A 72-year-old male with a history of CHF is admitted for elective total hip arthroplasty. On postoperative day one, he develops dyspnea and hypoxia, and is diagnosed with acute pulmonary edema by the hospitalist co-managing his care. Furosemide is prescribed, and he improves, and by day four is ready for discharge following another dose of diuretics. Overnight, he develops acute onset of shortness of breath and is diagnosed with a pulmonary embolism (PE). Under new regulations, the hospital will not be reimbursed for the extra cost associated with subsequent patient care. Should the hospitalist be paid for the subsequent care?
PRO
Nonpayment won’t improve quality or significantly decrease costs
Dr. Grace is a hospitalist and area medical officer for the Schumacher Group Hospital Medicine Division in Lafayette, La. He is a member of Team Hospitalist.
The real essence of the question raised in the clinical case above is “Should doctors profit from errors?” The answer might be “It’s better than the alternative.” Allow me to explain. There essentially are two reasons to withhold payment in this scenario: one, as a mechanism for promoting quality; two, as a mechanism for decreasing costs to the payor.
The quality argument assumes the physician will deliver higher-quality care (i.e., prescribe chemical thromboprophylaxis) if a threat of nonpayment exists. This concept is simply hogwash. If expensive medical malpractice threats fail as quality-improvement (QI) mechanisms, it is absurd to think withholding a few subsequent-care charges will generate better results.
The key issue is the type of error involved. As defined by Lucien Leape, MD, in his celebrated 1994 article on medical errors, “mistakes” reflect failures during attentional behaviors, or incorrect choices.1 “Slips” reflect lapses in concentration. “Slips occur in the face of competing sensory or emotional distractions, fatigue, and stress,” and “reducing the risk of slips requires attention to the designs of protocols, devices, and work environments.”
Misjudging the type of error—in this case, a slip (find me a hospitalist who doesn’t know total hip arthroplasty requires thrombophrophylaxis)—and misapplying corrective actions will have little to no effect on outcomes. Thus, pay-withholding schemes can have a negative net effect by diverting resources from QI projects that truly improve patient outcomes.
Withholding payment in this case generates approximately $160 in direct savings to the payor (assuming Medicare payments for one 99233 and two 99232 subsequent care visits), yet the operational costs are not negligible and must be factored into the equation. The payor needs to first determine who is truly at fault: the hospitalist or the orthopedic surgeon. Answering that question requires the payor to review the co-management agreement, perhaps aided by an attorney. That’s a costly endeavor.
For the sake of argument, let’s assume in this case the hospitalist is at fault. The next step is determining if the hospitalist who failed to prescribe prophylaxis prior to the PE is the same hospitalist caring for the patient after the PE. It is inappropriate to withhold payment to hospitalist A if hospitalist B made the error. Again, significant manpower will be required to determine fault, as this is not information one finds on a UB-04 claim form submitted to Medicare.
Further eroding the $160 savings is the cost of determining whether a contraindication exists: Bleeding ulcer? Subdural hematoma? Heparinoid allergy? Let us not forget the additional costs in copying, shipping, warehousing, and eventual shredding of the records. One can readily see that the operational costs can quickly negate the $160 anticipated savings. In fact, it’s likely a negative return on investment.