

This hospital has "intensive care medicine" administered by a consortium of pulmonologists, nephrologists, and ID types. There is no triage, and of course, the consultants love to DO things (reimbursable, of course) to the patients before they start to stink. These problems are old hat, as you have so eloquently pointed out.

I see several items as sine qua non for any hope of a solution:

1. Physicians must actively be trained in the comprehensive understanding of life, death, and being a "good" physician, and how to make good decisions regarding end-of-life care. This should not be a few ethics conferences here and there, but rather a body of knowledge taught by weathered, moral physicians in both the classroom and important part of residency training, as Ake Grenvik made it in Pittsburgh.

2. We must (without "scaring" the elderly) have a national educational campaign about end-of-life care. Most folks do not want "futile" care. Their docs must talk to them about it ahead of time, and the elderly must make their wants known. In addition, we as the physicians of this country must tell the population that they cannot have all this fancy futile care. Neither physicians nor politicians want to touch this tar-baby.

3. There is no way to take physicians' financial motives out of "doing things" (procedures) in the ICU except by having capitation of each patient, or making intensivists hospital employees. The disheartening thing about this scenario is that there is no incentive to work hard, and we may find it hard to fight off the VA mentality of "manana."

Dick Burrows (South Africa):

Is there anything, anything, amongst all this techno-speak which teaches doctors to be doctors - as opposed to being a super-duper technology jock - willing only to indulge themselves in a technological imperative? That surely must be the most disastrous failing of modern medical technology. It is also false logic to blame the "system", whether this be fee per item or salary, for the simple reason that nothing addresses the integrity of the individuals working the system. Doubtless people like Crippen, Streat, Fisher and Roy-Shapira are men of high integrity who would work well in either system. But I would venture to say that they are unusual people.

The assumption that the "system" is wrong leads to vast energies being wasted trying to change it or, when this fails, legislation is introduced in another futile attempt to address every miniscule eventuality. It can't be done and the only rational solution therefore is to legislate for the average and police the extremes but this approach of reasonableness has apparently proved to be unacceptable in the world's greatest democracy. The problem is not one of 'the system' or 'the technology' The problem is as Shaw pointed out - that doctors consciences are no different from the average individual.

The paternalistic attitude of medicine of many years ago was removed as anathema. Ethicists, lawyers and doctors who wanted no part of a decision which could be interpreted as an act of omission causing death even though the contrary assumption that all life could be saved was equal hubris. The ONLY way forward is the realization that doctors of integrity be allowed to make medical decisions. But as doctors are going to remain average in terms of conscience it seems the only way to stagger forward is to ask the economists to make the decisions in a faceless unfeeling way. Which they are doing.

It is, as Dostoevsky says, a situation where nobody wants to face the responsibility to make the decision - not even the patient. It is a situation of little hope.

Chris Ansley (Australia):

The issue of patient selection is one of the major stumbling blocks and I believe it is insoluble. There is currently no system of 'number crunching' that will deliver accurate, reproducible and individualized probabilities for prognosis and all of its attendant socioeconomic problems and I may add, I don't think there ever will be. We continue to rely on the educated guesses of experienced staff and this, I think, is Dick Burrow's point -

Malcolm Fisher (Australia):

I would respectfully submit that the way people die in Us hospitals (Support I and II,) and the range of SMRs (0.6 to 1.6) in the USA make reimbursement issues a mini crisis at best. The baby boomers are getting old and all Western Societies have a big problem. In the US because of what you are spending now and your population radical changes in th way physicians are reimbursed seems mandatory. With regard to procedures it interests me that those who try to sell noninvasive monitoring in the US constantly complain that the biggest hurdle they face is physicians fear of loss of revenue from putting in and using thermodilution catheters. It may be that attacks on the way physicians are paid is part of the solution not part of the problem!

Dick Burrows (South Africa):

In life we are all beholden to decisions made by others in all walks of life - the taxman (God bless 'im) - the pilot of the aircraft - your boss (whatever the profession) - the jury which decides on your guilt - judge who decides on your sentence - the captain of the ship. If you told anyone of those individuals to take a hike you would find yourself in deeper shit than you ever thought possible. Previously priests and popes ruled our lives through a mixture of.......whatever you like - but a secular world and a burgeoning democratic (populist?) rights culture gives each of us a greater control over our lives.

