Cohen had strong ideas about the hospital’s place in the community, and he wasn’t sure if Maimonides—if any nonpublic hospital—was right for him. But when Brezenoff and Brier beckoned, he went.
Shock number one: Unlike those at Bellevue, where almost all the physicians were employed by the hospital, a substantial number of Maimonides patients were treated by private physicians (like the Bashevkin group). “There seemed to be an awful lot of concern by the medical staff of finances in terms of their own compensation,” said Cohen. “That was a surprise. I kind of felt that . . . I looked at the place as . . . this is so quotable I don’t want to say it.” But he did anyway. “It looked to me like a little factory for Jewish doctors to take care of their patients and make lots of money. I was much more interested in the role of a hospital in the community and advancing medicine and clinical practice and care. I just didn’t think I was going to be happy or comfortable here.”
Even Cohen, who kept his emotions under wraps, wasn’t immune to the weird, compelling pull of the place. He began to see a desire to adapt and transform as the hospital struggled to find its place in the intersection between individual well-being and public health care, between expensive, efficient high-tech medicine and the human needs and demands of a community. “I think the place has changed considerably, and I know I have as well,” he said. “It’s hard to say which is which. I think it’s both.”
Cynicism and sentimentality are common enough in hospitals, but something about Maimonides brought it all to the surface. Winnie Kennedy, a senior nurse in psychiatry, told me she thought the exaggeration of all feelings had to do with jamming so many cultures into such a tight spot. “It’s like the yeast in bread,” she said. “It gives the place its rise.”
Brier depended on Cohen to keep the dough from overflowing the pan, to rationalize an irrational system. He was in charge of the front end and the back end, checking patients in and helping them find care after they left the hospital—the transition points. He described how things had changed since he’d trained as a physician thirty years earlier. In those days the crucial nexus for patients and physicians came in the first twenty-four hours: get a history, make a diagnosis, set up a therapeutic plan, carry it out. Then everyone could take a breath, because the patient would stay for two weeks. Convalescence was still part of the plan. There was time for reactions to medication to manifest themselves, or for the patient simply to regain strength.
In 1983, Medicare began linking payment to DRGs, Diagnosis-Related Groups, about five hundred categories determined by disease, age, gender, and possible complications. This formula eventually became the standard payment for all patients. Reimbursement was set not by individual but by group. Thus began the push for hello/good-bye. Discharge planning began almost simultaneously with admission. It wasn’t a bad idea in theory; hospitals were dangerous places full of infectious diseases, even when the staff did remember to wash hands. But, often, speed was achieved more readily than were efficiency and coordination. Even little things that got lost in the shuffle could have a big impact. For example, patients might come into the hospital taking one set of medications and, while in the hospital, be prescribed a similar medication with a different name. If the patients wasn’t made fully aware before they left, they might fill the prescription for the new medication, the one with the different name, and then unwittingly double the dose when they get home.
The entire system had changed. More and more care took place outside hospitals—though patients ejected from hospitals often found they were stranded. As recuperating patients were shoved out the door earlier and earlier, hospitals increasingly resembled intensive-care units. The cottage-industry model, where doctors went back and forth between their patients and their offices, was becoming obsolete. Patients increasingly were handed off by their primary-care doctors to hospitalists like Todd. “Team approaches” and “interdisciplinary models” were meant to maximize efficiency, because everyone had less and less time to spend with each patient.
That’s why the charts were so thick. Every new person who took a look also took a history and made a new notation. That’s why the potential for mistakes increased. Who had time to read all that and get to the next patient in time? And that was assuming you could read the notations, which was rare. Even at a computer-savvy place like Maimonides—one of the one hundred “Most Wired” hospitals—electronic records (outside the emergency room) were still used primarily to relay lab results and to place orders for medication. Patient progress was still scribbled into charts.
