Anybody else's Hospitalists not admitting patients anymore?

[KGflyboy]

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I feel like our hospitalists admit less and less at the smaller hospitals where consultants are not available, and that creates big problems when bigger facilities don't have beds available.

- CHF on 2L O2 -> Might get worse so needs transferred for Cardiology. Whe we call Cardiology, they are confused about why our Hospitalists won't admit for diuresis here.
- Grandma has the stomach bug going around and is dehydrated, so her creatinine increased from 1.5 to 2.3. She would benefit from observation, fluids, and rechecking until po intake improves -> Hospitalist says the patient needs transferred for Nephrology consultation.
- Grandpa has a lumbar compression fracture, is having a hard time ambulating despite your best pain control efforts in the ED, and needs better pain control before he can go home. He might also benefit from PT/OT, and SNF placement. Spine surgery has already been consulted by phone, recommends supportive care +/- a TLSO for comfort, and follow up in the clinic -> Hospitalist won't admit because we don't have spine surgery here "in case he gets worse."

Whenever we try to transfer these patient's the doctors at the receiving hospitalist act like we are crazy for trying to transfer patients that can clearly be managed at any hospital with a general medicine service.

At our tertiary hospital, the Hospitalists seem to consult Cardiology for every slight CHF patient needing diuresis for a day or 2, ID for run of the mill infections and ABX management, Nephrology for mild or moderate pre-renal AKI, etc.

At this point... I'm not really sure how our Hospitalists can even justify being there. I guess they exist simply because the specialists won't admit their own patients.

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

 

[BoardingDoc]

I feel like our hospitalists admit less and less at the smaller hospitals where consultants are not available, and that creates big problems when bigger facilities don't have beds available.

- CHF on 2L O2 -> Might get worse so needs transferred for Cardiology. Whe we call Cardiology, they are confused about why our Hospitalists won't admit for diuresis here.
- Grandma has the stomach bug going around and is dehydrated, so her creatinine increased from 1.5 to 2.3. She would benefit from observation, fluids, and rechecking until po intake improves -> Hospitalist says the patient needs transferred for Nephrology consultation.
- Grandpa has a lumbar compression fracture, is having a hard time ambulating despite your best pain control efforts in the ED, and needs better pain control before he can go home. He might also benefit from PT/OT, and SNF placement. Spine surgery has already been consulted by phone, recommends supportive care +/- a TLSO for comfort, and follow up in the clinic -> Hospitalist won't admit because we don't have spine surgery here "in case he gets worse."

Whenever we try to transfer these patient's the doctors at the receiving hospitalist act like we are crazy for trying to transfer patients that can clearly be managed at any hospital with a general medicine service.

At our tertiary hospital, the Hospitalists seem to consult Cardiology for every slight CHF patient needing diuresis for a day or 2, ID for run of the mill infections and ABX management, Nephrology for mild or moderate pre-renal AKI, etc.

At this point... I'm not really sure how our Hospitalists can even justify being there. I guess they exist simply because the specialists won't admit their own patients.

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

I occasionally fight with hospitalists about unnecessary transfers, though it's thankfully rare. Yours sound particularly incompetent and/or spineless.

There is one person who used to push back on admissions all the time. When she insisted on transferring some nonsense I started insisting that she speak with the transfer center herself about the reason for transfer, because I didn't have one. She has since become much better about accepting admissions, but now passive aggressively takes a solid 2 hours from time of admission to time of evaluating the patient in the ER and accepting. It's an improvement.

If they refuse to talk to the transfer center either, I'd tell the transfer center that the hospitalist is refusing admission because of <stupid reason> and document that the hospitalist refused admission because of <stupid reason> when you transfer. If it's a routine event, you escalate it to your chief and/or the chief of medicine.

As to the 2nd question: I've never worked at a hospital without any gen surg coverage, but yeah, those patients get admitted to medicine, not surgery.

 

[DOswag]

 

[CajunMedic]