Now we are all supposed to be autonomous individuals keenly aware of each other's right to his or her piece of the sun. Mankind is however still uncomfortable with such wonderful rights and ducks and dives at every chance he gets in order to avoid the issues Although ethicists tell us that patients should make decisions patients tell us they don't want to make the decision (Tomlinson & Brody) Although doctors want lawyers to make the difficult decisions lawyers say "No - doctors must make them" The Vatican says doctors must make such decisions.

But doctors steadfastly refuse to don the mantle of responsibility. Which is why you are about to be screwed into the ground - by everybody - from quack to actuary - lawyer to patient (sorry - customer!). We need Doctors who have sufficient depth and breadth of knowledge, experience, common sense, empathy, sympathy, communication skills, altruism etc etc ....., none of which is innately available in technology. Mostly you just need doctors who care enough to ask themselves if what they are doing is "right".

Intensive Care in Australia, like NZ, is run largely by salaried medicos delivering a high standard of care, though private hospitals are getting in on the act more and more - which brings me to Malcolm Fishers point - never get between a Doctor and his cash flow :-) There is a large private sector critical care here and they surely make money from it but I'm not so sure that it is necessarily the fault of the private practitioner that costs are so high. It is the same problem of inability to make decisions and the force of relative demands that causes the problem in many instances.

Anyone footing the bill for a service has the right to know how, what, when, where and why things were done and this is no different in Government funded systems ( eg Oz ) or Insurance funded systems ( eg USA) and nor should it be. If that is true, and given also that medical expenditure tends to go up not down with technological advances, it falls to us ( not lawyers, not ethicists, not committees ) to make the hard decisions again whilst convincing the interested parties ( funders, public, government ) that we are doing it right.

Tim Buchman (USA):

Dr. Crippen presents a pessimistic view of the future of CCM in the USA. I respectfully suggest that his crystal ball is no better than anyone else's, and offer the possibility that he might be incorrect. Pertinent to the argument are the following items:

1. In the beginning, there were patients. The earliest ICUs were probably specialized post-op units organized by Walter Dandy at Hopkins to care for post-op neurosurgical patients. These were quickly eclipsed by large units aimed at caring for the legions of young people infected with poliomyelitis during the mid century pandemic. All of these efforts were aimed at providing highly focused care to specific patient populations. Their (the patients') success was, and remains, remarkable. Consistently through the history of critical care medicine, we have had the privilege of improving outcomes when care is administered to well-defined patient populations. Patients get better, and third party payors are generally willing to pay with few if any questions asked.

2. We remain in the midst of a great experiment. The "indications" for admission to a specialized care unit have been broadened to include nearly all patients who require synchronous analysis and intervention in multiple deranged physiologic systems. What is surprising is that so many patients appear to benefit from this comprehensive approach to integrated multi system support. It is surprising because, at the turn of the 21st century, life expectancy is 50% longer than it was at the turn of the 20th century. We routinely manipulate complex interactions in physiologic states unanticipated by evolution and unseen by prior generations of clinicians and medical scientists. Mortality rates are surprisingly low following admission to the ICU. We in the ICU are "pushing the envelope" of the human experience, extending life and living (the two are not synonymous in my lexicon) of individuals far beyond any biological need to ensure the survival of humans as species.

3. It seems highly unlikely that society will turn around and globally devalue individual survival. More likely, society will turn around and revalue the quality of that individual survival. Individuals are discarding the shackles of paternalistic approaches to care in many arenas (HMOs for one) and making individual decisions about their futures. This is, libertarianism at its best. FL has the dubious honor of living/working in an environment where many members of the particular community he serves value indefinite survival in a totally dependent, non sentient state anticipating miraculous recovery. That is an increasingly rare position for a community and its members to take, and the situation elsewhere in the USA is generally not as bleak as at his hospital in Pittsburgh. There is a place for raging against the night, and there is a place to pay Charon for his services. Providers, payors and patients are coming closer to agreeing which is which.

4. Studying the process of critical illness and dying is teaching us volumes about how we live. While I do not anticipate a return to the blind confidence placed in science at mid-century (FL probably watched the 16mm movies from Bell labs with the white-coated scientist-actor assuring us of a safe nuclear future just as I did) we are doing a fair bit better at blending science and art on behalf of the critically ill. I don't see anyone rushing to strip this privilege from us.

