As noted above in the stated purpose, our cost of healthcare is ridiculously high compared to what it could be with a tractable alignment of incentives. However, the precedents of improved healthcare logistics are historically sparse. To that end, I will offer a case study of a patient presentation, various incarnations of which I have witnessed many times. After this, I will offer an analysis and suggestions for improvement.
One evening, while I was on call as a resident (postgraduate medical doctor in specialty training, in my case internal medicine), an ER physician called me to admit a patient whom he had in the ER. This otherwise healthy female in her early 50s had signed in because of chest injury and underwent chest x-ray, presumably to identify any fractured ribs. No ribs were fractured but she had a notably enlarged heart. She had no symptoms related to this, i.e. no trouble walking up and down stairs, no fluid retention, no shortness of breath, positional or otherwise, etc. Her physical exam and EKG was entirely normal. Thus, she had an asymptomatic finding unrelated to her visit.
What to do, what to do.
The ER physician insisted that she must be admitted. I disagreed with this and suggested that she be scheduled for an appointment for the next morning at the hospital’s cardiology clinic. It was benign serendipity that her heart’s enlargement was found before she had any symptoms and did not require monitoring overnight (I opined). The ER physician who was an attending (senior, autonomous physician) overruled me. Since he was “uncomfortable” with discharging the patient on his own authority, I suggested that he contact the cardiologist on call for the hospital to discuss the situation and increase his comfort which would’ve taken possibly 8 minutes. He declined this suggestion and offered an observation which I have held onto for decades- “Who is this going to hurt except the intern?” (If I ever write a book on wasteful medicine, I will name it Who Is This Going to Hurt except the Intern? even with the suboptimal use of “who”).
The patient was admitted to the hospital’s telemetry unit. She occupied an expensive bed that night and the next morning. Early that next day, the cardiology team saw her, evaluated her, and discharged her with all follow-up tests to be done as an outpatient. The team was curious as to what compelled admission and I had no answer. The admission was not necessary and, I estimate, cost a few thousand dollars. Discharge from the ER would have been a safe plan, representing no significant risk to her but allowing for significant savings. These marginal decisions seem to be par for the course in all hospitals many thousands of times daily across the US, I would estimate, suggesting that just for this 1 type of scenario (ER physicians admitting patients for marginal indications), hundreds of millions of dollars/day (each and every day of the year) are wasted.
This is my 1st level analysis of the situation.
The ER physician was by no means a “bad” physician. He had what I would later term Young Attending Syndrome in which he had not fully developed enough depth of experience regarding this kind of situation to be comfortable sending her straight home with proper follow-up. However, not calling up the on-call cardiologist was suboptimal if not shading on lazy. Of note, ER’s are chaotic places with a great deal of time pressure.
By this time in my training, I had noted that this type of situation had occurred many, many times. Our university had a very strong cardiology program. For patients with asymptomatic heart disease at very low risk (e.g., this patient), timely follow-up as an outpatient is good care. Of note, I had ordered from the blood collected in the ER a thyroid test and it turned out that she was hypothyroid leading to her heart enlargement. This came back after she was discharged.
Please note that we are all heroes in our own narratives.
An analysis of this from another point of view must be done.
Hospitals love admissions. Empty beds are anathema since they make no revenue. Thus, ER physicians are not cited for what I would euphemistically term marginal admissions. In fact, the opposite incentive is in effect (although never discussed). It takes less time to admit a patient to the hospital than to discharge one home, one should note. Also, because their training teaches them little about patient transition options from ER to outpatient settings, they hesitate to use that option and defer to expediency.
Insurance companies have insufficient resources to study every admission for legitimacy.
Thus, there is a misalignment of incentives here (a phrase that will turn up often). Hospitals should be paid on a per patient per month basis in their coverage area and not based on total services provided. The latter incentive is the parent of chaos. This will allow them to develop systems for better patient follow-up without allocating hospital beds for those not truly in need. To a degree, this has started to happen but certainly not enough. Improvement in the process for choosing the best disposition for patient care is ripe for attention.
In summary, this is an example of just one type of “crack” in the system leading, in my estimation, to many millions of dollars lost per day and likely billions of dollars per year in the United States (please remember that the United States has somewhat more than 6000 hospitals in operation). I have personally seen many many more system failures like this and believe that we must fundamentally review behaviors born of historical precedent without review.