May 30, 2008
REAL MEDICINE:
What hospitals teach doctors and nurses
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Dozens of the top nurses in the New York Area march into Montefiore every day. They are bright, seasoned veterans of nursing, and they’re armed with laptop computers as they walk into the hospital. They are there to review charts, and to teach nursing staff, and physicians.
With the obvious need to improve patient care, this effort would seem to be exemplary. Finally, a center has invested heavily in the education of their staff. However, reducing hospital-acquired infections, removing the risk of prescription errors, improving hospital services, and finding better ways to communicate with patients ... is not what these people were hired for.
They are there for one reason only: To make sure the hospital submits bills for the most lucrative diagnoses, and specifically to educate doctors on what to write in the chart so the hospital can bill for the most substantial and remunerative DRG diagnosis.
Others are there to push the staff, and perhaps the patient, into going home — as in pushing them out the door. And in the event that you’re shocked at learning this, some doctors are even given bonuses for getting their patients out of the hospital quickly.
This is where some of the brightest nurses are devoting their efforts these days. Forget that there is a nursing shortage, and forget that these very nurses would be the best front-line educators to help improve patient care and patient outcome.
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I’m looking for a patient’s chart but I cannot find it. I call out to the staff, I go to the intercom, I check to see if it is in the patient’s room, but I still can’t locate it. Then I notice two well-dressed nurses with their personal computers, reviewing a chart. It is the chart I was looking for. It is the chart of a patient that I am caring for.
I ask to see it. They reluctantly hand over the chart but there’s a price to pay. Might I consider that the patient has systolic heart failure, and that it was caused by a heart attack, they say to me. (This seems to require a little more justification on your part for being skeptical about what they want. It seems to sort of be left hanging.)
I can’t place all the responsibility on the hospitals, though, since it is the HMOs and Medicare that are forcing them to hire more and more personnel to make sure they get paid as much as possible for each and every admission. An example what often happens occurs to me. It involves the billing for the diagnosis of congestive heart failure (CHF).
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Doctors have for years been diagnosing, treating, and writing CHF in their charted history and progress notes. Medicare and the HMOs, however, decided to pay less for CHF if the type was not specified. One type of CHF is known as systolic heart failure; it describes circumstances in which the pump is weak; another type, diastolic heart failure, is when the pump is strong but the heart is too still to fill; there is also a combination of both.
In addition to doctors being trained to write the diagnosis in the chart, every single chart is reviewed by these trained nurses, for specific diagnosis. If they don’t see what they like, notes are placed in the patient’s chart (that are then removed before the chart becomes a permanent record), instructing the physicians to record the specific type of heart failure. If physicians do not comply with that request, calls are made to their offices, charts are shipped to their offices, and letters are generated to pressure him into putting down the correct billing diagnosis. (You have to make clear why this is bad. What is wrong about having what may seem to be an oversight corrected? If they’re suggesting that you lie, however, then say it.)
And why not? By the addition of just one word, “systolic,” the hospital can be paid $6,500 more than if it’s left out. For example, Montefiore can collect only $22,000 (from Medicare based on 2006 Medicare payments) for a patient who had a coronary stent placed, if the doctor only documents heart failure in the chart, but will be paid $28,000 if the word “systolic” is added to heart failure.
The same patient, the same illness, but the addition of one word results in an extra windfall for the hospital.
Dr. Levine lives in Ridgefield and is the author of “What Your Doctor Won’t (or Can’t) Tell You: The Failures of American Medicine — and How to Avoid Becoming A Statistic.” Questions for this column may be e-mailed to him at VANLEV @ aol.com.
© Copyright 2008 by Hersam Acorn Newspapers
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