5. The issues of cost control have been, and will continue to be, addressed only painfully. We are going to be held accountable for what we do, and we as a critical care community are going to rise to this occasion. Choices about what works and what doesn't are going to be made, and we are going to be the ones making them. If we as care givers decide that some aspect of care is inappropriate (much less futile) we are not going to be held hostage to patient/family/attorney. The notion that some entity is going to make our tasks economically unfeasible by retrospective disallowing of payment for care generally accepted as appropriate is untenable. The patients and their families won't stand for it. On the other hand, making evidenced-based decisions is going to be part of what is expected of us. We ought to be expecting it of ourselves. We are purchasing agents on behalf of society as a whole, and we are going to have to accept that responsibility. No one is going to take it from us, because no one else really wants it. It's not a problem, it's an opportunity to do a lot of good for a lot of people.

FL, I respect your opinion, and I respect your right to hold that opinion, and I respect your right to advance your dark visions about our future in CCM. I think you are wrong. I am willing to debate you on this because, frankly, the facts are on my side . I am not about to look for another job or dissuade students from looking to our future in CCM which is in reality very bright. Go spread your doom and gloom. But don't expect many to take it to heart.

David Crippen (USA):

Tim Buchman sez: "It seems highly unlikely that society will turn around and globally devalue individual survival. More likely, society will turn around and revalue the quality of that individual survival. The notion that some entity is going to make our tasks economically unfeasible by retrospective disallowing of payment for care generally accepted as appropriate is untenable. The patients and their families won't stand for it".

I reply: this reimbursement for "services" rendered in critical care units are NOT made by society, but they directly affect "quality" of such care. Society's wishes are clear.....they want it all, they want it now and they don't want to pay for any of it. The wishes of the reimbursement industry are clear.........they want to ration and they don't want society to see who is responsible for it. As long as Joe Society gets taken care of at the point of service, he cares not who pays for it. The true nature of these payers will never be revealed until the bank breaks. Both are willing to go right to the brink in order to find out who will be found ultimately responsible.

we are doing a fair bit better at lending science and art on behalf of the critically ill. I don't see anyone rushing to strip this privilege from us.

In fact, they are more than happy to have us do it and do it well, as long as they don't have to pay for it.

We are purchasing agents on behalf fo society as a whole, and we are going to have to accept that responsibility. No one is going to take it from us, because no one else really wants it. It's not a problem, it's an opportunity to do a lot of good for a lot of people.

And our efforts to cut cost have so far revolved strictly around finding cheaper ways to do things for the same expensive population of patients, not redefine that population. We feel very good about restricting our drug formulary to the cheapest drugs we can find and then use them indiscriminately on a burgeoning population of patients for which no known drug has any meaningful effect. In the NewSpeak.........cheap is good because it diverts thousands of dollars from a windfall of billions. A situation not unlike rearranging deck chairs on the titanic for a better view.

FL, I respect your opinion, and I respect your right to hold that opinion, and I respect your right to advance your dark visions about our future in CCM. I think you are wrong. I am willing to debate you on this because, frankly, the facts are on my side . I am not about to look for another job or d issuade students from looking to our future in CCM which is in reality very bright. Go spread your doom and gloom. But don't expect many to take t to heart.

"But Mr. White....this is the Titanic....it CAN'T sink!"

"My dear, this ship is made of steel........it can most certainly sink."

Dick Burrows (South Africa):

Regarding Dr. Buchman's comments: In the beginning...........but...... What was not considered was the propensity to prolong death at an enormous cost to the individual and to society. Doctors worked against a yardstick of the "Sanctity of Life" and that to shorten any life was to commit a crime. To my oversimplistic mind the 'success' of these early units lay in the simplicity of the concept - put your sickies together and nurse 'em properly and they got better because of the better nursing. The technology we developed destroyed that simplicity and became an expensive surrogate for simple care. Indeed the technology was invaluable and did save lives but we did not learn to use it wisely. Perhaps we couldn't because the essential nature of (scientific?) advances in treatment has been trial and error but just couldn't shed ourselves of the other paradigms.

I think it is pure hubris to suggest that ICU is responsible for the increased life expectancy of the average patient. (I doubt that you believe that and maybe I am reading it wrong) It is no longer tenable merely to 'push the envelope' Patients with living wills (or whatever you like to call them), administrators, economists and so on are no longer allowing you to slip the leash of your responsibilities to use your resources as a bottomless pit. They are putting you back on a very tight leash from which you can only be released by learning their ideas of what your responsibilities should be and that will be disaster. You will have been domesticated - yuck.