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

Absolutely no luck. I had something related the other night: Signout from day doc (who went home with Norovirus early), to "Chair of Medicine/Hospitalist Director" covering the ED, to me as night doc. 65 y/o F with Flu-like symptoms. Flu A positive. But has RLQ pain. CT shows appendix at upper limit of normal, no appendicolith, no stranding. Afebrile somehow, no white count, Alvarado score of 3, AIR score of 2. Totally unimpressive exam and presentation. Probably someone I would have D/C'd out of triage after a swab. Was told patient needs transfer for emergency appendectomy. Our OR is down yet again due to a municipal water line break. Closest hospital went on diversion and won't accept her, Won't go 20 miles up the road because a family member died there. Get a surgeon on the phone at the next closest shop. Unequivocally says she doesn't need to be transferred, keep her overnight, serial abd exams, rescan in the morning, and if it's worse, call him back on his personal number and he'd direct admit from our place straight to their OR... Gets admitted to the only private doc we have. 3 hours later I get a call with him freaking out: why didn't I transfer? what was I thinking? why did I admit to their service? OMG, we're all gonna get sued!! etc. He promptly calls the private doc, talks them out of the admission, then their NP calls me, then he calls me again to tell me, then calls again a few minutes later to tell me he talked to the CMO (who is a general surgeon that works the ED), who said it was not unreasonable to keep her. So, he transfers her to their service, puts her in the last ICU bed, and has the overnight NP do serial exams. Ultimate dispo? D/C with a negative scan and repeat labs, pain resolved without meds. Just. the. Flu.

I actually have the opposite problem with this guy. He's christened himself the "Admitting Hospitalist" and parks in the ED from 9-5, or until he gets 8 admissions. We only have 16 floor beds, and 6 "ICU" beds on a great day. Will go in rooms before the ED doc and discuss admitting patient before they're even seen by us. Fills the beds up with questionable admits and then I get stuck boarding the real patients in the ED...

FML. April 1st can't get here fast enough. Where's my bottle of Jack Daniel's?

 

[eforest]

If a patient declines transfer to an accepting facility- can you just document the refusal? Sounds like she’s part of the problem.

Right now- it’s more impossible to transfer patients than ever (aside from maybe COVID days- that was a whole other kettle of fish) especially ones that *can* remain in house.

Blogger

 

[EMhawkeye]

I have noticed recently hospitalists ordering everything under the sun, consulting every service. Very weak clinical skills.
For example, patient had a glf on xarelto. Found to have a pneumonia. Already pan scanned and no injuries. Ask me to consult trauma.
I asked them “do you need a trauma surgeon to read the negative ct report to you?”

 

[RustedFox]

Not at my shop, but I see the HCA IM residents have hit the streets running.

 

[thegenius]

I feel like our hospitalists admit less and less at the smaller hospitals where consultants are not available, and that creates big problems when bigger facilities don't have beds available.

- CHF on 2L O2 -> Might get worse so needs transferred for Cardiology. Whe we call Cardiology, they are confused about why our Hospitalists won't admit for diuresis here.
- Grandma has the stomach bug going around and is dehydrated, so her creatinine increased from 1.5 to 2.3. She would benefit from observation, fluids, and rechecking until po intake improves -> Hospitalist says the patient needs transferred for Nephrology consultation.
- Grandpa has a lumbar compression fracture, is having a hard time ambulating despite your best pain control efforts in the ED, and needs better pain control before he can go home. He might also benefit from PT/OT, and SNF placement. Spine surgery has already been consulted by phone, recommends supportive care +/- a TLSO for comfort, and follow up in the clinic -> Hospitalist won't admit because we don't have spine surgery here "in case he gets worse."

Whenever we try to transfer these patient's the doctors at the receiving hospitalist act like we are crazy for trying to transfer patients that can clearly be managed at any hospital with a general medicine service.

At our tertiary hospital, the Hospitalists seem to consult Cardiology for every slight CHF patient needing diuresis for a day or 2, ID for run of the mill infections and ABX management, Nephrology for mild or moderate pre-renal AKI, etc.

At this point... I'm not really sure how our Hospitalists can even justify being there. I guess they exist simply because the specialists won't admit their own patients.

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

So much of that stuff is bullchitt and I get some of that too. WTF how are hospitalists trained. It’s within their scope of care to manage CHF, AKI, non operative compression fractures. Them not admitting has to be an EMTALA issue.

 

[thegenius]

If a patient declines transfer to an accepting facility- can you just document the refusal? Sounds like she’s part of the problem.

Right now- it’s more impossible to transfer patients than ever (aside from maybe COVID days- that was a whole other kettle of fish) especially ones that *can* remain in house.

Blogger

You can go home, or go to the other hospital. There isn’t much choice to the matter. Standard of care has been met. If patient doesn’t like it, then document well and d/c.

 

[Radetzky]

SBOs under medicine is a terrible idea. Yes anyone can put in an NG tube and give some bowel rest, but the real decision making is when to change approach and take to theatre, something that IM docs just have no experience in

 

[Apollyon]

SBOs under medicine is a terrible idea. Yes anyone can put in an NG tube and give some bowel rest, but the real decision making is when to change approach and take to theatre, something that IM docs just have no experience in

The old saw, before CT, was "never let the sun rise or set on an SBO". Concur. SBO on medicine is bananas.