“It’s about teams, not lone rangers practicing anymore,” Cohen said. “It’s not even about who’s the captain of the team anymore. It’s about teams, one component of which is strictly medical care. There’s no captain. Someone has to be coordinator, but at each point somebody else is going to have to take charge.”
Cohen described his day.
“By about ten, ten-thirty, I get a list of expected discharges, and I can match them with patients coming in. Probably about sixty discharges a day, actually more. In medicine it’ll be fifty-to-sixty range; that doesn’t include critical-care units. Drop-offs on the weekend. Total surgical-medical discharges are in sixty-to-eighty range. Busy busy. If you consider a seven-hundred-bed hospital minus psych and maternity beds, you’re talking about turning over about one-fifth of the hospital.”
The potential for tension was there every step of the way.
“Before, it would take us ten minutes beginning to end to clear an admission. Now it’s forty-five minutes to an hour,” said Maria Ferlita, vice president in charge of admitting, medical records, in-patient insurance verification. Ferlita was another Maimonides character, Italian-born, a compact woman with long dark hair and dramatic eyebrows who wore snug-fitting skirts and spike heels. Her gravelly cigarette voice issued thoughts as decrees with the rapidity and punch of machine-gun fire.
“That’s what’s put tremendous financial strain on the hospitals,” she said. “I would say on the patients as well. In the past we had five, six payers—Medicare Medicaid, Blue Cross, private, workmen’s comp, and unions. Now you have myriads of HMO companies, mandatory enrollment of the Medicaid population, which has affected hospitals adversely, fiscally. Medicare and Medicaid, very simple. You have documentation guidelines you need to meet. You meet the guidelines, you get paid. With HMO companies, much, much, much more challenging. These are private companies. Their goal, or what we’re finding—they deny a tremendous amount of admissions due to no authorizations. It’s a method of postponing payment to the hospital, and if the hospital doesn’t appeal these cases, there’s a time element, money in their pocket.”
No one was turned away if admitted through the emergency room, but Ferlita made sure her people did all they could for the hospital to be paid by someone. She knew that the system was a mess; her job wasn’t to fix it but to game it. “If there is a discrepancy—a doctor has booked a patient as an inpatient and managed care says it has to be ambulatory—we contact the physician and say, ‘If you want to book this patient as inpatient, you have to send more documentation.’”
NEW SUCK JOURNAL VOLUME A, ISSUE 7 OCTOBER, 2005
Dudes,
Ok. Sorry it has been awhile. A resident gets busy sometimes you know. I think I worked like every day for the past month. I guess I had a few days off, but they were fake days off—I really don’t think you can count a day off after you just worked 27 straight hours (as you sleep the entire day), or when you have to go in to work that day at 7pm (as, again, you try to sleep the entire day). I just finished my month of Obstetrics, which I enjoyed, except for the fact I had to work (to some extent) every day, and had multiple 30 hour call shifts. Our hospital delivers 6,800 babies a year (about 20 a day)—the most in the country, so I was quite busy. But I gotta admit, Obstetrics is cool. For those of you who don’t know (I hope not many), Obstetrics and Gynecology is the medical specialty of Woman’s health/surgery/baby delivering, and such, and I nearly went into t
hat specialty myself, as I really like it. I still think that it’s possibly the coolest job in the world, with the exception that it sort of sucks. The hours suck at least. Also we all know that the greatest job in the world is being paid to fish. Duh. Either way, I am done with OB/GYN for now (and perhaps ever?). But I got to deliver a lot more babies, in a lot more languages than ever before. I learned transiently how to count to ten and say “push” in Cantonese, Mandarin, Russian, and at least two other languages that I’m not sure what they were. But that is done now, the times with young healthy pregnant chicks and their babies is finished—it’s back to the ER and all the about-to-die old people . . .
Ok, until next time, carry on smartly
Love, Davey
“Fishing kills me exactly as it keeps me alive.” The Old Man and the Sea
Hi Dave,
Could I meet you at the E.R. on Tuesday around 11-11:30 and hang out for a few
hours, maybe find some time to talk, too?
