Tuesday, December 8, 2009

Will Rogers Phenomenon and the Cost of Healthcare


"When the Okies left Oklahoma and moved to California, they raised the average intelligence in both states." - Will Rogers

In medical terms this is called Stage Migration bias, because it was first observed in cancer. If there are more intensive efforts to detect or stage cancer, patients who would have been classified as Stage 2 before the more intensive effort, may be classifed as Stage 3. This has the effect of taking the sickest Stage 2 patients (those whose cancers had spread more widely but that spread can only be found with the more intensive workup) and moving them to Stage 3, where they are the healthiest Stage 3 patients (since other Stage 3 patients are those whose cancer spread was more obvious and did not need the more intensive work up to detect). Because the patients moving out of Stage 2 are sicker than those that remain, Stage 2 patients will average be healthier and will appear to do better. Because the patients moving into Stage 3 are healthier than those there already, Stage 3 patients on average will be healther and will appear to do better. Overall mortality for all stages will be unchanged.

I think this is also going on in hospitals. I was recently talking to an ICU doc who was complaining about how many non-critically ill patients are in his ICU. He talked about 20 years ago, ICU care was reserved for the critically ill, who had a signicant chance of death in hours or days. Now, there has been a steady erosion for the entry criteria for ICUs such that many patients who would previously been cared for on the wards or TCU are transferred to the ICU. There are many incentives driving this: For the patients' doctors, generally more monitoring means less likely poor outcomes, so they don't fight it. For the ward nurses, transferring out the sickest patients means that there is less work for them, and their outcomes will look better. For the ICU nurses, transferring in patients who don't need ICU care means less work for them, and their outcomes will look better. For the hospital, treating the same patient in the ICU brings them more income.

The losers in this scenario are the payor, such as Medicare, and elderly patients. For Medicare, it is impossible to determine w/just administrative data who "really" needs ICU care vs who does not. For elderly patients, ICU level care comes with increased risks for hospital complications such as delirium. I don't know how this problem can be fixed, except maybe certificate of need requirements (such as those required by some states to have a CABG program) to build ICU beds.

8 comments:

John said...

As an ICU nurse for the last 11+ years I can concur that the acuity level (at least where I work) has dropped off considerably. At one time almost everyone in our units was receiving mechanical ventilation while today the opposite is true.

When we redesigned our critical care units several years back we did not change the total number of beds (combined step-down and "full" critical care) but the allocation was more heavily geared toward "full" critical care. About two years after this we hired a medical intensivist who instituted tighter control over ICU admissions and discharges but was given no control over the step-down beds and admissions (it is open with almost no oversight).

An interesting, albeit not surprising, trend has occurred -- the number of step-down patients has mushroomed. We are now at the point where we have doubled the number of step-down beds and are also "boarding" these patients in the "full" critical care units (where the total number of beds has remained unchanged).

My question has always been does the hospital actually receive a higher reimbursement rate for these "critically ill" patients or is reimbursement from Medicare and/or insurance simply based on the diagnosis? Many of these patients are ones I would have cared for on the floor when I was a med-surg nurse in the mid 90s.

I agree that this may be good for the hospital's bottom line but we needlessly subject patient's to critical care admissions and the resulting iatrogenic effects (delirium, infection, sleep deprivation, etc.). It is frustrating when you want to put the patient's best interests at heart.

A certificate of need would be a good idea but where I practice (Pennsylvania) this idea was thrown out several years ago by the state legislature. It also explains why now nearly every hospital in the Philadelphia area has an open-heart surgery program. In contrast across the bridge in New Jersey there are just a handful.

Alex Smith said...

Brilliant post Sei. Love the way you tie Will Rogers, cancer staging, and ICU transfers together!

Appreciate the perspective John. I am no expert in costs, but I'm pretty sure ICU's are money LOSERS for hospitals, not money makers. My understanding is that hospitals generally try not to build more ICU beds, because if you build them...

This may not be true in certain situations. For example, certain types of surgery may be big money makers for hospitals (CABG, transplant) but require ICU care routinely after surgery. But I believe for the general medical patient, ICU care costs the hostpial money.

I believe the expansion in the growth of ICU's came from the patient safety movement. Are patients safer? Sei and John suggest they may be harmed by iatrogenic complications. Are these harms outweighed by the increased monitoring and intensity of care? I don't know...

ken covinsky said...

Interestingly, despite the prominnt role ICUs play in our health system, I am not aware of any studies that clearly demonstrate which patients benefit from care in an ICU. It seems that what dictates ICU need is often local custom, at least in part.

It seems there are two general reasons patients go to an ICU. One is because they need a type care that can not be provided in another setting, such as mechanical ventilation, pressors, etc. These indications are pretty clear. The second, clinical instability is more amorphous. These are the patients we are worried about, and we feel they need more intensive monitoring than can be provided on the floor. For most of these patients, it would at least theoretically possible to care for them if there were adequate support, such as a better nurse/patient level. Perhaps better defining what level of support is needed under different clinical scenarios is an area in more research is needed.

Cyndi Cramer, BA, RN, OCN, PCRN said...

I am a Nursing Supervisor at a large teaching hospital & find our ICU patients are just sicker and sicker. Now, this may be different at hospitals with more private MD's--but not for us!
Our floor patients are extremely sick also! (we send kidney transplants directly to the floor from PACU)
But we do, on occasion, have trouble getting some MD's to let their patient's leave the ICU when the nurses think they should be out. If we had Intensivits over all of our ICU's, we would have more control & consistency in who should be moved out & when...
But more often then not, we are moving them out when they are still pretty darn sick.
A comment on floor patients going to ICU: Often it's because it is just too much to ask of a nurse that has several patients (need of hourly vitals, closely monitored drips that are titrated, or just very close ongoing assessment skils)

Bob Wachter said...

Nice post, Sei. Regarding whether ICUs make or lose money, the answers are "yes", and "it depends". As you might guess, the payment system is chaotic and difficult to understand. Most Medicare patients are paid under a DRG (fixed payment for a given diagnosis) system -- the use of the ICU may bump the patient into a higher payment DRG, but if the patient really isn't sick enough to be in the ICU, the payment for that category will often not be enough to cover the costs.

Some payers (such as most private insurers) pay hospitals on a per diem, and so extra ICU days may well be profitable to the hospital (depending on that per diem rate vs. the costs of providing ICU care).

The real disconnect is that even under Medicare, the doctors are paid a daily rate based on the patient's complexity, and ICU care generally pays more (there are special "ICU codes"). So, in the average hospital, the hospital actually has an incentive to lower ICU utlization (or at least to preserve the ICU beds for patients who really need them), whereas the docs have a financial incentive that pushes them toward overutilization.

This is merely a snapshot of the broader problem of "lack of alignment" -- you've heard about the wonders of the Mayo and Cleveland Clinic, Geisinger, Kaiser Permante, and similar systems during the healthcare debate over the past few months. These systems employ their docs and pay them a salary (come to think of it, sorta like the VA), which has the impact of aligning the hospital/physician incentives. Thus if it is in the hospital's interest to lower ICU utilization (as it usually is), the docs are on board. But most of American healthcare doesn't look like that, which is a big part of the problem. And there seems little in the current bills bouncing around in Congress to promote these kinds of arrangements, which provide demonstrably higher quality and more efficient care.

Keep up the great work with the blog!

-- Bob Wachter

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