The Legend of the Avoidable Hospital Readmission

A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well.

Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a Very Big Business.

In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper or perhaps merely a gleam in your father’s eyes, Medicare and Big Insurance started collecting premiums from workers and dole it out to hospitals when the workers or retirees needed hospital care.

At that point, hospital fees became confusing. The people who received care didn’t see what the charges were, and the payers didn’t really know how much care was medically necessary or even actually delivered by the increasingly profit-driven hospitals, let alone how much it cost to provide those services.

Insurers demanded deep discounts, and hospitals raised charges. Billing became more and more convoluted and required more hospital documentation and more business staff at both the hospitals and the insurers.

When an aspirin became as expensive as a four course meal and an overnight hospital stay became more expensive than the monthly lease payment for a Bentley, Medicare thought they had figured out a way to outsmart the hospitals: They started paying a flat rate for each hospital stay, based on the diagnosis. Suddenly, the hospitals were penalized if patients stayed longer or required more procedures or more aspirins than the average case.

That’s when patients no longer got to stay until they were well. People were discharged home at five o’clock on Friday afternoons, only partway cleared of their symptoms, with promises of a visiting nurse the following week and instructions to call their family doctor first thing Monday morning for an appointment.

A few years went by, and Medicare realized patients often ended up back in the hospital shortly after their discharge. Hospitals, of course, got to bill twice for each such episode and Medicare was obligated to pay the hospitals twice – not what they had expected would happen.

Medicare’s next move came swiftly: They didn’t retreat and say “we were wrong, keep patients in the hospital until they are well enough to go home”. Instead, they announced they would penalize hospitals if patients with certain hot button diagnoses got readmitted within thirty days of discharge.

This was an ingenious move on Medicare’s part. They are now imposing this penalty not just for patients who were sent home before they were stable, but also for patients who have severe chronic or near-terminal illnesses. For these patients, even the best possible prognosis is multiple admissions or a lengthy stay until they die. Medicare is now forcing the hospitals to spend more money than they receive during each such hospitalization, and, through the penalties, Medicare is giving itself a rebate every time one of these chronically ill patients gets readmitted appropriately, weeks after any shortcomings in the initial care would have been compensated for by the follow-up care or the passage of time.

Today, Medicare is looking outside the hospital wards for a happy ending to this situation. They are starting to spend money (presumably the money they are taking away from the hospitals) paying primary care practices for reaching out to patients immediately after they come home from the hospital in order to identify gaps in care and plan for follow-up visits. We are now becoming more and more involved with the social and economic barriers to health.

So the legend continues to evolve. But, like all legends, it is only partly true: Hospital care doesn’t cure everyone or everything. Primary care practices and their new partners – Community Care Teams and all the other agencies they network with – can only do so much to help patients overcome the obstacles that our society as a whole cannot remedy. And as primary care practices shoulder more and more chronic disease management responsibilities, even with some extra money thrown in, will we be able to also provide the timely urgent medical care our patients need in order to stay out of the Emergency Department and the hospital?

A Black Hole

Theresa arrived in a cloud of noise and commotion.

She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic.

Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart and a couple of other stores, slinging her big handbag over her shoulder, opening it to pull out her wallet, stuff receipts and her reading glasses away and fumble for her asthma inhaler.

In my exam room she repeated her story and demonstrated how she had held the bag open, pulled things out of it and then put them back in, and then realizing that her two pill bottles were missing. She proceeded to also show me how she rummaged around for the pill bottles and even emptied the large, brown bag with its purple lining.

In a loud voice and with oversized gestures, she replayed every conversation she had had about her missing pill bottles with store clerks, her girlfriend and her pharmacist in the last thirty six hours.

I sighed. Theresa had a small amount of pain pills on hand, which she could safely go without, but she was one of those patients who had seemed stable and truly helped by her long-term alprazolam. This was endorsed for selected patients at the psychopharmacology courses I had attended in Boston many years ago, but it has now fallen out of fashion.

“Well, Theresa, you know these controlled substance agreements you’ve had to sign always say that lost or stolen medications will not be replaced”, I said.

“But this has never happened to me before.” Her voice was as shaky as her large, bony hands. “I’ve been on alprazolam for years, what happens if I stop it suddenly? I took my last pill last night, one I had saved in my nightstand.”

“You’re right. Stopping alprazolam suddenly can actually be risky”, I agreed. “Here’s what I can do: I can give you half your usual dose, in weekly refills that you will have to pay for yourself, and I’ll see you back every Wednesday until your next regular prescription is due. Then we can assess how you’re doing.”