 

[Tenk]

 

[JacobMcCandles]

I’ve noticed similar things. I think there are a lot of reasons but I see it a lot with newer attendings. Besides the fact that COVID negatively affected residency training, I think a lot of IM residents are used to consulting every service under the sun.

 

[Restart13]

My hospitalists are notoriously difficult to admit to. To their defense, just like we often do, they are practicing defensive medicine. I have seen patients fall through the cracks, someone tries to be a good guy and take one for the team, yet a patient starts to decompensate. The specialized service says turf to tertiary care center as it is too complicated for them and not one of their bread and butter cases, so the hospitalist is stuck with a sick patient and it's even harder to transfer from the floor than the ED.

I don't even mind those, it's the old grandma social admission, mild AKI patients, EtOH super users to just easy admit and day team dc in the AM patient I wish they wouldn't fight as hard.

 

[JacobMcCandles]

so the hospitalist is stuck with a sick patient and it's even harder to transfer from the floor than the ED.

I've seen every hospitalist mention this. What makes it harder? The accepting hospital doesn't really care if they're in the ED or admitted from my experience. Is it because the hospitalist may be the one having to make the various calls?

 

[oldtown]

I've seen every hospitalist mention this. What makes it harder? The accepting hospital doesn't really care if they're in the ED or admitted from my experience. Is it because the hospitalist may be the one having to make the various calls?

I think it’s a reimbursement issue. If patient is transferred from Hospital A from the ED (as a ED patient) to Hospital B as an inpatient, insurance/medicare/medicaid pays Hospital A for the ER visit and Hospital B for the inpatient admission.

When the patient is admitted to Hospital A as inpatient, then transferred to Hospital B as inpatient, insurance/medicare/medicaid only wants to pay for one admission/DRG, but now two hospitals are laying claim to that payment. I imagine there’s paperwork/appeals and such involved.

 

[JacobMcCandles]

I think it’s a reimbursement issue. If patient is transferred from Hospital A from the ED (as a ED patient) to Hospital B as an inpatient, insurance/medicare/medicaid pays Hospital A for the ER visit and Hospital B for the inpatient admission.

When the patient is admitted to Hospital A as inpatient, then transferred to Hospital B as inpatient, insurance/medicare/medicaid only wants to pay for one admission/DRG, but now two hospitals are laying claim to that payment. I imagine there’s paperwork/appeals and such involved.

That should have nothing to do with transferring the actual patient.

 

[oldtown]

That should have nothing to do with transferring the actual patient.

Hospital B doesn’t want the patient because of all the hassle involved. They will throw up any reason not to accept the transfer. The hospitalist at hospital A knows this. If you think it’s all about “what’s best for the patient” and not about money, you’re being naive.

 

[Rendar5]

I’ve seen some ridiculous transfers to my hospital recently. We receive, don’t send out. Someone’s got a borderline cbd dilation with normal labs? Please transfer it to me because your GI doctor on call can’t do ERCP. Don’t bother admitting for an MRCP and actually diagnosing choledoco ::eye roll::

That said, I do think it would be foolhardy to admit an SBO to a hospital without general surgery coverage. Medicine can easily admit, but you need a surgeon to say when they need to go to the OR.

 

[JacobMcCandles]

Hospital B doesn’t want the patient because of all the hassle involved. They will throw up any reason not to accept the transfer. The hospitalist at hospital A knows this. If you think it’s all about “what’s best for the patient” and not about money, you’re being naive.

I can almost guarantee you that most hospitalists don’t have a clue with regards to the billing aspect.

Also, it looks like your understanding of the billing is wrong but, of course, I could be misinterpreting it: https://www.cms.gov/files/document/r11189cp.pdf

 

[emergentmd]

Reasons

1. Hospitalist - Consult = less work = little liability = less calls overnight = less need to find outpt follow up. They get paid the same if they consult a cardiologist vs doing all the work. Win
2. Specialist - Easy pts. Go right a note, maybe do a procedure, bill pt, get paid. Do the real stuff, send back to hospitalist to do the social worker stuff. Win
3. Hospital - More docs touching the pt, pt more complicated, increase billing. Win

So where is the incentive for the hospitalist to take care of the pt from start to finish with same pay and increased work/liability?

It is not the hospitalist but the system that has been set up to do little and consult more. Admission barriers are the worst part of EM medicine.

