A woman rushed to the hospital with shortness of breath and tightness in her leg because of blood clots that had travelled from her leg to her lungs. Doctors prescribed injections of a fast-acting blood thinner every twelve hours and ordered a slow-acting, oral medicine to prevent future clots. It usually requires more than a week for the oral medicine to thin the blood to the recommended level.
The woman had suffered similar clots several years earlier. She is highly educated. She’d had no difficulty injecting herself at home, following instructions about diet, and monitoring her blood until the pills took full effect. This admission, her condition stabilized within thirty-six hours, but the doctors chose to keep her in the hospital. Why?
Her current health care benefits covered medicine only in the hospital, and she could not afford it. A social worker found a drug company to donate the medicine, but policy stated that “the hospital cannot dispense medicine.” The woman’s admission lasted five more days, at a rate of about $2500. per day.
WHAT’S WRONG WITH THIS PICTURE?
1) Insurance would rather pay for medication AND hospital expenses than extend coverage into the community at a lower total cost.
2) Although the hospital pharmacy “dispenses” medicine daily, it had no outpatient pharmacy and no protocols to allow even donated medicine to leave the building. Would these licenses cost more than $2500. daily, multiplied by the number of patients in similar predicaments each year?
3) This capable and willing woman could have gone home more than three days earlier, enjoying the comfort of her own home, with a safe and effective treatment plan that cost thousands of dollars less.
Hospitals are scrambling to control cost. So far, they focus on hospital admissions because there are severe reimbursement penalties for unnecessary inpatient care. However, the “do more, collect more” doors are closing all over the health care system. Reimbursement based on providing the most effective care under the appropriate and most cost-effective circumstances will be the order of the day. Our health systems, insurance plans, and professionals need to take a comprehensive look at how to meet these goals.
Medical training programs offer doctors little instruction about integrating cost-containment strategies into care plans. Neither are there any financial incentives to learn these skills in practice. Physicians who work for health systems may see smaller year-end bonuses when their employers fail to follow cost-effective practices, but these penalties do not yet affect up-front income, nor payment to private doctors. As long as these incentives are misaligned, most doctors are not likely to provide leadership in this area.
We have to get onboard anyway. Comprehensive, coordinated care plans are better for patients. Also, the financial penalties will eventually apply to us, too. No one wants doctors to make care decisions based on cost alone, but we need to learn to individualize care plans according to what is best for a specific patient. This means considering the most effective treatment in the least restrictive environment possible, and at the right cost.