I entered the new dose in the computer and clicked with my trackball on the “print” button. I doubted that Theresa was trying to scam me with diversion or addiction, but rules were rules. Obviously, I didn’t want risk withdrawal seizures.

Later that night I thought about Theresa again. I couldn’t completely ignore a slight shade of doubt. Was she becoming addicted or irresponsible with her medication? A mental black hole lay open but I resisted falling into it.

The next day, I heard Theresa’s resonant voice again, talking with Autumn somewhere down the hall. A short while later, Autumn appeared at my door. In her hand she held three pill bottles.

“Remember Theresa’s missing pill bottles?”

Without waiting for my answer, she continued:

“Well she was just here with that big handbag of hers. She lost her cell phone last night, so she emptied out her whole bag again and found a five inch hole in the lining. There, between the lining and the outer shell, was her cell phone, her two pill bottles and one of her spare pairs of reading glasses!”

The black hole was real, I thought, not in my mind, but in that big handbag of hers.

A Very Careful Driver

“I don’t know why Dr Brown took my license away”, the 92-year old man said. He was visibly shaking with anger. “I’ve been driving since I was a young boy, and I could find my way to California without a map”.

My associate, Dr. Wilford Brown, had sent in a State Driver Profile a few months ago, and made reference to an attached letter by a family member, which in his words would be “very damning, if true”. Apparently, the Department of Motor Vehicles had thought so too, as the elderly man explained their action through clenched jaws.

“I called them up, and they said that if you wrote to them, they would give me my license back”.

“They did, huh…” I said, while mousing and clicking my way back and forth in the documents section of the electronic medical record in search of the damning letter. I could not find it.

“How could Dr. Brown say that I’m not a good driver? What does he know about that?” The man raised his trembling hand and pointed in the general direction of Dr. Brown’s office.

“He says I have memory problems. My memory is excellent. I remember everything!”

I looked at his problem list, where “Dementia” was the first diagnosis.

“Maybe someone contacted the DMV about your driving”, I said cautiously, thinking I wouldn’t want to cause conflict or mistrust in the family by revealing everything I knew about the letter. “Maybe someone didn’t like the way you drive”, I tried, wondering if perhaps the missing letter might have been inaccurate or exaggerated.

I looked at his birth date on the computer screen and did a quick search in my memory bank about old cars.

They were still making Model T Fords when he was a little boy. Maybe he even learned to drive in one. I pictured traffic around here in those days, and my mind suddenly switched to the tourist traffic on Route One every summer weekend.

“My memory is excellent”, Mr. Gordon said again.

“Well, it’s not just memory, it’s eyesight, hearing, reaction time, judgement and reflexes”, I started.

“I am a very careful driver”, he interrupted. “When I come to an intersection, I stop, even if the light is green, and I look both ways before I go”.

As in a movie flashback, I saw him as a young boy, sitting next to his father, honking a rubber and brass horn and proudly maneuvering a Model T on an empty country road, surrounded only by cow pastures and potato fields.

“Well, Mr. Gordon”, I began. I knew what I had to do.

“And Stay Away From Doctors”

Earnest Tipp was very overdue for his blood pressure follow-up. Almost a year and a half overdue, as a matter of fact. The last few times I had refilled his medications, I had added “needs follow up” to the signum on his scripts.

The other day I finally saw him in my schedule. I thought about him all morning. A tall, muscular 90-year old widower with an appetite for golf and fine food, he always exuded contentment and gratitude over his good health.

After Autumn had checked him in, I looked at his vital signs screen. His weight was stable and his blood pressure was still well controlled.

“He’ll tell you why he didn’t come back sooner”, she said. “And he’s pretty smug about it, because you had joked with him about staying away from doctors!”

I remembered. Somehow, the topic of health screenings and medicalizing common ailments had come up and I had jokingly, as I often do, said “and stay away from doctors“.

As I entered the exam room, Earnest told the story of how he had taken my advise seriously and stayed away from all doctors, including me.

It didn’t take long to establish that Earnest seemed to be in good health, and, at age 90, how you seem to be is generally all that matters. No screening tests are indicated at that age, even whether and how to treat many diseases and risk factors for disease is usually controversial in that age group.

I remember the nephrologist I send my toughest hypertension patients to sometimes points out how little we actually know about treating people over 80 years old. That is even more true when it comes to 90-year-olds.

The other thing I remembered about my previous visit with Earnest was how he had told me he was about to have lunch with his prom date from seventy years ago. I asked him if he was still seeing her.

“Yes, we see each other almost every week”, he smiled.

I renewed his prescriptions and asked him to come back in a year. “Keep your good diet, play lots of golf this summer, enjoy your prom date…”

“And stay away from doctors”, he interrupted.