 

[AlmostAnMD]

It is not the hospitalist but the system that has been set up to do little and consult more. Admission barriers are the worst part of EM medicine.

we need a medical version of DOGE

 

[EMhawkeye]

I distinctly remember the attendings who consulted the most for simple things like AKI when I was a resident on the floors. It’s the same kind of people who order every test under the sun and shotgun everyone instead of actually practicing evidence based / cost effective medicine. They do it because they have no confidence in their own clinical judgement.

 

[RustedFox]

we need a medical version of DOGE

I've said this to my wife so very many, many times.

 

[Arcan57]

I distinctly remember the attendings who consulted the most for simple things like AKI when I was a resident on the floors. It’s the same kind of people who order every test under the sun and shotgun everyone instead of actually practicing evidence based / cost effective medicine. They do it because they have no confidence in their own clinical judgement.

Agree with everything except the last statement. Lack of confidence is a reason but there's plenty of confident hospitalists that engage in the same behavior. A lot of hospitals have self sustaining ecosystems based on these BS consults. Hospitalist A consults Consultant B who drops a note. Consultant bills for the consult which is good, but also then has the patient follow up for their stable CHF, CKD, etc in their clinic which means reliable outpatient clinic volume. Bonus points for the consultant if you manage to snake a patient who had those conditions already being managed by a rival consultant or a PCP. In return the hospitalist gets their business on the in-patient side, especially patients that ordinarily would just have been admitted by the specialist. Hospitalist gets to carry a big census of "complicated" patients while not actually having to spend the time that would normally be required. Only downside is this jacks the LOS for the hospitalist up as they wait for the consultant to finish clinic and see the patient. Which drives the midlevel-ization of medicine since the consultant hires an array of nocters just for the inpatient side so the hospitalist can put the patient up for discharge by noon.

 

[Siggy]

On a related note... Has anybody had luck convincing hospitalists to admit uncomplicated SBOs at smaller hospitalist without General Surgery? The vast majority of SBOs do not require surgery, so I feel like it's reasonable to admit for bowel rest, fluids, NG tube if needed, and then transfer later if no improvement or if the patient decompensates. Obviously this would not apply to patients with an obvious anatomic cause of the obstruction such as an incarcerated hernia or other surgical problem.

Thoughts?

Because transferring patients inpatient to inpatient is a disaster that takes forever. I've gotten front row seats several times to watching people deteriorate and expire over days because multiple tertiary centers refused to accept the patient. We can't just throw an EMTALA violation around when an inpatient to inpatient transfer is refused.

Also the window for "patient clearly needs subspecialist care" and "patient is too sick to move" can be extremely small. Once the patient becomes too sick to transfer everyone is going to be asking, "Why did we accept this time bomb in the first place?"

 

[Siggy]

I've seen every hospitalist mention this. What makes it harder? The accepting hospital doesn't really care if they're in the ED or admitted from my experience. Is it because the hospitalist may be the one having to make the various calls?

Patient doesn't have insurance, medical team accepts, admin declines transfer.

ER to ER: EMTALA violation.

Inpatient to inpatient: Meh, why would we eat the cost of your mistake?

 

[emergentmd]

I distinctly remember the attendings who consulted the most for simple things like AKI when I was a resident on the floors. It’s the same kind of people who order every test under the sun and shotgun everyone instead of actually practicing evidence based / cost effective medicine. They do it because they have no confidence in their own clinical judgement.

I know of some very very strong hospitalist but eventually they become the same. If you are getting paid the same for doing twice as much work as your partner while having less liability and not being a "team" player, then what is the incentive?

You partners will start to hate working with you also. Imagine doing overnights and some diabetic pneumonia nursing home pt crashes. If they have a pulmonologist on board, then you can just tell staff to call them. If they have chest pain, you tell them to call the on call cardiologist. If you hospitalist from a named program didn't consult anyone, guess where all of the work lands at 2am.

Most of the time it is the system and not the hospitalist.

 

[pkwraith]

we need a medical version of DOGE

Ah, yes, nothing like fixing the hospital by firing all the wasteful lazy doctors (they make the most per hour), refuse to pay any payroll or accounts, offer all the RN early retirement, then send all the money to the CEO.

 

[AlmostAnMD]

Ah, yes, nothing like fixing the hospital by firing all the wasteful lazy doctors (they make the most per hour), refuse to pay any payroll or accounts, offer all the RN early retirement, then send all the money to the CEO.

You're clearing joking but I do think you're not far off. That's one nidus for me to learn to make money investing.

EM docs don't realize they're on an island. Nurses have massive lobbies. Healthcare corporations have massive lobbies. Insurance industry essentially owns congress and can deregulate my next point in the next paragraph. Our biggest lobby is ACEP which is effectively a CMG in sheep clothing.

