This week the CBS news magazine, "60 Minutes," included a segment on Health Management Associates alleging that HMA pressured doctors to admit more patients to HMA-run hospitals so as to increase revenues.
HMA, according to 60 Minutes, set goals for doctors to admit a certain percentage of patients who visited the emergency department for care. Specifically, the program said HMA set a goal of 20%, according to emergency physicians at some HMA facilities.
The percentage of patients admitted from the ED varies greatly from one hospital to another. The ED at a tertiary-care hospital in a metropolitan area may see patients with a high likelihood of being seriously ill. The percentage of patients admitted from such an ED may be well upwards of 30 or even 40. On the other hand, the ED at a small-town or rural hospital, where the large majority of ED patients have minor illnesses or injuries, may admit fewer than 10% of the patients to the hospital.
The claim in the 60 Minutes segment was that HMA runs mostly smaller, more rural hospitals, especially hospitals that were financially struggling before being taken over by HMA. Such a hospital would not be expected to admit 20% of its ED patients, and setting that as a goal would put undue pressure on the doctors in the ED to hospitalize patients who don't really need inpatient treatment.
The show's producers found emergency physicians from HMA hospitals who described in detail how they were pressured to admit more patients. They explained that hospital administrators wanted to fill beds, thereby improving the hospital's revenue stream - and its "margin," which is what you call it if you don't like the word "profit," or if you are running a not-for-profit entity (which doesn't mean you don't need to have revenues exceeding expenses).
This makes HMA look bad. But there was a lot 60 Minutes didn't explain. Perhaps the most important is that there is a good deal of subjective judgment involved in deciding whether a sick patient should be hospitalized. It is often not a straightforward matter to figure out whether the evaluation and management of a patient's illness, beyond what has been accomplished during the ED visit, can be carried out at home or requires admission to the hospital.
Medicare, which was a primary focus of the TV report because it pays for so much hospital care, has criteria we can use to judge this, called "severity of illness" (how sick is the patient?) and "intensity of service" (what care does the patient require, and is it best provided in-hospital?) criteria.
HMA was allegedly pressuring doctors to admit patients who met such criteria for hospitalization. What, you might ask, is wrong with that? Well, not everyone who meets criteria for admission actually requires admission. It's just not that simple. And it requires clinical judgment.
And here is where we run into an interesting paradox. The Centers for Medicare and Medicaid Services (CMS - don't ask me what they did with the extra "M") is perfectly happy to have us use clinical judgment to decide that a patient who meets criteria for admission can, instead, be treated as an outpatient. Thank you, doctor. No questions asked. But flip the coin and try to get the hospital paid for taking care of an admitted patient who didn't meet the criteria used by CMS. Good luck with that.
I find this very frustrating, although I would like to say that in any number of ways that would require impolite language. I bristle when my clinical judgment is questioned, especially by people who don't practice medicine but like to tell doctors how to apply their science and their art. We call them bureaucrats, with every bit of the derision and negative connotation that word can carry.
So this is at least partly about clinical judgment. These are judgments we must make many times a day, every day. An emergency physician may initiate a conversation with an internist about a patient by saying, "This is a 'soft admission.'" That means it's a patient the emergency physician feels uncomfortable sending home but that the internist might think doesn't really need to be in the hospital.
During every shift I work, I see patients who might benefit from hospitalization but also might be safely managed as outpatients. I often discuss the options with the patient, the patient's family, and the patient's regular doctor before arriving at a decision agreeable to all concerned. It's not always simple and straightforward.
So you can imagine what HMA was saying to the doctors. You have a patient in the ED and you're considering hospitalizing that patient? Just do it. The hospital has empty beds. We want to fill them. After all, we need the revenue. We need the margin. This hospital exists to serve the health care needs of the community. That is our mission. You know the saying: no margin, no mission.
Should HMA tell doctors at a hospital that admits 7% of its ED patients that they have to get that up to 20%, or tell doctors who don't admit 20% of the ED patients they see that their services will no longer be required? Of course not. And if HMA did that, I would be the first to criticize that practice.
But I must say that there are many motivations for hospitalizing patients who might be "soft admits." The further evaluation and treatment the patient requires might be conducted more expeditiously in the hospital. The likelihood that everything that is envisioned actually gets done is greater. The chances that something is missed, and an adverse outcome results, are reduced. (And maybe, correspondingly, the likelihood of a malpractice lawsuit is reduced.) The satisfaction of the patient and the family with the care provided at the hospital goes up. And everyone in health care wants satisfied patients.
The 60 Minutes segment didn't tell us any of that. No, instead, they intimated that HMA might be guilty of "Medicare fraud." Was HMA providing services to patients that were unnecessary or inappropriate? No evidence of that was set forth. Was HMA billing Medicare for services not provided (which would clearly have been fraud)? That was not even implied.
Far be it from me to say that 60 Minutes, that paragon of investigative journalism, would take a potentially interesting or important story and sensationalize it. Oh, no. Why would they do that? Just for ratings? To get more people to watch the show? To make more money?
We certainly expect our providers of health care to be above such motives. But we have no such expectations of journalists. Should we?
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