“Yes, by all means”, I answered. He stood up and offered a firm handshake. I have nothing to teach this man, I thought to myself.

Missing the Old A&P

Sometimes, after crafting an important or complex plan of care with a patient, I say: “Let me type all this into the computer so that, in case I run into that big bull moose up on Vaillancourt Hill on my way home tonight, the next doctor who sees you will know what we were thinking today.”

Patients sometimes squirm or laugh nervously at that, but then they usually indicate understanding and appreciation of what I am doing.

I am a physician who started out in the era of handwritten office notes. I often reminisce about the pediatricians who simply charted “LOM Amox” when a child had come in with a left-sided ear infection and received amoxicillin. From a medical point of view, there’s usually still little more to say, but now we don’t document for ourselves or other doctors anymore. These days we have to document for the insurance companies, the government, the legal system and for all kinds of lay people. And what we document isn’t just the medical facts of each visit, but also to what degree we did our job as the eyes and the voice of the government.

Treating the sick or counseling the well, we now have our agenda dictated by the government, from what we do when a patient’s body mass index is in the obese range all the way down to the sources of our patient education handouts – if I provide the best written information I have gathered over years of practice, instead of the rudimentary boilerplate materials from my EMR, I fail at “Meaningful Use” (of my EMR)!

I have seen the documentation requirements of what we do to fulfill the government’s public health agenda grow so much that what we think, beyond the patient’s ICD-9 (soon 10) diagnosis code, has become harder and harder to discern in many colleagues’ medical records, possibly also in my own.

Just before our clinic bought an electric medical record system, I walked through a much larger office with their Executive Medical Director. He and one of the clinic doctors explained, “with the EMR, we start with the superbill and work backwards”. I was used to start with the undiagnosed symptom or the presenting known diagnosis and work forward, carefully crafting a plan of action.

I didn’t quite grasp at the time how significant his statement was. Now, years later, I see the depth of this: In the first few years that we used our new system, I and all our doctors in our organization lost our quality certification with NCQA for diabetes and cardiovascular care because our new EMR didn’t track what we did for our patients. It wasn’t enough to do foot exams and to write (type) when patients last saw their eye doctor: Anything we do or even think we might track must appear as an “order” in the superbill, because our EMR is hardly a medical records system at all, but essentially an accounting or bookkeeping program. (We did re-qualify with NCQA last year.)

Referrals, imaging and lab tests are all “ordered” from pick-lists in the “superbill”. If I want to send a patient to a specialist in Connecticut, where my patient will be visiting with her family, I can’t enter the order, even though I have the doctor’s name, address, phone and fax number. I must call the EMR coordinator on call to have the specialist entered in the master list so I can “order” by clicking. Anything just typed in doesn’t exist in a bookkeeping sense.

When I do a foot exam, I also have to “order” it. And later, when I sign off all my incoming test results, there are all the foot exams I did myself, requiring my electronic signature, as if I hadn’t already noted what the findings were. Such ordering and sign-off becomes central in our new “workflows” – a word I never needed to contemplate until I started to understand my new role as a medical line worker, feeding the government-imposed computer.

When eye doctor reports come in from doctors who have been following my patients since long before our EMR, my nurse has to create a “non-billable encounter” for each one, and “order” the eye exam, so she can scan and “attach” the report to the order.

Between rooming patients, she is supposed to be “working her pending orders“, starting at the list of electronic orders I have entered, not organized by patient, but by order type, devoid of any personal connection: First all the X-Rays, then all the lab tests, and so on.

My nurse has a lot less time these days to read my office notes, so when patients call with questions, she isn’t as aware of what’s going on with them as she was before the computer.

And with all this “ordering”, there is simply less time for me, too – not only to think, but also to document what I am thinking. There is only so much you can accomplish in fifteen minutes!

Which brings me back to the A&P, or Assessment and Plan. In the beginning, documentation of those two things was the purpose of the medical record. Clinical notes were just that, clinical, not billing instruments or government compliance documents. So many other things got piled on top of the purely clinical agenda that we have almost lost what we all set out to do as doctors.

No wonder I feel a little sentimental sometimes and wish for a system that serves the clinical process more than today’s EMR.

The Man With the Shrinking Lung

I see some odd things in my clinic. One recent diagnostic dilemma was a man in his late fifties with shortness of breath.

He had been born with a Ventricular Septal Defect and had undergone surgery for this in his infancy. During his lifetime, he had seldom gone to doctors, and always thought he was in fairly good health, maybe just of a weak constitution. A smoker since age 13, he had a morning cough and got a little winded running up and down the basement stairs or shoveling snow in the winter.