The very effing moment AI can replace EM docs your 400ish salary is going to look very lucrative to make disappear for a software package. The only reason, the only reason, it hasn't happened yet, is the technology isn't there. That trigger gets pulled the moment the gun is loaded.

 

[Apollyon]

You're clearing joking but I do think you're not far off. That's one nidus for me to learn to make money investing.

EM docs don't realize they're on an island. Nurses have massive lobbies. Healthcare corporations have massive lobbies. Insurance industry essentially owns congress and can deregulate my next point in the next paragraph. Our biggest lobby is ACEP which is effectively a CMG in sheep clothing.

The very effing moment AI can replace EM docs your 400ish salary is going to look very lucrative to make disappear for a software package. The only reason, the only reason, it hasn't happened yet, is the technology isn't there. That trigger gets pulled the moment the gun is loaded.

Or, replace docs with NPs, as my last hospital did (after I left).

 

[AlmostAnMD]

Or, replace docs with NPs, as my last hospital did (after I left).

I see that as the intermediary step. My wife works in medical device development and has an "in" about a lot of biomedical research, which without saying much more is half the reason I'm somewhat confident the moment they can figure this out, the moment they do it.

Midlevels will be involved for sure. Did you know healthcare regulations that essentially govern what AI could do were written 40 years ago, before it was even conceived as a thing? There are remarkably ~very~ few regulatory barriers if someone comes up with a good AI model to replace you.

The main one is is from the FDA, which clearly states that "all diagnostic tests must be interpreted by a clinician." This is so vague it can be extrapolated to a program that interviews a patient, possibly even does a procedure (much further down road), comes up with a plan and discharges or admits the patient. All it takes to fall into compliance is an NP that reviews the recommendation--the test was interpreted.

That's where I see the role of NP's lol

 

[The Knife & Gun Club]

I've seen every hospitalist mention this. What makes it harder? The accepting hospital doesn't really care if they're in the ED or admitted from my experience. Is it because the hospitalist may be the one having to make the various calls?

Once a patient has an admission order it’s no longer an ED to ED transfer, so if “tertiary hospital” doesn’t have beds (and guess what they never have beds) the patient can sit waiting for hours to days.

When I’m covering our little hospital I’ve been burned a couple of times putting admit orders in quick to help out the ED docs, only to find the patient actually needs X specialist that we don’t have (usually NSGY or CT surg). Then I’m stuck managing a brain bleed in a tiny hospital with limited capabilities for advanced neuro interventions, trying to keep someone from herniating for 24+ hours with manitol and prayer

 

[JacobMcCandles]

Patient doesn't have insurance, medical team accepts, admin declines transfer.

ER to ER: EMTALA violation.

Inpatient to inpatient: Meh, why would we eat the cost of your mistake?

I still don't believe this plays a factor as I've never had a potential receiving hospital ask what insurance a patient has and I suspect a hospitalist hasn't either.

Once a patient has an admission order it’s no longer an ED to ED transfer, so if “tertiary hospital” doesn’t have beds (and guess what they never have beds) the patient can sit waiting for hours to days.

When I’m covering our little hospital I’ve been burned a couple of times putting admit orders in quick to help out the ED docs, only to find the patient actually needs X specialist that we don’t have (usually NSGY or CT surg). Then I’m stuck managing a brain bleed in a tiny hospital with limited capabilities for advanced neuro interventions, trying to keep someone from herniating for 24+ hours with manitol and prayer

This still doesn't explain why it would be more difficult for a hospitalist to transfer a patient compared to the ED doc. In your situation, the patient would just be sitting in the ED instead of admitted. The receiving hospitals either have beds or they don't.

So far the answers have pretty much confirmed my suspicion that it seems to be that the hospitalists would rather the ED doc do the leg work and that the process is basically the same and the only difference is who is doing it.

 

[JacobMcCandles]

Because transferring patients inpatient to inpatient is a disaster that takes forever. I've gotten front row seats several times to watching people deteriorate and expire over days because multiple tertiary centers refused to accept the patient. We can't just throw an EMTALA violation around when an inpatient to inpatient transfer is refused.

Also the window for "patient clearly needs subspecialist care" and "patient is too sick to move" can be extremely small. Once the patient becomes too sick to transfer everyone is going to be asking, "Why did we accept this time bomb in the first place?"

Instead of sitting in an inpatient bed they just sit in the ED and do the same thing.

 

[southerndoc]

Patient doesn't have insurance, medical team accepts, admin declines transfer.

ER to ER: EMTALA violation.

