II. Hospitals
a. Communication is key
A hospital can be one of the most confusing places you may ever be in your life; or it could be high above what you expected and really impress you. The former is far more common for those of us who are not very well off financially. One of the fundamentals lacking in many hospitals today is communication. Without communication it all falls apart in the world of healthcare.
Though I work in a private medical office, we closely interact with hospital staff almost constantly; scheduling tests, scheduling procedures, calling for reports, taking messages to relay to the doctors, taking consult requests and so on. Working with hospitals has taught me one very important thing – hospitals are the masters of misdirection.
When it comes to what patients are told in any aspect of their care, whether it be; the status of their care, the coverage their insurance is going to provide, their next plan of treatment, or their communications with the doctors – what they are told is almost always a bureaucratically vague and ambiguous representation of what’s really going on. This is generally due to not just bad communication but a complete lack thereof – one doctor or nurse isn’t passing on the vital information to the next properly; and there you have the first break in the chain. All it takes is one piece of vital info to slip through the cracks and the patient is put at risk – many times this happens continuously throughout their stays due to the sheer chaos going on in most low level hospitals today.
All this miscommunication and bouncing around of patients from one doctor/nurse to the next leads to the eventual confusion of any patient and when it comes down to ‘who do I blame for this mess?’ the hospitals always play the same card – they find a way to blame it on us every time.
The hospitals I am collectively referring to are notorious for:
- Doing the wrong test on the patient; then claiming that the office scheduled it incorrectly
- Cancelling patients because they needed the spot for something emergent; then telling the patient that we called to cancel their appointment
- Deciding at the very last second that the test we ordered needed to be changed to a slightly different one; then making patients wait (I’ve heard of up to 5 hours) while we change the authorization – telling the patient we authorized the wrong thing
- Cancelling major, life saving surgeries because they decided the night before that they wouldn’t make enough money off of it; then they refuse to tell patients and leave it up to our office
- Giving patients medication being oblivious to their allergies; then telling the patient that the doctor’s office did not inform them of the allergies
- Nurses many times refuse to tell patients anything claiming that the doctor didn’t tell them anything yet; even though they were already given the answer hours prior
All in all it comes down to accountability they refuse to explain anything that someone else can explain to them, passing the buck down the line indefinitely until patient’s finally give up asking questions. As mind-numbingly irritating as all that is to the doctor, and their office – think about the big picture, the real reason it matters; and that is the effect on patient care – devastating.
b. Remember – hospitals = big money
If you thought that your care matters one bit to a hospital at almost any point, you are delusional. Hospitals are about making the most money out of the least amount of care provided. This is quite simple if you examine the medical billing system.
Billing of any procedure is done with codes; diagnosis code (ICD-9) and procedure code (CPT/HCPCS). Diagnosis codes are really just references to supporting the medical ‘necessity’ of any given procedure code. For example you had a breast mass (ICD code 611.72) so you had an excisional breast biopsy (CPT 19120). Fairly simple right? Trick question!!!! WRONG!!!
You see when you are talking about the treatment of diseases, illness, conditions etc. nothing is really chiseled in stone. Every patient is unique, as is every case any doctor will ever see. As such the terminology used in Current Procedural Terminology (CPT) books is written to leave large room for interpretation.
Example – Patient is involved in a minor motor vehicle accident, ends up with a severe abrasion to oh lets say both forearms (basically – wicked hamburger meat road rash). The doctor cleans out the wounds, removes some excess tissue, and uses a skin graft to begin the closure of the wound. The diagnosis is abrasions to both forearms; your treatment was debridement and removal of devitalized tissue and secondary closure with a skin graft.
This particular example should be billed with 2 procedure codes. There are 4-5 separate codes for the debridement (cleaning) of the wounds alone; varying by how extensive the procedure was, how far down the wound penetrated, and the area of the wound treated. There are more than 20 different codes that can be used for a skin graft – because there are hundreds of variations. Basically as you would expect, the bigger the wound, the deeper the wound, the more difficult a wound is to treat and close – the more money the doctor makes.
You would think the doctor would be bound by some sort of regulation to bill for what he did and in a sense you are correct; however the doctor can just as well dictate excessively in the report and therefore it looks to the insurance payer like a legitimate claim.
Hospitals will almost as a rule of thumb over-bill and under treat basically every patient they see. There is a huge grey area in the billing aspect of care. When I say huge I mean that more than 90% of the CPT codes used are open for a vast amount of interpretation – much like the law. Also consider that this example was merely the easiest to explain without writing a novel; but the underlying theme applies to the majority of care received at any hospital.
Tragically many patients never understand how negatively all of that impacts their overall well being.
So…How does it actually affect patient care?
- Contrast materials used in radiological tests (such as CT scans, CT angiography, MRI) are almost always comprised of substances that impair kidney function (thus the reasons for the blood levels commonly tested prior to any such studies – BUN & creatinine; these are indicators of kidney function) for anyone with diabetes; too many scans with contrast can cause kidney failure if incorrectly monitored, and for those who are allergic to the contrast materials it can be lethal.
- Any radiological exam when done by the book is still using exposure to radiation to gather the images. Need I explain in any more detail what can happen when you get too many
- Wrong test? Need a do-over? Guess who’s paying for both?
- If a procedure in interventional radiology goes incorrectly and a vascular surgeon isn’t on hand – patients can end up needing amputation of limbs
- Just going through such a bad experience at the hospital in general can make a patient waste precious time finding all new doctors and an all new hospital – hoping all the while their illness doesn’t kill them
c. The telephone effect
If you ever played telephone when you were a child – you know as well as I that at the end of the game the message is usually nothing even remotely related to what it started out as. It seems odd but you can apply the same theory to healthcare. On average your information must be coordinated between at least 5 to 6 medical personnel for treatment of any given problem (depending of course on number of employees of course)
Who’s in the need to know:
1. Got the flu
- Primary doctor
- Primary doctor’s staff
- Insurance company
- Phlebotomist
- Laboratory staff
- Pharmacist
- Pharmacy staff
2. Need a CT scan
- Primary doctor
- Primary doctor’s staff
- Referral coordinator
- Insurance company
- Phlebotomist
- Laboratory staff
- Pharmacist (if contrast is used)
- Radiologist
- Radiology staff
3. Need a surgery
- Primary doctor
- Primary doctor’s staff
- Referral coordinator
- Insurance company
- Cardiologist (if you have any kind of cardiac condition)
- Anesthesiologist
- Surgeon
- Surgeon’s staff
- Surgeon’s referral coordinator
- Phlebotomist
- Laboratory staff
- Radiologist (for chest x-ray – standard pre-op exam)
- Operating room scheduling
- Operating room nurse (scrub nurse)
- Director of surgery
- Coding department
- Billing department
I don’t feel I need to explain the inherent margin of error that comes with all this. There’s even a saying we use in our office all the time when a patient’s care is literally being over-complicated to the point that it puts them at risk – Too many cooks in the kitchen. Onto the end of that I’d add – and too many pots on the stove, and too much food in the pots, and too much food to cook!
Oh what a tangled web we weave.
This article was a bit different from the last in its focus, but when you take it all in and really look at the big picture it all comes back on the patients and at the end of the day – they are paying the price for healthcare industries major shortcomings.
Let me add a short disclaimer here – This absolutely does not apply to all hospitals, in fact the ones that don’t absolutely scare me are actually extremely well run facilities; usually tertiary care facilities. That being said, the well run facilities (out of those that I personally work with) make up less than 10% of the total. The really scary part is that they are all certified by multiple agencies and healthcare review panels designed to ensure the safety of us all when under the care of hospitals.
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