Do your hospital sites let residents discuss whether patients warrant admision with the ED?

[efle]

At my current hospital site all the residents are explicitly forbidden from any kind of pushback against ED admits. This leads to some pretty absurd stuff - for example I recently admitted a patient in the ED who was already improved to baseline s/p IVF, just to be told to write their discharge about an hour later when the attending saw them at the floor. Another example would be a LOL in NAD denied at their usual hospital because they "dont accept admits for placement"...admitted here. Multiple admits for ACS ruleout this week with negative trops, normal EKG and no cardiac history but still having their "weird chest feeling" after GERD treatment.

At the other hospitals I've rotated through theres usually some ability for residents to push back on this kind of thing to stop the unwarranted admission in the first place - what's your experience been like? Anyone else out there with a strict policy to accept any and all admits?

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[Clean7795]

If there is appropriate workup the residents must take the consult/admission. ER is staffed 24/7 by attendings whereas most other services have residents/fellows, meaning ER will win those fights. The only situation where we can give pushback is if it wasn't appropriately worked up (meaning that the patient may need to go to surgery or ICU instead).

Medicine attendings get paid for the admission/consult so you don't really have anyone to back you up if the ER attending gets aggressive unfortunately. Surgery attendings are more likely to actually have some bite because they don't want to waste beds that could go to surgical patients instead.

 

[chessknt]

It is a bad habit to pick up to fight admissions. Admissions generate money, rejecting them pisses off the Ed docs and doesn’t make money. When you go in to practice if you fight admissions you will not be popular.

 

[Osteoth]

I’m at a community shop which has historically been staffed by traditionalist IM people (inpatient + outpatient) so we have a lot of ability to push back admissions because the other specialties are scared of our attendings.

I have successfully punted on an ED attending and made the department chair of surgery (aka his resident team) admit their own patients.

YMMV but IM isn’t and does not have to be as castrated as the ivory tower makes you believe.

 

[efle]

I was wondering how the billing worked on that first example - does any H&P bill the same whether the person gets 2 hours of mIVF or 24 hours of busy workup?

 

[chessknt]

I was wondering how the billing worked on that first example - does any H&P bill the same whether the person gets 2 hours of mIVF or 24 hours of busy workup?

There is a code for admit and discharge in the same day. You can bill by time or complexity.

 

[DrMetal]

At my current hospital site all the residents are explicitly forbidden from any kind of pushback against ED admits.

It's the way of the real world. There's no pushing back. Some systems give the authority to admit solely to the ED. I actually like this, b/c then they get heat if they fill up the hospital with crap (and especially the uninsured, which the hospital has to eat). Paradoxically, it actually results in fewer admissions.

 

[NewYorkDoctors]

As a resident , just think of a bogus admission as an easy admission that counts to your ACGME admissions cap and also your team cap. If you are in night admission team , think of it as a quick HP so you can catch a break .

 

[efle]

As a resident , just think of a bogus admission as an easy admission that counts to your ACGME admissions cap and also your team cap. If you are in night admission team , think of it as a quick HP so you can catch a break .

Yea its actually not too bad to admit the little old ladies with chronic deconditioning for placement. But it's pretty annoying being on the wards teams capped with 9-10 patients all the time and multiple discharges every day because of it

 

[NewYorkDoctors]

Yea its actually not too bad to admit the little old ladies with chronic deconditioning for placement. But it's pretty annoying being on the wards teams capped with 9-10 patients all the time and multiple discharges every day because of it

True. But would you rather have a team full of decompensated COPD, CHF, CKD/ESRD, cirrhosis, cardiorenal, hepatorenal, pulmonary-renal, no family support, difficult placement issue, or patient without capacity and family is not practicing appropriate substituted judgment by demanding "everything to be done?"

Usually if one wants to see the super interesting and serious cases all the time like oh i dont know.... platelets of 1 ... TTP .. new presentation... or somethin along those lines, one usually subspecializes.

 

[NotAProgDirector]

We have a dedicated PGY-3 resident who in charge of all triage. We have a great working relationship with our ED. Our hospital is always 100% full, so there's no room for pointless admissions. The system works well, if there's disagreement between the ED and IM residents, then the faculty discuss and make a decision -- which is rare.

 

[gutonc]

We have a dedicated PGY-3 resident who in charge of all triage. We have a great working relationship with our ED. Our hospital is always 100% full, so there's no room for pointless admissions. The system works well, if there's disagreement between the ED and IM residents, then the faculty discuss and make a decision -- which is rare.

This is how it was where I went to med school and I think it's a good system. The "admitting resident" was down in the ED 24/7 and medicine admits went through them for evaluation. They were usually brought in early on when a patient looked like they'd need admission and it took most of that pressure/pushback out of the equation.

In my residency, we had no such thing, and as such, a lot of the time, the appropriateness of the admission came down to the attending in the ED. Some were great, some were...not.

 

[collegestud2013]

It's often easier for an ED attending to admit than discharge, and they take on a lot less malpractice liability when they admit than discharge (a full time ED doc probably sees 5,000 to 10,000 patient encounters per year so even missing something 1% of the time means they may in theory be up to 50-100 malpractice lawsuits in just a year). So when there's any gray area, they'll often try to admit unless there are specific policies at your place to limit otherwise. B.S. admissions are definitely frustrating as as a resident, but as attending, as long as your job includes an RVU bonus component they could potentially be easy money.

 

[Chemist0157]

Where I trained, there was a third year IM resident taking calls from EM residents and attendings for admission. Most of it was straightforward. The expectation was that they would work it out if the IM resident did not think patient warranted admission. The resident could escalate up to an attending, but I would say most of the time, the EM folks would get their way more often than not.