Society only values the individual in respect of the society's perceived value of that individual - Kings, queens, princesses and presidents get what society deems fit i.e.everything - all else pay. Here we are now in the situation where, if you are no longer considered fit for transplant, you will then be removed from a dialysis program unless you go private and pay for it. The Medical Aids (quasi medical insurers) have cottoned on and refuse to pay in some instances.

Whether anybody likes it or not the prolongation of life in the medical sense (ICU merely ups the ante) is inextricably linked to economics and it is no different today than it was at the turn of the century when Shaw expounded on it, or 2000 years ago when Plato commented on the problem. A solution is unlikely - even in another 2000 years. Furthermore it is arrogant to assume that this is simply a problem of the First world or the Third world. It is the same everywhere it's just the stakes that are different.

Paternalism has rightly been crucified but it has been replaced by an unworkable ethic. No matter how 'right' that ethic is it will be unworkable if the individual does not want it. Oh sure most people will say that most people will eventually come to grips with their impending mortality - occasionally seen it but more often it's the way FL describes it.

Maybe FL is simply a lousy salesman - ever thought of it that way. From his posts however I would say that he is a man of integrity and fairness and the point of my argument. As far as I'm concerned it is the nub of the issue and it is all anyone can expect - in any walk of life.

Tim Buchman (USA):

Didn't learn to use it wisely, eh? Let's see. A couple of days ago, a 27 year old woman, 22 weeks pregnant was brought in following the most minor of fender benders. she was the passenger and received the tiniest conk on the head. She was GCS 15 at the scene, GCS 4 on arrival, no localizing signs. She was intubated, lined, CT scanned (showed huge SDH with midline shift) and in the neuro OR less than 18 minutes after she hit the door--and the neuro OR is 4 minutes from the resuscitation area. She and her fetus are doing fine. This is not "better nursing". This is the timely used of advanced technology. While an anecdote is not an antidote for the Luddite poison, the constant complaints of "technology run amok" ring (or ping?) hollow considering our digital exchanges. Perhaps you would like to return to the Pony Express? ;-)

My point is that our expectations of critical care outcomes for a 50 year old patient are quite different for that of a 75 year old patient. Most of the extension in life expectancy has been due to public health initiatives (truly the greatest unsung triumphs of the 20th century). What is surprising is that the interventions that work so well in generally young people work at all in people for whom there is no evolutionary rationale for survival.

The real question, of course, is why someone would not be considered fit for transplant. The surgical stress of an extraperitoneal operation is quite small. The data suggest that transplant is far less expensive than prolonged dialysis. The limiting factor in our corner of the world is organs, not fit patients. "Whether anybody likes it or not the prolongation of life in the medical sense (ICU merely ups the ante) is inextricably linked to economics and it is no different today than it was at the turn of the century..."

The sooner that individuals understand that there are real costs associated with prolonging death ("we don't want to terminally wean Uncle Joe until the entire family gathers from points distant...") the sooner that society as a whole will get the message that there are real decisions to be made.

FL is an excellent salesman. He simply has a lousy package to sell. He is certainly a man of integrity. Dick and FL, I follow your logic but I simply don't agree with it. You paint practitioners of critical care at best as acolytes in a health care system worshiping false idols and at worst as emasculated shells powerless to manage their own destinies much less than those of their patients. I view the situation quite differently: we practitioners of the science and art are our patients strongest advocates, and the frustrations we face with paperwork, retrospective reviews and so on are bumps in the road.

Jeff Whitnack (USA):

While not versed on overall reimbursement, I do see the outlines of a potential strategy to counter this. If they come at you later, with a retrospective audit, you must counter by demanding pre-authorization for all ICU patients immediately. A combination of legal strategy, political action, and strategic consensus may blunt this. But some will get hit hard before the threat sinks in.

The irony of this strategy of retrospective audits seems to be that the very intensivist group which does the best job of using the ICU resources to bring about the best outcome will be the most penalized (in retrospective audits they will have seemed to have needed an ICU admission less). If your enemy fights hard, fight soft back. If he fights soft, fight hard back. If your enemy comes at you from behind, counter by a brazen frontal assault.

