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

Medical Rationing by Reparations.

David Crippen

"I noted in your recent posting that you said that Attending Physicians are always present when the residents are doing procedures. I presume you realize that that level of supervising is downright extraordinary. Lack of supervision of the residents/fellows at XXXXX hospital was a huge concern to me when I was there. The only physicians we had to work with after about 7 pm were an intern and a junior resident. The seniors, fellows and Attendings were on call from home. It wasn't in the least unusual to have patients on Nitric, ECMO, and any other invasive therapy. It was pretty well accepted that the nurses and therapists ran the unit. I was always assured there was an Attending Anesthesiologist in house ... but I never saw them. This is the way to deal with the sickest patients in the hospital? (In addition to dealing with sick patients) when are the rest of the" teaching" hospitals going to get a clue that leaving residents out there spinning on their thumbs at 3 am is NOT a great "learning" experience?"

In order to truly savor the above comment, just a little background history must be understood.

Everyone choosing to grapple with this problem simply must accept two important concepts:

1. Third party reimbursers desire to ration scarce resources by limiting services but can't, because it's a politically non-viable option.

2. Third party payers MUST ration in some fashion or go out of business in a system where providers have an incentive to provide and consumers have no incentive to conserve.

Once these facts are accepted, it becomes a lot easier to understand how reimbursement evolved into rationing-by-inconvenience. For the reimbursement industry, slowing and controlling the use of and payment for services by impeding, inconveniencing, and confusing providers is profitable. Delayed payouts increase interest on the residual funds, and savings due to bureaucratic inefficiency favor the reimburser. Therefore, computer reimbursement programs have a strong bias toward denial when processing claims. Incredibly simple errors grind the process to a halt for weeks, and no one will take responsibility for straightening it out so otherwise legitimate claims just eventually fade away. Such a deal. It must also be understood that this strategy on the part of reimbursers has been extremely successful. Statistics of Medicaid denials show that 59.7% occurred because of paperwork or documentation whereas 21.4% occurred because the recipient made too much money to be eligible (Grumet GW: Sounding board: Health care rationing through inconvenience. NEJM, Aug 31, 1987 321(90, 607-612).

Remember also that the government has a selective memory for historical events manipulatable into it's best interest. The next logical step was to follow the apotheosis of "black reparations" which became briefly popular in the late 60's. If white America was willing to admit that blacks were victims of discrimination, it naturally followed that those victims were economically disaffected as well, so they demanded to be paid off for this deficit. Unfortunately, these claims were met with the same policy the Internal Revenue Service uses. If you make a mistake- you pay. If the IRS makes a mistake- you pay. But, be that as it may, reimbursers figured out that paperwork glitches are not only non-payable, but they can go back and demand payment already rendered if glitches can be proved retrospectively....just like the IRS does it. So, if they catch you in a non-reimbursible deficit...not only can they deny payment, they can also demand reparations.

What, then, constitutes a "non-reimbursible deficit" in critical care? Why, anything that the reimburser thinks isn't worth paying for. Since the burden is on you to convince the payer that your services are needed and necessary, their conception of your net worth is the rule. So then simply picture in your mind's eye what kinds of things they might frown on. "Ghost Surgery (resident doing the case)", billing for services not performed (fraud), billing for services not needed (pot churning) and so on. For purposes of brevity, lets choose one and explore it fully .We already know they won't pay for procedures and treatment not documented. Why not procedures and treatment documented but performed by persons other than the documenter? Wow...now it starts to get interesting.

Lets argue that you are a CCM attending in a large tertiary care teaching hospital, and you take care of critically ill patients from 8 am to 5 pm and then you go home and "cover" housestaff by phone. Lets further argue that you have the option to come in in the middle of the night for disasters, but, fess up now, how often do you really do it and for what kinds of disasters? The incentive for helping the housestaff deal with problems over the phone instead of coming in are dramatically higher than crawling out of the rack and plodding in at 0300 and you know damn well that's true. In my experience, the way it usually works, is that the algorithms for calling you at home get very wide after 6 pm and wider still after midnight. OK, lets yet further argue that you bill for "cognitive decisions" made by the housestaff with your advice and consent over the phone, and you also bill for procedures they do because you are ultimately responsible (the next day).

Now, remember that you have come to deal with a payer who has a maximum incentive to ration and a minimum capability to do so effectively. They are looking for ways to beat you at your own game without limiting services. They have scored a big victory by not paying you for uncrossed T's and undotted I's. They are looking for variations on this theme. Here you are billing for treatment and procedures in absentia. Billing for treatment and procedures someone else does while you sleep. Are you getting my gist here? This is the biggest bonanza they ever hit...the mother load. Not only can they avoid paying for treatment you are unlikely to provide (you can't be there every night), but they can demand reparations for past performance, or lack thereof. You and they both know you cannot afford the legal fees to fight it even if there were a chance you could win.....just like the IRS.

The handwriting is on the wall. You will not get paid for any activity in which you do not actively participate and that is a natural fact. Telling the resident to do the right thing from home has been weighed in the balance and found wanting. Tonight shall the souls of those who persist in this notion be required of them, metaphorically speaking :-). The burden is on those who resist this solution to devise a plan that will be found acceptible to horses running wildy, bits firmly clamped between clenched teeth.

Here is the future of Critical Care in the USA IMHO: We are a six man, one woman group of fully (fellowship) trained critical care physicians who provide services in the ICU of a 750 bed major tertiary care hospital in the big city of Pittsburgh. We are all multi-Board Certified (or eligible and working on certification). We have an exclusive contract for those services with the hospital. We become "automatic co-attendings" for anyone admitted to the Medical or Surgical Intensive Care. This policy does not constitute automatic transferal of ownership of the patient once they cross the threshold; it means that their care becomes a team effort (Yes..Ken Mattox...I said TEAM). We are also contractually obligated to perform structured teaching activities for the housestaff and attend all cardiac arrests and resuscitations. We provide other services such as consultations, placement of catheters and clinical research.

The critical care team, led by the attending physician makes rounds on every patient in the ICU twice per day, 9 am and 5 pm. Problems are assessed, plans are formulated, orders are written, housestaff get plugged in, other attendings are consulted and informed, families are spoken to. Each patient gets a DICTATED (so it can be read by humans) note twice a day extensively detailing problems, assessment of problems, plans for reversal of problems and rationale for procedures. We put down what we see, how we think we can fix it, what procedures are necessary and why, and the plan for the rest of the day. We keep a file of commonly used ICD-9 codes and these are updated every day by the attending physician in charge. All procedures done by housestaff are supervised by a flesh and blood attending in the same room. As of January 1, there will be an attending in house to supervise (just a little more loosely) all procedures done by a critical care fellow as well. There is a CCM attending physically present in the Hospital 24 hours a day, 7 days a week 365 days a year.

Why is this the future of Critical Care in the USA? It started with the Emergency Department and it evolved to the ICU as well. I am old enough to remember how it was when housestaff ran emergency rooms and attending doctors called in advice in the middle of the night. How does anyone think this situatiton is any different that intensive care units. An ICU is not REALLY an ICU unless there is an ICU physician present in perpetuity. Don't believe it? Look again at the post from Mike Rie a few days ago. Government demands thirty million back from hospital because residents making decisions and doing procedures unsupervised. Hospital elects to pay up because they can't afford legal fees to fight it.

It's not so bad...look at me, where do you all think I find the time to come up with these strange and wonderous posts to CCM-L :-)