Let me know.
Julie
Ms. Salamon-
If it is ok with my attending that day (not sure who it is yet), that would be fine. I’m not sure though. I think it would be fun. But if it is really busy and we start falling behind because i’m not seeing patients fast enough, i might get in trouble. I’ll figure out who is the attending that morning and if i see them before tuesday, I’ll ask them. If not, i’ll ask them that day. And as far as just “following around”, I’ll warn you that probably 50-60% of my time is spent documenting on the computer . . . not very fun to watch.
Dave
Madeline Rivera, associate vice president for case management, reporting directly to David Cohen, told me about the three calls that preceded my visit one day. “I’ve got one patient that wants to be taken off the vent and get out and one who isn’t ready to leave. The wife is upset. She’s eighty-seven years old, husband not doing well, he has to go to a facility. The managed-care company has already told them they’re denying. I’ve talked to our liaison from managed care, saying we have an eighty-seven-year-old who is trying to choose a facility and needs to take fifteen thousand dollars out of the bank, and she can’t do that in one day. Let’s give her until Monday to do that.
“There’s a child who is handicapped and needs placement, and we’re working with the mother, who doesn’t speak English, to help her understand she isn’t sending her child out to die, to reassure her she has visitation rights. She thought she would lose rights because she is of Mexican background, not legal. There are a lot of sad stories. Every day we deal with these things.”
Rivera was a registered nurse, in her forties, pretty, with big, round, dark eyes and hefty from weight gained incrementally with the birth of each of her three children. Spanish was her first language; she didn’t learn English until pre-K. Her parents were from Puerto Rico. They had one message for their three children: “You gotta go to school, you gotta go to school, you gotta go to school.” One became an accountant, another a teacher, and Rivera, a nurse. “I went to Catholic school, Our Lady of Sorrow,” she told me. “When I look back at my autograph book from eighth grade and it said profession, the answer was ‘nurse.’”
None of her three kids spoke Spanish, and she spent most of her time moving patients through the system, but she wasn’t a machine. Sometimes she needed to see firsthand that she was helping.
“Every day we collect clothes to give to patients who come in without clothing, or medication budget for folks coming through ER,” she said. “I had a thirty-one-year-old coming in needing insulin he couldn’t afford to pay for. He told me he survived on a can of tuna fish a day, an illegal, Mexican. My drawers are filled with stuff—glucose monitors I can give out as charity. This man would be compliant if he could afford to be. We charged him a sliding-scale fee, whatever he could afford, because he was working off the books. About five days later, he knocked on the door downstairs and carried in a floral arrangement the size of this table. I started to cry. ‘Why did you bring this? You can’t afford to eat, you shouldn’t do this.’ He said, ‘Señora, yo quería.’ ‘I wanted to.’”
Charity was random and unofficial. Getting paid kept the hospital in business. Enter the documentation specialist, whose job was to review charts and make sure doctors had filled in the diagnosis correctly—not for treatment but for reimbursement. The government issued thick manuals of diagnosis codes listing tens of thousands of code numbers, indicating diseases and their gradations.
Say, for example, a patient has a gastric ulcer. There are more than twenty variations on the diagnosis; the addition of specific details indicating severity could drastically change the amount paid to the hospital and to physicians. Precision was required. If you “upcoded” inaccurately about a diagnosis that was reimbursed at a higher rate, the government asked for its money back and could charge a fine as well.
When the documentation specialist taught residents, she brought a stack of charts from recently discharged patients—with patients’ names and doctors’ signatures blacked out—to protect the innocent (the patients) and the guilty (doctors who had screwed up the coding). Over and over she demonstrated the difference a word could make. For bacterial pneumonia, writing “staphylococcal pneumonia” instead of “pneumonia” meant a DRG (Diagnostic-Related Group) paying $14,690 instead of $9,453; noting the cause “TIA—transient ischemic attack, a slight stroke possibly due to carotid stenosis,” instead of just “TIA” changed the DRG to one reimbursing $8,851 instead of $6,498. Case by case not much, but making such changes had cumulatively increased hospital revenue by $5 million the previous year.