Every ICU admission should engender a mailing, emailing, singing telegram, legal notice filed, such that the reimburser's will be served in no uncertain terms a notice to "speak now or forever hold your peace". I could forsee a notice to the reimburser saying something like, "last night we admitted John Smith for a case of acute pancreatitis complicated by alcoholism and ARDS. We have sent his medical records to our association's review board for clarification of any unwarranted ICU admission. We have been given immediate authorization to admit and treat this patient in the ICU. If you have any disagreement with this decision please reply within 24 hours. Otherwise we will maintain, and our legal staff will agree, that any belated claims to the contrary will be invalid".

You have to put the onus for denial of ICU resources back in their court. They of course, will drop it like a hot iron. It may take large groups of CCM Groups to muster the full monetary, legal, and political muscle to counter the latest threat. But even if you win this one, the band will play on.

David Crippen (USA):

As one might have expected, I am taking some heat from apologists of the current mode of providing critical care services in this country. "It can't fail because of it's long and illustrative history". It can't fail because it's heart is pure". It can't fail because blah.....blah....and I am a grump and a pessimist and this whole thread is a big drag. I have also been told my personal proclivity for pessimism is coloring my view and that there is no real evidence that any of this is true.

OK......lets construct a microcosm of critical care delivery that is representative of the way it's really done, then stress it and see where it goes. Lets say you live and work in Indianapolis, Indiana (Sorry Judi) the heart of the heartland............a place such a perfect blend of urban and rural Americana that the citizens think getting a cow in a family way is accomplished with a bull and some Barry White tapes in a heart shaped stall.

Lets deliver critical care medicine in a 500 bed general hospital in Indianapolis via a five physician group that leases it's services to the hospital. Lets call them the IPG (Indiana Intensivist Group). This group bills insurers for services and if the proceeds from billing are not sufficient to meet expenses, the hospital makes up the difference by contractual agreement. There isn't much Managed Care in Indianapolis: 75% of the patient mix is Medicare, the rest is Medicaid and a few with the Blues. The admission policy is liberal. Any attending that desires a patient admitted to the ICU can do so and the IPG are automatic co-attendings for all such patients. There is no objective test of admissibility. "I think we should watch this guy a little closer" is the rule of the day, and once admitted, "I think we better keep an eye on this guy another day or so", replaces it. The IPG uses the critical care billing code 99291 for all comers and they bill for procedures that are allowed.

All is well. The National sanctioning and lobby body for the IPG and others like it has extensively lobbied those in the billing and reimbursement industry to define roughly how the 99291 code should be used. Procedures are defined for how to use it. The IPG does the usual cognitive and procedural care for patients, then translates those things into legalese and proceduralese that the reimbursers understand and they get paid regularly. Accordingly, the IPG senses that all is well and begin to build families and creature comforts based on expected stable incomes.

So lets say that IPG does one million dollars worth of business a year. Out of that, they pay salaries, benefits, expenses and the like for five physicians and several secretaries, non-physician associates and the like. Every year billing brings in about 9/10 of that figure and the hospital antes up the rest. This isn't a bad deal. The hospital gets a lot of valuable services from IPG, including supervising in-house cardiac arrests, research and development activities, administrative things and formal teaching for the resident staff. IPG is imminently affordable. And, of course, the IPG does their part to keep down expenses, just like Dr.s Bleck and Buchman. They all sit on cost control committees. Their PharmDs buy the cheapest drugs possible in 55 gallon drums from trucks parked under bridge underpasses and, with nervous laughs, assure all that all these drugs are the same. They buy into Continuous Quality Improvement schemes that prove it all. "I only dropped one PA line on the floor in August, therefore I am delivering quality care".

Storm clouds over Americana. Like Scrooge McDuck, the reimbursers look with alarm at the disappearing cash from the huge vault. Time for immediate action of the bank will break and if that happens, THEY, not others will be held accountable to the public and congress who never take any responsibility for anything. Damage control. Using the Internal Revenue as a model, they send out auditors to look at the books. Not the cooked books, the patient care books. What kinds of ways are there to get money back after patient care has been delivered (insulating them from that group's political activity). Find gray areas and milk them, just like the IRS does it.

