A “Culture of Hospitalization”

Public Policy Contributor Bradley Flansbaum writes…

Or so a quoted doctor says.

From a briefing today out of the Kaiser Foundation, comes a closer examination of the High Medicare Spending for Beneficiaries in Long-Term Care.

As I read one of the associated papers (see executive summary, pages 1-5 only), it was a veritable potpourri of Groundhog Day moments.

Briefly, it is a 360 degree look at the broken long term care facility, hospital interface from the perspective of all the relevant players: docs, nurses, medical directors, family members, etc. By page two, I was saying, my goodness, “this is my life.”

A quote:

Interview participants indicate that the hospitalization of long term care facility residents occurs routinely. In many cases, hospitalizations occur with little discussion or active decision making among facility staff, particularly in cases when a resident has fallen, has an infection, or becomes disruptive or violent due to dementia or behavioral health issues. Interview participants suggest there are no disincentives to sending a long term care facility resident to the ER when there is a suspected medical issue. Rather, they say that hospitalizing a medically compromised resident reduces liability concerns, allows for more timely diagnostic work, often is more convenient for physicians, and frequently is believed to be financially beneficial for physicians and, in some instances, the facility.

Attempting to treat a medical condition or conduct diagnostic testing at the facility, participants suggest, even when the condition is minor and the test is routine, is much more difficult and can be fraught with risk. Nurses and physicians wanting to perform bedside care can bump up against licensing restrictions, anxious families, liability concerns, staffing or skill limitations, delays in obtaining lab results, and a “culture of hospitalization.” One physician pointed out that many nurses and physicians are trained in hospital settings and are less comfortable practicing the “slow medicine” that may be more appropriate for some long?term care facility residents, depending on the circumstances.

This section does not address the financial issues of cost-shifting from the nursing home to the hospital, which most hospitalists are familiar with in detail.

What makes the two settings so unique? Medicaid pays for nursing home care via a fixed daily sum, and Medicare takes the skinning for the acute hospital stay. Would you deal with the fiscal headache if you ran the nursing home? Given the current payment structure, I do not blame the nursing facilities given their budgetary constraints and limited capabilities. That obviously has to change, and this aberration stems from a disordered payment policy that is a legacy from a simpler time when the programs were less complex and overarching in scope.

Read the report and file it under, “more care transitions that need fixing on the CMS to do list.” The solution is tailor made for the hospitalist practitioner.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

1 Comment

  1. Mike Radzienda on October 13, 2010 at 9:49 pm

    Great post.
    What do you think will happen when snfs and ltachs share risk with hospitals in an ACO model?

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