Inpatient to inpatient: Meh, why would we eat the cost of your mistake?

EMTALA usually doesn't apply to patients admitted. Observation status, however, is still subject to EMTALA. If the patient was admitted for stabilizing treatment, and has not been stabilized, then EMTALA may apply.

One thing people don't realize is a hospital who transfers a patient when they have the capability to stabilize/treat the patient is also an EMTALA violation. In the OP's three cases, all three of those likely would meet EMTALA violations for transferring a patient unnecessarily unless the admitting hospitalist has exclusions on their privileges to not be able to treat those types of cases he/she is refusing to admit.

 

[Siggy]

EMTALA usually doesn't apply to patients admitted. Observation status, however, is still subject to EMTALA. If the patient was admitted for stabilizing treatment, and has not been stabilized, then EMTALA may apply.

How many observation patients do you admit to the ICU on average per year?

 

[Siggy]

I still don't believe this plays a factor as I've never had a potential receiving hospital ask what insurance a patient has and I suspect a hospitalist hasn't either.

For the inpatient side case management handles sending over the clinical data. It’s going to take a lot to convince me that case management isn’t sending insurance info AND admin rejection isn’t insurance based.

 

[JacobMcCandles]

For the inpatient side case management handles sending over the clinical data. It’s going to take a lot to convince me that case management isn’t sending insurance info AND admin rejection isn’t insurance based.

Of course they get a face sheet. I guess we’ll disagree because it’d take a lot to convince me that hospitalists are getting told no solely because of insurance status if they’ve got a bed. In my experience, the transfer line typically looks to see if they even have a bed before really getting much information. If they do have a bed it’s a go. If not, then I move on to a different hospital. You’re saying that the transfer team is being trained to collect insurance information and make the decision to accept the transfer based on insurance status? Big, if true.

I’d still like to hear from a hospitalist on why it’s harder because so far the only reason seems to be it’s thought they won’t accept patients based on insurance status. Every time I’ve been told this it’s before the hospitalist would even know the patients insurance status.

 

[Arcan57]

I see that as the intermediary step. My wife works in medical device development and has an "in" about a lot of biomedical research, which without saying much more is half the reason I'm somewhat confident the moment they can figure this out, the moment they do it.

Midlevels will be involved for sure. Did you know healthcare regulations that essentially govern what AI could do were written 40 years ago, before it was even conceived as a thing? There are remarkably ~very~ few regulatory barriers if someone comes up with a good AI model to replace you.

The main one is is from the FDA, which clearly states that "all diagnostic tests must be interpreted by a clinician." This is so vague it can be extrapolated to a program that interviews a patient, possibly even does a procedure (much further down road), comes up with a plan and discharges or admits the patient. All it takes to fall into compliance is an NP that reviews the recommendation--the test was interpreted.

That's where I see the role of NP's lol

What does the rest of society look like in your scenario? Being an emergency physician requires emotional intelligence, extrapolation from incomplete data, making decisions with multiple competing and undefined risk/benefit ratios, procedural skills, and team leadership. If AI can take over and do the job well, I'd argue that there isn't much in the cognitive realm that we would need humans for. AI is coming for us is a weird take when it would sweep through so many othee sectors and jobs first.

 

[AlmostAnMD]

What does the rest of society look like in your scenario? Being an emergency physician requires emotional intelligence, extrapolation from incomplete data, making decisions with multiple competing and undefined risk/benefit ratios, procedural skills, and team leadership. If AI can take over and do the job well, I'd argue that there isn't much in the cognitive realm that we would need humans for. AI is coming for us is a weird take when it would sweep through so many othee sectors and jobs first.

My real answer circles back to Andrew yang's answer to the same question. We are a society of capitalism. As long as there is a cheaper way to do things, that's how things will be done.

My local white castle no longer has people to take our orders. All ai. They are also testing flippy in our market, a burger flipper that also makes fries. Staffing by humans slowly being reduced. The same technology is being tested for picking fruits in the field to replace migrant workers.

Not saying it bodes well for most, but its inargubly cheaper, and as long as it's cheaper and no guardrails are in place much of society will end up on some sort of welfare. That's the basis of yang's universal basic income.

At the time even I thought it was strange to say that. Yet, job by job....

EDIT: more of an FYI. When I was looking for advisor jobs i came across a listing that I wish I had saved. They were looking for an experienced advisor to develop AI software for advisors. Probably wouldn't replace them entirely but reduce the workforce considerably by streamlining an obfuscating process

 

[Siggy]

Of course they get a face sheet. I guess we’ll disagree because it’d take a lot to convince me that hospitalists are getting told no solely because of insurance status if they’ve got a bed. In my experience, the transfer line typically looks to see if they even have a bed before really getting much information. If they do have a bed it’s a go. If not, then I move on to a different hospital. You’re saying that the transfer team is being trained to collect insurance information and make the decision to accept the transfer based on insurance status? Big, if true.

