June 10, 2014 | Posted By Jane Jankowski, DPS

No one seems to know what the answer is to keeping costs down in healthcare but grand efforts have been undertaken to find someone to blame. Some of the targets are patients, others are providers, and sometimes the insurers are dragged into the fray as well. The rhetoric is tired and worn on both ends.  Is it the folks with chronic diseases like diabetes? Is it the folks who need dialysis? The smokers? The patients who do not follow the doctors’ advice and stay sick and expensive? The people who want ‘everything done’ at the end of life? Is it the doctors who acquiesce to patient demands or the laws that obligate them to do so? Do doctors order too many expensive tests, bleeding insurance system? Is it the liability insurance that must cover them if they fail to order a test? Maybe it is the insurance companies paying high salaries to executives while handing down ever-shrinking reimbursements pressing institutions to find new ways to eek out enough income to sustain an operating budget. Newer to this menu are penalties for staying in the hospital too long and coming back too soon. This latest addition to the list is perhaps among the most absurd.

I will agree that there are instances where patients remain in the hospital too long, and poor discharge planning or malingering behavior should not be paid out endlessly. However, to both restrict length of stay AND penalize facilities for patients who then return still sick is never going to achieve better health outcomes. This becomes an infinite loop – the kind of revolving door noted in a recent New York Times blog NYT blog . If the goal of medicine is to improve health, well-being, and to restore function to the degree possible then this should be achieved before heading home or to the next level of care.  The very nature of medicine requires clinical judgment which cannot fully be captured in coding and billing categories though millions of case managers across the nation are tasked with this tricky job. Common sense and attention to symptoms ought not to be  overridden by other concerns, yet pressure to discharge compounded by pressure to not readmit patients for the same diagnosis creates an impossible bind for providers and families who may be appropriately hesitant to have a patient go home who really does not seem quite well enough. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

1 comments | Topics: Cost , Health Insurance


Janice Szalkowski

Janice Szalkowski wrote on 06/13/14 10:11 PM

Dr. Jankowski,

You have no idea how excited I was to see that you are examining this question. This has been a topic near and dear to my heart for close to a year now at AMC. COPD is one of the disease states that falls under this new MC rule. Starting October of this year if a patient with a diagnosis of COPD is readmitted in less than 6 months, the hospital will not receive full reimbursement.
As a respiratory therapist and due to my background in pulmonary rehab ( and a personal passion for this population), my director asked me to head-up a project to help educate the patients. The goal in mind is to give the patients tools to better manage their own care. Sadly we can't cure the disease, but I have witnessed over and over again the difference that education, emotional support,and hope can make in the quality of life for these people.
We don't have a program running, but each week I meet with my director and we plug along a bit further. It is our hope that this will help protect our patients and our hospital. Hospitals are between a rock and a hard place. Hospitals are closing and cutting staff. It is frightening on a professional and a personal level. I can't imagine not having an institution like ours in my backyard. I credit AMC for saving two of my family members.
I think we can make a real difference in the lives of some of these patients. I hope that we are able to find a way to implement educational opportunities with these patients to allow them to avoid the repeated admissions that take a toll not only on them physically but also on their spirit.
Any ideas that you have that might be helpful for our project would be greatly appreciated.
Thank you again for the topic.
Janice Szalkowski

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