Has anyone noticed that hospital stays are much shorter than they were many years ago, in spite of the severity of the medical problem? Do people ever feel that they were sent home from the hospital too soon?
An experience with my wife having heart bypass and aortic valve replacement surgery on a Monday, and being discharged on the following Friday, caused me to look into this. Just to set the stage for this, my wife had the risk factors of having had a kidney transplant and insulin-dependent diabetes prior to the surgery, and developed a post-surgery risk factor that was described as common (arrhythmia).
Interviews with co-workers, nurses and doctors revealed that most feel as if discharges from hospitals occur too quickly for all kinds of treatment. Those preliminary interviews and guidance from the nurses caused me to delve deeper into a health care concern. I found a system that is not known to many, but should be known to all who use hospitals for inpatient treatment (or impatient discharge, depending on your point of view).
Consider who is ultimately responsible for making the decision about the time of discharge for hospital patients. Would it horrify anyone to learn that the primary force driving the length of stay at hospitals is health insurance companies? The length of stay for almost all hospital stays is established using a manual for Diagnosis Related Groups. Simply stated, each diagnosis is given a number that uses patient age, sex, diagnosis, discharge status and, supposedly, risk factors. The diagnosis and prospective treatment are then assigned a hospital stay length that is designed to minimize cost to the insurance company.
DRGs began because the Medicare and Medicaid programs that were started in 1965 were rapidly heading toward financial insolvency by the mid to late 1970s. The program began in New Jersey hospitals in 1980 and lasted for three years. The theme of the program was to control the "behavior of the physicians and surgeons" on the hospital staffs when it came to providing treatment. In spite of unclear or even dubious results in New Jersey, the program was implemented nationwide.
The original DRG pilot state had a very specific problem in early 2001. The JFK Medical Center in Edison, N.J., had sent letters to 30 physicians threatening to revoke their hospital privileges because their combined patient length of stay exceeded the DRG by 30 percent. The physicians expressed concern over the quality of care because of the imposition of the DRG. Eventually, JFK Medical Center withdrew from the DRG plan.
DRGs have evolved. There are several varieties. All varieties serve the same purpose - restrict treatment decision-making by physicians and surgeons within hospital settings in order to manage costs. Cost containment is the priority, rather than patient care.
Talking to professionals
My favorite part of this story involved discussions with physicians. I talked to three of them. Two of the three agreed that insurance companies have taken too much control over length of stay by using DRGs They felt that the DRG system was intimidating to their professional practice. One, thankfully, readmitted my wife following her woefully inadequate DRG for the type of surgery and risk factors that she had, and promised that she would not be released until she recovered from the surgery. One of the physicians claimed that the brief DRG for heart bypass and aortic valve replacement surgery was because of risk of infection during hospitalization. One of the other two physicians actually laughed at this assertion when I related it.
The next part of my adventure into length of stay was suggested by a nurse. I called around the state, pretending that I was looking for a hospital for my wife to have the same surgery, given her exact pre-surgery risk factors. Recall that my wife stayed from Monday (surgery) to Friday (discharge). There was great consistency between hospitals concerning length of stay, suggesting that North Carolina hospital care is heavily invested in one of the DRG systems. The only exception was FirstHealth of the Carolinas (Pinehurst). The nurse there actually told me over the phone that my wife's risk factors would cause a lengthier hospital stay. I wonder why Cape Fear Valley Medical Center did not take the risk factors into account when they quickly discharged her.
What happened after my wife's discharge was the result of obsessive implementation of a DRG. The Saturday after discharge, she had to go to the Emergency Department because of arrhythmia. She also had elevated blood levels of a kidney failure indicator. She was admitted to the ED around noon and discharged from the ED about 7:30 p.m. My wife developed terrible leg blisters, and had low arterial oxygen when she went to the ED on the following Tuesday. Her regular physician said that she would stay at the hospital until she got better.
This column is not about a personal story, even though that is part of it. The public needs to know who controls hospital care. People need to be aware of Diagnosis Related Groups. Relatives of those receiving treatment need to receive information about DRGs when their loved ones are hospitalized because it is part of the informed consent for treatment. DRGs need to be the subject of malpractice suits when and if it can be documented that a patient dies because of the overzealous application of a DRG.
However, the liable party to the suit must not be a physician. Insurance companies must be held responsible for the results of their DRG (standing for Darned Rigid Guidelines) limitations on care. That includes Medicare and Medicaid.
From the author's article in The Fayetteville Observer, November 12, 2010