I’d still like to hear from a hospitalist on why it’s harder because so far the only reason seems to be it’s thought they won’t accept patients based on insurance status. Every time I’ve been told this it’s before the hospitalist would even know the patients insurance status.

Then why are they having me call report to multiple services? If it's "we don't have room" then why aren't they saying, "We don't have room" instead of "administration has reviewed the case accepted by the intensivist team and the specialist team and has declined the transfer"? I've certainly had patients accepted and then had to wait a day or 2 for a bed to actually be assigned. So why not that? They're clearly capable of accepting a transfer when no bed is immediately available.

There's a reason I think that my county needs to withdraw funding from the county hospital system. Don't be a tertiary safety net hospital system and constantly refuse transfers. What the heck am I going to do with an acute liver failure patient and no hepatology? Hopes and prayers? Why do I have to watch a nec fasc patient die after 2 separate surgical teams recommend transfer only to have the county hospital take 4 hours to tell me "no" and no reason? Mean while the much maligned HCA facility (multiple residencies, a level 2 trauma center and burn center) takes just about everyone.

 

[JacobMcCandles]

Then why are they having me call report to multiple services? If it's "we don't have room" then why aren't they saying, "We don't have room" instead of "administration has reviewed the case accepted by the intensivist team and the specialist team and has declined the transfer"? I've certainly had patients accepted and then had to wait a day or 2 for a bed to actually be assigned. So why not that? They're clearly capable of accepting a transfer when no bed is immediately available.

There's a reason I think that my county needs to withdraw funding from the county hospital system. Don't be a tertiary safety net hospital system and constantly refuse transfers. What the heck am I going to do with an acute liver failure patient and no hepatology? Hopes and prayers? Why do I have to watch an nec fasc patient die after 2 separate surgical teams recommend transfer only to have the county hospital take 4 hours to tell me "no" and no reason? Mean while the much maligned HCA facility (multiple residencies, a level 2 trauma center and burn center) takes just about everyone.

Are you a hospitalist? Have you honestly been told that administration has refused the transfer? Them having you talk with multiple services and then saying administration refuses the transfer makes no logical sense. If insurance is what they base their decision on wouldn’t that be the first thing they look at? And, what administrator is reviewing transfers 24/7 in real time? I’ve never heard of that happening in real life. You should name the hospital because I’d think there’d be a big expose if they had capabilities your hospital didn’t have, they had space available, they had an accepting physician, and then administration declined the transfer.

It’s not uncommon for a patient to be accepted pending a bed because nurse staffing constantly changes. The same thing happens to us in the ED…”we accept the patient but aren’t sure when we’ll have that bed”.

That’s been my experience with HCA. They basically have an auto-accept policy. A for profit hospital system known to be ruthless accepts basically everyone. This makes it much less likely that other hospitals aren’t accepting transfers solely because of a patient’s insurance.

 

[Arcan57]

My real answer circles back to Andrew yang's answer to the same question. We are a society of capitalism. As long as there is a cheaper way to do things, that's how things will be done.

My local white castle no longer has people to take our orders. All ai. They are also testing flippy in our market, a burger flipper that also makes fries. Staffing by humans slowly being reduced. The same technology is being tested for picking fruits in the field to replace migrant workers.

Not saying it bodes well for most, but its inargubly cheaper, and as long as it's cheaper and no guardrails are in place much of society will end up on some sort of welfare. That's the basis of yang's universal basic income.

At the time even I thought it was strange to say that. Yet, job by job....

EDIT: more of an FYI. When I was looking for advisor jobs i came across a listing that I wish I had saved. They were looking for an experienced advisor to develop AI software for advisors. Probably wouldn't replace them entirely but reduce the workforce considerably by streamlining an obfuscating process

It’s weird that capitalism says you have to destroy society and we go along with that like it’s inevitable?

 

[sloh]

The very effing moment AI can replace EM docs your 400ish salary is going to look very lucrative to make disappear for a software package. The only reason, the only reason, it hasn't happened yet, is the technology isn't there. That trigger gets pulled the moment the gun is loaded.

