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

Tuesday, May 10, 2016

There's so much more to the whole observation versus inpatient debate

A few weeks ago I wrote a piece about my hero patient, a World War 2 veteran who landed on Normandy beach, and how he had been left in a difficult position by the whole observation versus inpatient situation while he was hospitalized. The original title of the essay was: Inpatient versus Observation: To all elderly patients from the Greatest Generation, so sorry this is the way it is.”

My intention was to draw attention to these types of scenarios and how they cause intense anxiety and concern to our elderly. It's a horrible and unacceptable situation when this happens. While I can't obviously divulge the individual details of the case or make any claim to be an expert on the pyramid of rules and regulations (nor do I ever intend to become an expert on this either), all I can do is write about the essential truths of any given situation as I see them in my capacity as a frontline doctor. I received significant correspondence after writing the article, which I was very appreciative of. It's always good to stimulate debate on important topics that affect so many people. I wanted to address a few of the many questions and opinions I received.

1) Observation stays are not always more expensive for the patient.
This is certainly true, but the designation of observation status does make the patient potentially liable for more out-of-pocket costs, as co-payments and coinsurance for additional services that are not covered by Medicare Part B kick in (typically 20%). Home prescription medications are sometimes not covered either. Medicare Part A, on the other hand, typically covers all inpatient costs after a fixed deductible is met. Whether or not a minority of observation patients end up with higher total out-of-pocket costs is irrelevant to the situation I highlighted. Nor should any respectable system allow uncertainty, “surprise bills,” or be a constant merry-go-round of moved goalposts, negotiating, and bargaining over final costs. This PBS article draws attention to the confusion that can arise by what's covered and what's not inpatient versus observation.

For whatever intrinsic checkbox reasons and history, my patient and his family had reason to believe based on their previous experiences and individual circumstances that they would be left with a higher bill for an observation stay. That was their reality, and a terrible situation for our vulnerable elderly to be left in as they are lying unwell in a hospital bed. Instead of focusing on getting and feeling better, they are concerned about the implications of this artificial distinction we've created and what the consequences are for them. Even if only one patient in our country is going through this and stuck in the system, especially a World War 2 hero, this is one too many.

2) Patients have a right to know whether they are inpatient or observation
Of course they do, and at least everywhere I've worked, are always given that information (usually by case management). In the particular story that I was highlighting, I didn't have the heart to tell the patient and his elderly wife immediately, since I didn't want to cause increased anxiety at a moment when he was acutely unwell and already not feeling good (especially when I wasn't 100% sure myself and needed to clarify). My job as a physician is to address clinical issues first, and always will be. After analysis of the case and making sure we were right, sure enough they were told a couple of hours later. We as physicians make that determination, but are guided by tick boxes and often told that “criteria for inpatient are not met”—even when we know a longer hospitalization is likely. In other words, physicians' hands are tied. I know I speak for the vast majority of physicians when I say that we find the whole process annoying and unnecessarily complicated, something we didn't go to medical school for.

3) Determining observation versus inpatient is costly for other reasons
There are many other financial factors at play, outside the scope of this article. In a nutshell, hospitals can take a big financial hit if this determination isn't made correctly (for reasons even including whether that patient is readmitted). Another huge financial consideration is whether the patient requires a rehabilitation or skilled nursing facility stay post-discharge. That really can be a financial disaster for anyone in observation status.

The story of that World War 2 veteran was just one of hundreds, if not thousands, of such situations that I've dealt with over the years. Ditto I'm sure for physicians all over the United States who on a daily basis face these difficult cases.

At the end of the day, we have created a monster of our own making, and this distinction causes a huge amount of stress, anxiety and wasted resources (in fact, it's actually spawned a whole new costly industry!). This applies to physicians, case managers, hospital executives—but most importantly to our long suffering patients. That's the bigger picture of why we need change. If you ever hear anyone ferociously defending the system or giving the impression that all is well, be sure to double-check their bio and make sure their job title doesn't depend on keeping the status quo intact!

The issue has finally been getting more public and political attention over the last couple of years, as congressmen and women up and down the country are hearing about this from their angry constituents. But rather than debate it and make rules to work around it, why not go back to basics and ask why we even need this distinction in the first place? As I said in my initial article, if you're sick enough to be in hospital, that should be the end of the story, whether it's for 1 day or 4 days. Same bed, same room, same medical equipment, same attention to detail and caring staff.

What we should really do is abolish this whole circus and start afresh. After all, if the ultimate aim was to control health care costs, surely there are better and more effective ways to do this?

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. This post originally appeared at his blog.

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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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