So they pick a random sample of 20 of the IPG's charts for one year and they send those charts to a paid consultant who ostensibly specializes in critical care medicine, but IPG is not told any further details about that person. After consideration, that person on the reimburser's payroll sends the charts back with a letter detailing how the IPG mismanaged the reimbursers money. Lets say they want US$250,000 back for one year's care of a random sample of 20 out of say 2000 patients treated in the ICU that year. (They took the sample of 20, figured out where the alleged deficits in care were, then used a multiplier to figure out how those deficits were applied to the rest of the population of patients treated.) And if the IPG disagrees with that assessment, they have the right to appeal......to the same agency that make the assessment, and if they still don't like it they have the right to have their own lawyers look into it for say the next five years, at US$150.00 per hour for every hour they think about the IPG's case.

The patients picked as "not requiring critical care services, and therefore services not payable", are patients who shared at least two characteristics. They had few complications during their ICU stay and they were discharged well. Ergo, they didn't need the service in retrospect. Never mind that they all had multiple organ system insufficiency, a history of sudden and unexpected decompensations in the past and that similar patients that DID decompensate and were resuscitated quickly in a monitored environment were savaged before long term complications set in. None of this was in the original agreement, such as it was, but that agreement had these kinds of gray areas built in for just such exigencies and now they are being interpreted by those holding the money.

So, the IPG has to pay the quarter million, and the reimbursers say they'll be back to look at another twenty sometime in the future and lathe word "fraud" is mentioned if similar lapses are seen. The IPG then goes to the hospital and informs them the reality that having to pay the quarter million has finished their ability to function, and if they continue to treat similar patients, they will get nailed again, but they are forced to treat everyone that the attending physicians of the hospital desire to admit. They inform the hospital they need protection from the reimbursers in order to continue to render ANY kind of care. They want the hospital to share the liability in order to continue receiving the service.

But the hospital is in a bind as well. As reimbursements for DRGs continue to dry up, their ability to cost shift and cherry pick has deteriorated with it. They have, of course, leaned heavily on any faction poorly equipped to fight back, namely nurses and employees. Now those seeds are beginning to sprout as well as the nurses and staff are now actively talking to Teamsters and shaved apes are starting to accumulate handing out flyers. "Sorry.....we'd like to help you guys out but we have our own problems."

OK...if you are willing to accept the generalizations of this scenario to be accurate, what are the real options of the Indianapolis Intensivist Association?

Here are the existing guidelines for the use of critical care codes 99291 and 99292 from the Director of Physician and Ambulatory Care Policy, Health Care Financing Office, distributed to all associate regional administrators for Medicare on January 23 1995. (Truncated and edited by me). This is the current law of the land.

"The CPT definition of Critical Care services states that: "Critical care includes the care of critically ill or injured patients in a variety of medical emergencies that requires the constant attendance of the physician (eg: cardiac arrest, shock, bleeding, respiratory failure, postoperative complications)."

"This statement seems to have been interpreted by some carriers to mean that there must be a medical emergency for critical care to be billed. Such an interpretation is too narrow and restricts the use of the critical care codes inappropriately. Based on the advice of a work group of our carrier medical directors and representatives of several specialty societies as well as a review of the relative value units assigned to these codes, we have determined that critical care also includes the care of patients who might not be in a "medical emergency" but who nonetheless require constant physician attention because they are unstable and critically ill."

"The care of such patients involves decision making of high complexity to assess, manipulate and support circulatory, respiratory, CNS, metabolic or other vital system functions to prevent or treat single or multiple vital organ system failure. It often also requires extensive interpretation of multiple databases and application of advanced technology to manage the patient."

"This expanded definition does not mean that the care of a patient who happens to be in a critical care, intensive care or other similar unit should be reported with the critical care codes. In such a unit, the care of a patient who is not unstable and critically ill is reported using the appropriate hospital care code (99231 - 99233) or inpatient consultation code (99251 - 99263)."

"The time that can be reported as critical care is not limited to time spent at the immediate bedside of the patient. The intent of the terms "constant attendance" appear to have been interpreted by some to mean that the physician may only report the time spend spent at the immediate bedside of the patient. For example: time spent reviewing laboratory test results or discussion the critically ill patient's care with other medical staff in the unit or at the nurses station on the floor would be reported as critical care , even if it does not occur at the bedside."

"Time spent in activities that occur outside the unit or off the floor (eg: telephone calls, whether taken at home in the office or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. "

"The following National policies on the amount of critical care services that can be billed were first issued on May 29, 1992 in a memorandum from the Director, Office of Payment Policy to all Regional Administrators for Medicare. These policies remain in effect."

A. "There are no absolute limits on the amount of critical care services that can be billed per day or per hospital stay."

