Tuesday, December 18, 2007

One of Those Difficult Conversations

I heard this week one of those conversations I’ve heard any number of times before. It goes something like this:

“The doctor has said that the person you love is ready to be discharged to another institution for (long term care, or skilled nursing). We’re planning for the discharge tomorrow.

“But, we haven’t had time yet to find just the right place. We have three appointments today, but we can’t possibly be ready tomorrow!”

“Well, we’re not really doing the person you love any good here that can’t be done there. Insurance won’t pay for the additional time in the hospital.”

“I knew it! It’s about the money, isn’t it? That’s how hospitals are: they’re just interested in the money!”

The only thing that makes that worse for me personally is when I’ve worked with the patient and family involved, and I get a phone call that begins, “Chaplain, can you get the social worker off our back?”

I go back and forth about those circumstances. I understand all too well the factors that get us into them. Unfortunately, patients and families seem not to, or at least seem to think those factors don’t apply.

The circumstances, really, are pretty straightforward. Medicare, Medicaid, and commercial insurance companies by and large don’t really receive your bill, figure appropriate percentages, compute how this affects your deductible, and send the hospital a check. There are some folks who still have that kind of insurance, but they’ve been fewer and fewer over the years.

Instead, Medicare and Medicaid certainly, and commercial insurance and HMO plans of many patients, commit to a fixed amount. For Medicare it’s by procedure: they determine what they think that colonoscopy and all its expenses ought to cost in your neighborhood, and then commit to pay a percentage, based on what they think it ought to cost (whether it actually does or not). They call those “diagnosis related groups,” or DRG’s. If the procedure can be done at lower costs, or the patient can be discharged a day earlier, the institution gets to keep the difference. If the procedure costs more, or the patient needs another day, even if it’s because of legitimate needs of the individual patients, the institution eats the costs. Politicians and administrators hope that this will encourage institutions and providers to be more efficient, and to find new, more effective ways of treating patients more quickly. Providers and institutions just hope all the time that a few patients who receive more care because they need it won’t ruin the institution’s margin for the year.

For HMO’s and for some work-base insurance plans the fixed amount is simply a flat rate per person. It’s called “capitated care,” which literally means, “so much per head.” Once again, the numbers aren’t based on actual expenses, but on what someone things the expenses should be. The results are the same. It’s good if the institution or provider can reduce costs of care. It’s hard on the institution or provider if the person needs more care and more time.

In any case, insurers, whether from government or from the private sector, negotiate limitations of what they’ll pay for a given patient or for a given condition or procedure. At some point, they don’t pay any more. Unfortunately, it may have little to do with what the patients need, and therefore what the expenses actually are for the patient’s care. That point comes when the patient gets enough better to not need hospital care – as determined, not much by the doctor and certainly not by the patient, but by the standards of the insurer. The difference costs the institution or the provider; and in the best tradition of American business practices, those costs get passed on to the patient.

So, sometimes I have the thought that we should simply tell folks: “Your loved one is well enough not to need hospital care. This care can be given in a nursing home or a skilled nursing center. If you’re not ready for the transfer, we won’t ask you to leave, but we need to tell you that the expenses won’t be paid by the insurer. They’ll come to the patient. And they’ll cost you a lot more.” It’s simple and straightforward, and it gets past the anxiety that someone’s trying to discharge a patient too soon.

At the same time, we can’t do that. First and foremost, we may have another patient who need the room, and who legitimately needs hospital care. Allowing the less sick patient to stay means the more sick patient doesn’t get the necessary care. And we can’t make exceptions for a reason we’ve all understood since elementary school: if we are willing to make an exception for one, we have to be prepared to make exceptions for all.

Second, while it’s not “all about the money,” we do have to take money seriously. If we simply let the money slide, and we go out of business, many people don’t get care. Now, my hospital is in a suburb in a large metropolitan area; and some might want to say, “Well, then, I’ll just go to another hospital.” But, another hospital won’t have the capacity to take all the patients of another hospital; indeed, even all the hospitals in a given metropolitan area might not be able to absorb the new patients. And, of course, those patients will still face the same economic issues.

Finally, it’s important to remember that a hospital is not a hotel. Hospitals don’t exist to provide patients what they want; they exist to provide patients what they need. Now, within the parameters of “what they need,” we do our best to provide “what they want,” both because it’s good care and because it’s good business. But, that category of “what they need” can set some hard and fast limits. For example, we’re not going to bring that much-loved burger to the patient who can’t swallow. We’re not going to provide anyone with cigarettes. With all that we do to make them comfortable, attractive, and amenable, hospitals still exist first and foremost to give medical care, and not to cater to any request that might come.

Would universal access to health care make a difference in that? It might, depending on how it was structured. But in our culture, and for the near future, that’s a matter of hope, and not of promise. And even then, there will be limits to respect regarding the most appropriate care and the most appropriate patients, and the most appropriate use of limited facilities.

So, for the foreseeable future we will be facing these difficult conversations. We’ll keep doing our best to care for families, and to help them make transitions from one level of care to another. And we’ll keep smiling, and do our best to help them, even when they say, “See? It’s all about the money.”


ReverendKathryn said...

It is interesting to hear the American version of this. In Canada, we too deal with the need to tell people that their loved one should be discharged to a facility versus home, and that they are no longer recieving acute care, but rather they are "medically stable". At times there are other issues, such as cognition and safety concerns, and for that reason, the individual is discharged to a facility, versus home. This is a hard conversation to have. "You/your family member is not well enough to return home to the place where they have lived for (numerous) years, so we would like to discharge them to a facility where they will recieve care that suits their situation." Often the shock that the individual is not as functional as they used to, is "getting old" is hard for some to deal with.
It is difficult to have these conversations as it is, and at times, the family member is not able to accept the information. Interpreting it differently or not "really hearing" what we are telling them. I agree with your wording.
Here in Canada, there is a streamline system for facility placement. (At least this is my understanding of it...) Persons are assessed for the level of care needed, either assisted living, Intermediate or extended care (they have recently changed these terms as well) and then their name goes on a waitlist for the first available appropriate bed in that area, taking into consideration the "prefered location".

There are a lot of psycho-social, grief and financial issues to consider in the aspect of a facility discharge. Either way, it is still a difficult place to be.

Marshall Scott said...

kathryn, thanks for your comments.

In general, the decisions about appropriate placement are made using the same information as used in Canada. However, we don't have universal coverage for such placement, and that gets us into issues of whether the patient is insured by Medicare or Medicaid; by private insurance; or by no insurance at all. For example, not all long term care institutions have Medicare or Medicaid beds (it's not required). Medicare also establishes limitations on what they will pay per day, and for how long. The person is then expected to pay down assets (including recovery of assets given as gifts to family members for the past five years - yes, five years) before qualifying for Medicaid. There is a concern as well that facilities that take Medicaid residents don't provide as high a quality of care as those who are "private pay" (private insurance or paid by the individual). It's not really true across the board; but institutions that rely to a high degree on Medicaid don't have the resources out of which to provide quality care.

It is estimated that there is at least one person who qualifies for long term care trying to carry on at home with help of family and friends for each person in long term care - and perhaps two. That's a statistic that hasn't changed for twenty years or more. Patients don't want to go, identifying them with warehouses and "heaven's waiting room." Families take seriously pleas of patients not to be placed, and feel guilt when the patient's care requires more than they can offer at home. And yet they reach the point at which acute care in the hospital isn't appropriate. And then we are back where we started....