It seemed crazy. But when I talked to Michelle Spector, a documentation specialist at Maimonides, she said the coding requirements weren’t just some sadistic bureaucrat’s idea of fun. “The regulations are not insane but to make sure that the entire team has similar documentation,” she explained. “The chart shouldn’t look like it’s a different patient on every page. That record is a business document, a legal document, and a big communications tool. You have so many people who don’t speak the same language in this hospital. They have to understand each other’s notes.”
On the other hand, sometimes the reimbursement rules did seem crazy. “What’s off the wall are some of the little decisions some insurance companies make, such as acute blood loss anemia is not reimbursed at the same rate as acute anemia secondary to GI bleed,” said Spector. “You don’t have to understand why, you just have to comply with it. That is part of the game.”
I asked Sam Kopel, medical director, about the difficulty of keeping track. “The charts are so thick with everyone documenting, documenting, documenting, you can’t make your way through them,” he said. “I rely on nurses’ notes, because their handwriting tends to be better, and I rely on the computer. I know all sorts of crap happens to my patients [that] I have no way of finding out, and I pray no horrible things are going to happen until the new computer system is in, in 2009. In the computer at least it’s legible and it will be organized.”
I first met David Gregorius after an early-morning lecture in a dimly lit, windowless room. One of the ER residency advisers had concluded the class by lamenting the disappearance of old-fashioned hands-on doctors. “We have lost the art of the rectal exam,” he told a roomful of sleepy novices. “The eighty-year-old guy who taught you how to do it in school and could distinguish one thing from another by moving his finger around.”
I was contemplating this thought when Steve Davidson, the department chairman, introduced me, telling the group I was writing a book about the hospital and it was okay to talk to me. After class Gregorius stopped by and asked if I would like to see an e-mail journal he’d sent his friends about his experiences. “Of course,” I said.
I finally caught up with Gregorius again for a few minutes in the ER, not long after another lecture, this one from the documentation specialist. He was, as promised, typing into a computer terminal, eyes glued to the monitor, while talking to me, apparentl
y tuning out the din around us.
“What did you think?” I asked him.
He lifted his eyes from the monitor for a second and laughed. “At first, we’re all kind of like, ‘Well, we get paid the same no matter what.’ . . . I can see maybe we’ll get a raise if the hospital makes more money. I ran into her a couple of times on the floor and showed her what I’d done. ‘Check it out! I wrote “Diabetes Type Two” instead of just “Diabetes.” An extra three thousand dollars.’”
Then, back to typing again, he got serious. “You have to learn how to bill properly,” he said. “One of the reasons I wanted to go into ER is because in most other specialties you have to do more business. I just wanted to work at a hospital where you go in and work and then you go home, because I’ve never been really business-savvy. But we get the same thing in the ER. You do a procedure, log it on the chart, because then they can bill for it. If you just put in an IV, apparently, you don’t even think about it, but if you wrote you did it in the chart, the hospital bills them for an extra fifty dollars, just by taking two minutes to write it down. I guess I’m getting better than that. I wonder if they keep track of how much we lost!”
They tried to keep track.
For several years Sondra Olendorf, head of nursing and hospital operations, had been trying to find the bottlenecks. Olendorf at first seemed to have no noticeable quirks; her unfussy short haircut, her manner of dress (conservative but feminine suits, often in bright colors) and way of speaking (vaguely Middle American) were cheerful and direct and would seem unremarkable anywhere else. She had grown up in West Virginia but had spent years working at a hospital in an upper-middle-class suburb of Detroit, where patients were predominantly white, Republican, and well insured and where the institution itself had, Olendorf said, “a kind of corporate culture.” She fit in easily there.
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