A while ago he came to see me because he felt he was getting more short of breath over the winter. On exam, his vital signs were normal and his oxygen saturation was 97%. He had a systolic heart murmur and his breath sounds were diminished in his entire left lung. I didn’t see any swelling of his legs and his neck veins were not distended when he laid down flat on my exam table. His EKG was normal.

I ordered a chest X-ray and some basic blood work. His X-ray report said his left lung looked normal but his mediastinum was shifted a little to the left. His heart was not enlarged. Routine labs were normal.

The day he came in to follow up on his testing he looked ashen. He had suddenly become much more short of breath the day before, just brushing snow off his car. He had had some vague chest pressure that lasted ten or fifteen minutes.

His physical exam and repeat EKG were essentially unchanged; perhaps he had even weaker breath sounds in his left lung. This time his oxygen saturation was only 90%.

I ordered a chest CT with contrast for later the same day and also put in for a chemical stress test and an echocardiogram.

A few hours later, one of the radiologists called me. The man’s IV had infiltrated and most of the contrast ended up in the subcutaneous tissues of his right arm. His Pulmonary Embolism protocol CT scan would have to be postponed.

“Ok, have him stop by the office on his way home”, I said.

I gave him samples of one of the new anticoagulant medications that just got approved for initial treatment of blood clots in the lung and gave him a lot of detailed instructions.

Over the next two weeks, I received a normal stress test and an echocardiogram report that said something about decreased flow across the pulmonic valve. I wasn’t sure what to make of that in the context of my working diagnosis of one or multiple pulmonary emboli, and called radiology to please get the chest CT rescheduled.

Finally, this Monday, he had his CT scan done. The chief if radiology called me immediately after the study.

“Your Mr. Faulkner, he doesn’t have a PE, but he has agenesis of his left pulmonary artery.”

I sat back in my chair. I’d never heard of this condition. All his life, I thought, his underdeveloped left lung has been without functioning blood supply, and that’s why his mediastinum was shifted to the left and his breath sounds were so diminished. Finally, all this caught up with him, and he ended up in my clinic one day.

I did an Internet search for pulmonary artery agenesis. It is extremely rare, and usually diagnosed earlier in life. Some cases are diagnosed after an incidental abnormal routine chest X-ray. Symptoms are shortness of breath and productive cough or recurrent respiratory infections, all common concerns among middle aged smokers in this part of the country during the winter months.

I saw him back to explain what I had found, stopped his blood thinner and told him I wanted him to see a cardiologist at Cityside Hospital. He wasn’t so sure he wanted to travel that far, but said he’d think about it.

As a rural frontline primary care doc, you just never know what’s going to walk through your door.

Humming Jeopardy

The last few days have been really busy, but they still felt controlled, almost leisurely and smooth. Patients have been seen on time, my office notes have been completed in real time and my superbills have been submitted before each patient reached the check-out station. Things were really humming.

The new nurse, who is orienting with Autumn, noticed that I was humming each time I dashed back to my desk to grab a printout, my tuning fork or something else. I, too, realized I was doing it again and again – humming the theme song of Jeopardy, the television quiz show.

I haven’t watched Jeopardy since TV went digital a decade ago and we refused to upgrade. But I still find myself humming its theme now and then through the day. In fact, I’ve been doing it ever since, in a gesture of generosity and solidarity, I volunteered to try fifteen minute visits during a lean spell in the clinic about twelve years ago.

Primary care is a lot like Jeopardy. You have to quickly think of the right answer, which is often disguised as a question, and then press the buzzer as fast as you can before you are presented with the next challenge:

Is it the thyroid? What will the EKG show? Have you traveled to West Africa? Am I meeting my Meaningful Use targets?

Every day I walk the fine line between well oiled efficiency and letting patients take the time they need to tell their stories. Again and again throughout my day, I switch from nudging things along to slowing them down as my experience and clinical intuition guides me in my work.

The patients who were squeezed in for acute problems appreciate my efficiency in getting them in and out. Those with complex medical problems or maladies of the soul expect me to give them the time it takes to grasp what’s important to them. When I can’t tell the two types of appointments apart I fail miserably in carrying out the visit, and kick myself for my misjudgment.

I guess what I do is like like many other things in life that I personally have never experienced much of first hand, like sailing – you’ve got to consider the elements and never try to go completely against the wind or the current, but find the correct angle, know how to rig your sails and be prepared to zigzag a little to get to your destination.

The challenge in what I do as a primary care physician is to accept the changing winds of each clinic visit, to see time as something more fluid than a Swiss watch, and to remain a little bit above it all – just enough so I don’t feel completely stuck in the muddy waters of our modern healthcare bureaucracy.

I do have to stop humming Jeopardy, though. It completely sets the wrong mood.

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