I think the moment AI can actually replace EM docs is going to be quite a bit in the horizon that anyone reading this thread doesn’t really need to worry about it. Mid level threat has and will continue to affect the job market and income but probably not AI to any reasonable degree

 

[Siggy]

Are you a hospitalist? Have you honestly been told that administration has refused the transfer? Them having you talk with multiple services and then saying administration refuses the transfer makes no logical sense. If insurance is what they base their decision on wouldn’t that be the first thing they look at? And, what administrator is reviewing transfers 24/7 in real time? I’ve never heard of that happening in real life. You should name the hospital because I’d think there’d be a big expose if they had capabilities your hospital didn’t have, they had space available, they had an accepting physician, and then administration declined the transfer.

It’s not uncommon for a patient to be accepted pending a bed because nurse staffing constantly changes. The same thing happens to us in the ED…”we accept the patient but aren’t sure when we’ll have that bed”.

That’s been my experience with HCA. They basically have an auto-accept policy. A for profit hospital system known to be ruthless accepts basically everyone. This makes it much less likely that other hospitals aren’t accepting transfers solely because of a patient’s insurance.

I’m an intensivist and yes, I’ve been told multiple times that the county hospital’s administrators have refused the transfer, normally hours after the specialist services have accepted the patient.

Jackson Memorial Hospital in Miami. Seriously, the county should pull funding if they aren’t going to act like the safety net tertiary center they claim to be.

 

[southerndoc]

How many observation patients do you admit to the ICU on average per year?

That wasn't the point of my reply. None of the patients mentioned in the OP's post seem to imply need for ICU-level care.

 

[JacobMcCandles]

I’m an intensivist and yes, I’ve been told multiple times that the county hospital’s administrators have refused the transfer, normally hours after the specialist services have accepted the patient.

Jackson Memorial Hospital in Miami. Seriously, the county should pull funding if they aren’t going to act like the safety net tertiary center they claim to be.

I agree that they should be investigating if what you’re saying is happening. This seems to be an issue at that one hospital and you confirm other hospital systems readily accept the patients. I suspect the ED would run into the same issues with Jackson.

Regardless, that still doesn’t broadly explain why hospitalists say it’s harder to transfer an admitted patient. My suspicion is that it takes basically the same amount of work that they just don’t want do, which I understand, because I’d prefer not to do something if I could get someone else to do it.

 

[southerndoc]

I’m an intensivist and yes, I’ve been told multiple times that the county hospital’s administrators have refused the transfer, normally hours after the specialist services have accepted the patient.

Jackson Memorial Hospital in Miami. Seriously, the county should pull funding if they aren’t going to act like the safety net tertiary center they claim to be.

An administrator can only decline a transfer to come at that present time based on capacity issues. If the hospital has no room for the patient wherein it would compromise care of current patients, then yes, any hospital representative can decline the transfer.

It could be interpreted as an EMTALA violation if patient demographics are sent before a determination of transfer is made. If the transfer is accepted, demographic information is subsequently sent, and then the hospital declines the transfer after receipt of demographics (including insurance information), then that could be considered an EMTALA violation. It would depend on the circumstances.

The OP's examples of things that can be handled at a local facility, but whose hospitalist is insisting on transferring, is why a lot of tertiary care facilities are overwhelmed and cannot accept the things that truly need to be accepted. No, we have no room to take your patient needing ECMO if the hospitalist is insisting that a DKA be transferred because of an AKI needing a nephrology consult with a creatinine of 2.5. Likewise, we can't accept your stroke transfer needing intervention because we filled all our beds with strokes that got alteplase/retavase just because your hospital isn't comfortable admitting them "just in case they develop a bleed."

 

[southerndoc]

I agree that they should be investigating if what you’re saying is happening. This seems to be an issue at that one hospital and you confirm other hospital systems readily accept the patients. I suspect the ED would run into the same issues with Jackson.

Regardless, that still doesn’t broadly explain why hospitalists say it’s harder to transfer an admitted patient. My suspicion is that it takes basically the same amount of work that they just don’t want do, which I understand, because I’d prefer not to do something if I could get someone else to do it.

Transferring an admitted patient is more challenging because EMTALA usually doesn't apply and the patient has to go to an available bed (as opposed to ED to ED; the admitted patient cannot go from floor to ED due to regulatory issues). We make exceptions for patients needing surgical intervention and just deal with it. We try to do what's best for the patient. Have an admitted patient on a blood thinner who falls, hits his head, and has a head bleed needing surgery? Yeah, we'll take that to the ER as a bouncing pad to go straight to OR. The last thing I want is for some patient to be dying because they can't get treatment. Now if we're holding 75 admissions and do not have capacity to care for the patients we have in our own department, then no, we don't have ability to accommodate that patient.