Blog | Thursday, August 25, 2016

The evolution of hospitals


Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really, if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get 1 bundled payment for the whole hospitalization based on the patient's diagnosis. Average length of stay for hospitalized patients went from 30 days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay. Depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

“Throughput” became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than 4 days. (Of course, for mothers with normal births, this is even less, about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go: the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they're better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:”Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives, and drop-in professionals.”

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now. Can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there's a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.