It is a well-recognized fact that medical malpractice injures many patients. When that happens, patients have legal remedies. What is less well-recognized is the damage done to patients by hospital administrators chasing the almighty dollar. Unfortunately, for patients injured by the actions of hospital administrators, there is often no plain, legal remedy.
I have written about the rise of hospital administrators and the ways in which their pursuit of profits conflict with the needs of patients and the concerns of the doctors caring for them. You can find some examples here and here. As hospitals become more profit driven, there is a greater temptation to game the system to make sure those profits keep on coming. A recent story in the New York Times discusses how this works at a VA hospital in Oregon. While VA hospitals have a different business model than hospitals in civilian life, many of the problems and behaviors are the same.
The Times story focuses on a VA hospital in rural Oregon which had poor ratings for important things such as good patient outcomes and patient deaths. The hospital administration was determined to change this. Of course, the obvious way to change it is to improve patient care. This would both reduce deaths and improve patient outcomes. There were a number of barriers to this approach, however, including budgetary issues and difficulty in attracting and keeping medical staff. In spite of these barriers, the hospitals ratings, which were based on a number of metrics established by the VA, improved substantially. The investigation by the Times suggests that they improved because the administrators were gaming the system.
One of the charges leveled against the hospital is that it improved its outcomes by cherry picking patients. When a really sick patient who might very well die presented at the hospital, it would refuse to admit the patient on the grounds that it could not provide the level of care needed by the patient. While it is never good to admit a patient whom the hospital does not have the facilities to treat, members of the medical staff claim that the refusals to admit were based, not on inability to provide needed care, but on the concern that the patient might die and thereby harm the hospital’s statistics. Staff members claimed that other patients were discharged or transferred either over the objections of the treating physician or without his or her knowledge.
Much the same thing happens in civilian hospitals. Once metrics are established for rating hospitals or for paying them, administrators begin looking for ways to game the system. Health care may not improve but the things being measured do. For example, Medicare stops paying after so many days in the hospital. There is therefore great pressure to transfer the patient to another facility before the money runs out whether it is in the patient’s best interest to be transferred or not. Another example is the practice of keeping the patients in the hospital for observation rather than admitting them. This avoids running afoul of the strict Medicare admission standards. Patients held for days of observation may incur co-pays that would not apply had they been admitted to the hospital. Observation may also be used to avoid a readmission which might make the hospital look bad for having improperly discharged the patient in the first place.
Patients are always at a disadvantage in these situations. They are usually sick, may be elderly, and certainly don’t understand the financial implications of the decisions being made by the hospital about their care. They may end up where they don’t belong, where they won’t get the care they need and where they may have to pay far more than they should. As usual, the best thing you can do is ask questions and have family or friends with you to watch what happens and to also ask questions.
