American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, November 13, 2013

What to do with ancient people

A 100-year-old woman is brought to the emergency room by a concerned friend because she can no longer get out of bed to get food or go to the bathroom. Other than being unwashed and a little confused, she is fine. Her electrolytes are pristine, her electrocardiogram the definition of normal, her blood count and chest X-ray perfectly mirror the expected physiology for her age. Even her urinalysis is normal. She takes no medications and hasn’t been to the doctor for a decade. She has no living family and her friends have their own lives and problems. She can’t go home because she has just gotten too old. What shall we do with her?

When the law establishing Medicare was enacted in 1966 as title XIII of the Social Security Act during the presidency of Lyndon Johnson, only half of seniors had health insurance and many had no access to healthcare because they couldn’t afford it. Now nearly all seniors in the U.S. have insurance coverage for both ambulatory and hospital care. Medicare also covers a limited amount of time in nursing homes as a bridge between hospital and home. This is truly intended to finish the work of an acute hospitalization and get a patient back home, when an acute illness has made them weak enough that going straight back would risk failure and return to the hospital. Medicare was never intended to pay for long term care, but then how is a person expected to afford care in a nursing home?

Nursing home costs are now around $220 per day or over $80,000 per year. It is pretty rare to find a person who has savings and pensions adequate to cover this much money. The way it usually goes is that a person spends their income and their assets, not including their house, if there is a spouse in it or an intention to return to it, a car and a few other odds and ends such as a wedding ring and a burial plot, down to a certain small amount after which time he or she applies for Medicaid, a state-run medical funding agency.

Some nursing homes don’t accept patients with Medicaid funding because they are either not certified by Medicaid or don’t want to accept the smaller amount of money that Medicaid spends for care compared to what a private patient pays. In Idaho, Medicaid pays nursing home expenses for 60% of the patients in these facilities. After a patient spends down their assets and ends up on Medicaid they usually remain in a nursing home for the rest of their lives, and Medicaid picks up the tab. After becoming destitute it would be impractical to return to independent living, even if one were to be miraculously made well again.

So back to our centenarian. She has been brought into the emergency room and, lacking a traditional multigenerational family living together to take on her care, she clearly needs a nursing home. The wheels of nursing homes work slowly, though, as do the gears and engines of the Medicaid program. She needs somewhere to sleep tonight. She is in a hospital, and in that hospital she will remain until a safe place can be found for her to stay. Unfortunately there is nothing really wrong with her except that she has had an excess of birthdays.

Medicare, which she probably has, will only pay for her hospital stay if she is acutely ill or we are suspicious that she might be acutely ill for some documentable reason. If she really is ill in such a way that she would need hospital care, not like a cold or a sore back or a urinary tract infection, we can make her an inpatient. As an inpatient, most of her costs will be paid by Medicare. If we think she might be ill, for instance if she has chest pain that might indicate a heart attack, we can admit her under observation for a day or at most 2 days while we make absolutely sure she is fine. If she is an inpatient for 3 days, Medicare will pay for skilled (usually nursing home) care, that is, care to rehabilitate her to go home, for a maximum of 20 days. If rehabilitative care is necessary for longer, Medicare will pay a portion of nursing home costs up to a lifetime maximum of 100 days. If it becomes clear that she will never be able to return home, Medicare will no longer pay, and if she can’t pay the nursing home costs, she will need to apply for Medicaid, which will then pay for her. Once she is at the nursing home, usually they won’t just kick her out, even if her Medicaid application is slow to be accepted.

Our patient in question is not sick and can’t be badgered into complaining of anything life threatening. She is admitted to the hospital because we can’t put her out on the streets and it is not safe for her to be at her home anymore. Since doctors are trained to look for disease, we look really hard and think that maybe her confusion is actually delirium and that perhaps she looks just a touch out of breath so we document anything that goes along with that and then the billing staff attempts to bill Medicare for her stay. If Medicare pays for this hospitalization and later audits the account and finds that she was actually fine, we have committed fraud and the penalties are steep. Deep in our hearts we have intended no fraud, but feel that this hospital stay is unavoidable and that Medicare should pay for it, but they see it quite differently. Our billing specialists have become much more vigilant in avoiding false claims since enforcement agencies have been coming down hard on cases of fraud. Still, they spin their wheels and struggle with verbiage and try to get us to document what seems like exaggeration or hyperbole in order to minimize the amount of uncompensated care that the hospital provides.

This grand old woman who has finally reached our emergency room deserves a gold medal for being not only healthy but for costing the health care system close to nothing for decades. If she had seen physicians for every wart and ingrown toenail she might have been gradually transitioning to a higher level of care as she aged, and some of her financial issues would be well in hand. We see few healthy 100 year olds, but stories similar to this are not uncommon and the problem of what to do with the not quite sick and yet not well enough to go home plagues hospitals, in particular emergency room doctors and hospitalists.

Emergency room staff spend scads of time trying to arrange dispositions for these patients that don’t involve an admission, and then have to explain to the admitting physician why admission is the only option. The hospitalist needs to care for the patient, often while trying to also care for the truly sick. We must also respond to the concerns of the billing specialist who wishes that any money at all would come in to defray the hospital costs that will come of this stay which might be prolonged depending on the willingness of a nursing home to accept the patient.

This is all so very complicated. Humongous amounts of energy are wasted. Social workers battle processes that are designed to make things more difficult and physicians lament that there aren’t systems in place to deal with the very real needs of people who age and need help. Hospitals try to bill for the hours of care and problem solving that they do, requesting money from Medicare which was never intended to fund this sort of thing.

I think that this hasn’t been solved because it is too painful to look at and the people who suffer the most, the very old and very disabled, don’t have an effective voice. The chunk of money that would need to be set aside to do this right would be significant, in a political environment that is already making loud squeaking noises (justifiable) about what medical care costs. What is being ignored is the fact that we are paying for this, and probably paying more because the routines are so horribly inefficient. Hospitals are paying physicians and billers and social workers and those costs are defrayed by higher charges for everything else that the hospitals do. Communities are paying law enforcement officers who are the first responders for folks who fail at home.

I would like to be able to present this ancient patient who presented to the emergency room with her medal of honor for an excellent and healthy life and seamlessly tuck her into a bed with clean sheets and regular meals, if that is what she wants. I would like her never to have to spend 12 hours in an emergency department getting tests she doesn’t need with physicians who will someday, if they are lucky, be in her shoes, arguing about who has to take care of her. There are many organizations and individuals thinking about the nuts and bolts of solving this problem, including ways to keep folks in their own home with the help they need and alternatives to governmental funding of nursing care and other great ideas. It is so vitally important to get important stakeholders from hospitals, in conjunction with Medicare and Medicaid, to look honestly at the problem and commit to coming up with some solutions.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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