All The Risk, None of the Benefit

Da Boss over at DB's Medical Rants has a nice post titled "Deconstructing Quality". Let me give my scenario. In a two day span, I recently discharged four people whom I was asked to admit. What were they you ask?

1. An uninsured homeless drunk with a history of "seizure disorder", documented and witnessed pseudoseizures and a brief and transient episode of hypoxemia.
2. An uninsured patient with a new onset DVT of the leg.
   
3. An uninsured patient recently discharged from the hospital with chronic abdominal issues presenting with abdominal issues.
4. An uninsured patient with a focal superficial skin abscess I & D'd in the ED, who's symptom complex had been improving on a week of outpatient antibiotics.

Each patient presented with their own unique set of circumstances. Two of them had no desire to be admitted to the hospital. They happened to be uninsured, but even if they had insurance, the cost considerations remain.

In each case, I made sound scientific decisions that none of them required admission to the hospital. That either their pathology was not severe enough to warrant inpatient admission, that they did not meet inpatient criteria (even though I could make almost anyone qualify), or that they could be safely managed as an outpatient with appropriate available services.

How do you measure that quality? For the uninsured, I personally saved them thousands upon thousands of dollars that would eventually make it to a collection agency. I saved the hospital thousands upon thousands of dollars of nursing time, supplies, medications, and all the overhead/billing/administrative time and dollars that goes into the financial aspects of inpatient care. I saved your premium paying insurance companies and the Medicare National Bank thousands of dollars for not having to subsidize the expense of these uninsured patients who will never be able to pay their bills, even if they wanted to.

How do you measure that quality? And what's in if for me? I ask what's in it for me because to me, it's obvious. I carry all the downside risk of bad outcomes and none of the financial success in practicing cost effective care. I can understand clearly why defensive medicine is so prevalent in this legal climate we practice in. A climate where a bad outcome is considered negligence and standards of care have become irrational.

In every situation, I did a thorough evaluation. I based all my medical decisions on what I knew about the disease, what I knew about the patient's history and exam, what I knew about where they came from and where they were going. I based my medical decisions on sound clinical practice that would limit the possibility of a bad outcome.

But can I guarantee that the patient won't get worse? Of course not. Can I guarantee that drunk with transient hypoxemia doesn't have aspiration pneumonia that will present itself in 3 days? Can I guarantee that the stable as a rock patient with a DVT won't have a PE and sudden death in 18 hours? Can I guarantee that the patient with chronic abdominal complaints won't have a perforated colon tomorrow? Can I guarantee that the patient with the I&D who had been getting better for a week on antibiotics won't suddenly get septic and end up in multiorgan failure?

The answer to every one of these situations is no. I cannot guarantee a perfect outcome in any situation. Nor could I guarantee a perfect outcome in any of them even if they got admitted to the hospital. Even if I did everything right, the patient may still have a bad outcome. The way I see things, in this culture of blame, it's a lot easier for a jury to place blame on a physician for sending home a patient that gets worse than it is to place blame on a physician for a patient that gets worse in the hospital. The perception of negligence may be just that, a perception. But it drives medical decision making none the less. It drives defensive medicine like you wouldn't believe.

I took a risk. A major risk sending those four patients home from the ED. Is the risk real? Yes and no. No because I did the right thing using the scientific evidence and my clinical skills. Yes because it doesn't matter. It's easier for a jury to say the patient may have had a better outcome in the hospital than being discharged. If they get worse in the hospital you can blame it on the disease. If they get worse after being sent home from the ED, you can blame it on the physician. I mean, how could the physician be at fault when the patient gets worse inside the hospital, filled with all that expensive technology and 24 hour supervision? You get my drift.

In my medical opinion, using sound clinical medicine, every one of those patients deserved to be discharged from the ED. So why do I always get a brief uneasy feeling when I discharge someone from the ED. "What if they get worse?", I ask myself.

And then I have to keep reminding myself that nothing in medicine is 100%. They could get worse even if I admitted them and wasted thousands upon thousands of dollars that we will all pay for one way or another.

The problem is, even though the science is sound, a bad outcome drives risk, even though no negligence was performed. It's easy to find 10 doctors say the patient should have been admitted. It's just as easy to find 10 doctors who say the patient could have been safely discharged. The risk comes down to whether the defense or the prosecution put on a better dog and pony show.

By discharging these patients, I'm saying the standard of care is discharge. The ED doc is telling me, by asking me to admit the patient, that the standard of care is admission. Now, we docs set the standards. That standard should be based on science. Too often the standard of care is based not on science, but rather on fear.

And in these four patients, I take in all the risk discharging stable medical patients who could get worse and therefor be accused of negligence by not admitting a patient who the ED is telling me should be (their standard of care). And I get none of the benefit for saving America tens of thousands of dollars in expensive, unnecessary hospital care.

I'm not sure if I'm the exception or the rule for docs out there. I am doing my best to establish rational standards of care, one patient at a time. And I find myself going up against a huge wall of fear, a wall that is creating standards of care that are bankrupting our country and adding little to no additional benefit to patient care. Instead of calling it defensive medicine, you can call it what it really is, the the lawyer xray, lawyer CT, the lawyer MRI, the lawyer lab, the lawyer admission. That's what it is. Testing out of fear, not out of science. We physicians have created standards of care based on lawyer science, not doctor science.

I think I practiced quality care today. Quality that saved at least $20,000 in uncompensated care. How many HgbA1c's would you have to check to save $20,000? How many patients would you have to put on ASA to save $20,000? How many hearth failure patients would you have to have on ACEi to save $20,000?

The Medicare National Bank wants to give me 2% back for playing their PQRI games. How about putting PQRI in perspective. I saved us all $20,000 in uncompensated care using sound science, took all the risk in the eyes of a jury for discharging the patient home when the ED is telling me, by them asking me to admit, that the standard of care is to admit. And I get nothing to show for it.

All the risk and none of the benefit.

It's just easier to admit and spread the cost over 300 million Americans. And that is exactly the current state of American health care. You don't worry about the cost because someone else is paying for it. FREE=MORE