B. "A physician must be prepared to demonstrate that the services billed meets the definition of critical care."

That was the original deal. But all is not well behind the scenes. After a few years the reimbursers see a LOT of 99291 activity and with it see a LOT of money exiting the coffers. Now, looking it from their vantage, they can't get any more from a congress under the gun to balance the budget. They can't tell consumers they need to limit expenditure (services) or break the bank. Politicians having advocated limiting services in the past were beaten like snakes every time they appeared in public and voted out of office immediately. They have one option ..... rationing schemes that shift the accountability to someone else more vulnerable.

In fact, HCFA views EVERY critical care admission as a hospital visit, and eagerly pays accordingly for that designation. Any conceivable data suggesting "stability" is interpreted as evicence the patient does not need to be in an ICU, including any salutory statement in a progress note "Patient stable" (after a cardiac arrest and multiple lethal arrythmias and intubation and IABP). More and more extensive descriptions of patient condition are required, many involving listing endless "negatives" (all of which, of course, mitigate against critical illness). The potential for rapid and unexpected decompensation between breaths or heartbeats is NOT considered if a statistical sampling of their data input matches a preformed template associated with the concept of "stable".

All "second" critical care codes in the evening are denied routinely, even if the patient fulfills the original definition of critically ill. Physician reviewers have created the standard of whether or not a hypothetical physician might be reimbursed to leave his or her bed and come to the hospital to see a patient from home (not a telephone consultation). A physician physically staying in the hospital to deal with a full unit of patients is undefined and and unreimburseable (even with an appropriate note fulfilling their original qualifications). Medicare clearly does not support a physician in the ICU and pay by visits only, but will pay for one driving to the hospital from home inthe middle of the night. A dedicated (in the temporal sense) ICU intensivist is a totally foreign concept to them.

Physicians seeking to appeal adverse audits (demanding payback to Medicare) have three options. The first two are essentially administrative requests to have the same people who ran the original audit reevaluate the data again. Sort of like asking Torquamada re-look at your particular profile before the axe falls. The third option would end all parties before an administrative judge. HCFA makes it clear in their lexicons that if a provider chooses this option, it will immediately prompt reexamination of ALL the services (not limited to just critical care) involved in the original audit. Like your ex-wife handing Torquamada additional files to support your appeal.

Clearly, they desire to go back in time to a time where generalists admitted patients to ICUs and consulted numerous SODS, each one writing orders based on isolated organ systems. There is no such thing as critical care in such a system, and each SODS is paid from whatever code they have protected unto their turf. It has always been my impression that this system of health care delivery to critically ill folks has been weighed in the balance and found wanting. And there seems to be an abundance of evidence that is is more costly and does not decrease mortality. But it has one thing going for it...........it appears cheaper in the short run, at least in their interpretation.

My final word:

I think retrospective audit for the purpose of rationing health care is quite possibly the final blushing crow and and a very real potential to sink critical care as we know it. Reimbursers will demand money back bi-yearly by interpretation of gray areas they built into the contract, such as it is. They have the authority to interpret non-reimburseable gray areas of patient selection on the fly, but we are mandated to take ALL patients that present for service.

The fundamental problem is PATIENT POPULATION SELECTION. Our previous notions of cost cutting such as selecting cheaper (not usually as effective) drugs and micro-rationing resources at the nursing and sub-nursing care are NOT germane to this kind of action. Any amount of money conserved by these things are equivalent to stomping on an army of ants while elephants raze the village. "Continuous Quality Improvement" does nothing but institutionalize and proceduralize medicine for the wrong agencies; ones that don't demand money back after it has been spent. With these guys, money talks and bullshit walks.

I say again, this is the single most important and urgent issue facing us today. The issue of who is reimbursable and who is admittable MUST be addressed and formalized. If we are mandated to an open door admissions policy, they will have to pay for it. If they choose to define patient populations they won't pay for, we must know those populations in advance so we can find other resources for them. They cannot be allowed to have it both ways or we will never know from one year to the next if we will be in the poorhouse and there is no defense against it. It's like shooting fish in a barrel.

I urge all of you to think about this and get involved wherever and whenever asked. I sincerely hope the SCCM suits are on the job here. This should go to the courts as rapidly as possible and to the Supreme Court if necessary. If it is allowed to persist, we are all going to be doing something else in five years. And you can quote me on that.