In the real world, there is going to be a preference to "better safe than sorry" so there will be some low yield admissions.

The ED also has to put up with every outpatient doctor just sending patients to the ED based on phone calls, inbox messages, or abnormal labs so consider it the "circle of avoiding liability."

 

[Osteoth]

Where I tried, there was a third year IM resident taking calls from EM residents and attendings for admission. Most of it was straightforward. The expectation was that they would work it out if the IM resident did not think patient warranted admission. The resident could escalate up to an attending, but I would say most of the time, the EM folks would get their way more often than not.

In the real world, there is going to be a preference to "better safe than sorry" so there will be some low yield admissions.

The ED also has to put up with every outpatient doctor just sending patients to the ED based on phone calls, inbox messages, or abnormal labs so consider it the "circle of avoiding liability."

We have this where I’m at, and having done this the ******** in the ED just lie half the time to get their pts in. Satting 85%? Yeah sure believe it when I see it. Encephalopathic? Watching tv chatting on the phone. Etc

 

[Chemist0157]

We have this where I’m at, and having done this the ******** in the ED just lie half the time to get their pts in. Satting 85%? Yeah sure believe it when I see it. Encephalopathic? Watching tv chatting on the phone. Etc

The third year resident would be in an office close to the ED so he or she could always walk out and take a look so it was harder to pull that kind of stuff.

 

[WhiteCoatWonder]

yeah.

we used to have 2 medicine PGY-2s on 7p-7a doing ED admissions to the resident teams. no admission caps. no oversight. it. was. terrible. the relationship with the ED attendings was mostly contentious and they had most of the playing power bc they had attendings in-house overnight and we did not. plus they always greased the wheels to even get on our triage list (see @Osteoth's comment). so, although there wasnt a "no pushback" rule, as residents, we just said screw it and admitted whomever, bc fighting with the ED took up infinitely more time than just admitting that placement or ACS r/o w/ neg trops x3 or positive cell phone sign person. aside from being terrible medical practice and a waste of resources to admit the unadmittables, the problem is that we'd (of course) hear about it in the morning from the medicine attendings whose teams we'd admitted those patients to. not all, but most. a lot of them trained under those same atrocious conditions, so they maintained a little compassion for our position.

anyway, its not like that anymore, we have like 3 shifts of triage attendings a day that screen PALs calls and ED requests to admit. for teaching purposes, they still have the residents "triage" the patients for admission but the IM/EM war has reached a detente.

 

[efle]

Where I trained, there was a third year IM resident taking calls from EM residents and attendings for admission. Most of it was straightforward. The expectation was that they would work it out if the IM resident did not think patient warranted admission. The resident could escalate up to an attending, but I would say most of the time, the EM folks would get their way more often than not.

We actually have a similar system at our site - a PGY2-3 takes the call from the ED before sending an intern to see the patient - but they're all told never to question an admit. Their main site does allow them to try and refuse unwarranted admits, so it's a stark contrast, I've had many admits they straight up laugh about while they tell me the story. I guess if it's easy money for the attendings/hospital I understand now why they have the no pushback policy - otherwise they'd get a lot of pushback from us H&P note monkeys.

 

[collegestud2013]

We actually have a similar system at our site - a PGY2-3 takes the call from the ED before sending an intern to see the patient - but they're all told never to question an admit. Their main site does allow them to try and refuse unwarranted admits, so it's a stark contrast, I've had many admits they straight up laugh about while they tell me the story. I guess if it's easy money for the attendings/hospital I understand now why they have the no pushback policy - otherwise they'd get a lot of pushback from us H&P note monkeys.

Problem is not all ED admissions are profitable for both the hospital and the physicians. It's only profitable for the hospital if the patient has at least decent insurance and they can be discharged very quickly. If the patient doesn't have insurance, hospital is probably going to take a loss on it so it's even worse if it's for a patient that didn't need to be admitted (major problem for hospitals located in areas with high rate of uninsured population).

Even if they do have insurance, if the patient is there mainly for a dispo issue and the length of stay ends up being excessively long to place them and the admitting diagnoses are low billing diagnosis (which is often the case for patients that don't really have a medical reason to be admitted), the physicians can make easy money with their E&M by writing almost the same note everyday, but the hospital (which is paid by DRGs) will probably still take a loss on admission. The issue is even worse when the hospital is near full and you don't have the staffing resources to care for the patients that are actually sick.

 

[Osteoth]

Problem is not all ED admissions are profitable for both the hospital and the physicians. It's only profitable for the hospital if the patient has at least decent insurance and they can be discharged very quickly. If the patient doesn't have insurance, hospital is probably going to take a loss on it so it's even worse if it's for a patient that didn't need to be admitted (major problem for hospitals located in areas with high rate of uninsured population).

Even if they do have insurance, if the patient is there mainly for a dispo issue and the length of stay ends up being excessively long to place them and the admitting diagnoses are low billing diagnosis (which is often the case for patients that don't really have a medical reason to be admitted), the physicians can make easy money with their E&M by writing almost the same note everyday, but the hospital (which is paid by DRGs) will probably still take a loss on admission. The issue is even worse when the hospital is near full and you don't have the staffing resources to care for the patients that are actually sick.

So I get the DRG vs EM coding thing but does this affect how Hospitalist are paid? Like on a group level how are most contracts with hospitals worded? Like percent of E/M or some other way?

 

[collegestud2013]

So I get the DRG vs EM coding thing but does this affect how Hospitalist are paid? Like on a group level how are most contracts with hospitals worded? Like percent of E/M or some other way?

DRG refers to the lump sum the hospital gets paid for an admission and is largely fixed at time of admission based on admitting diagnoses, and the amount doesn't usually change if the patient stays for 1 day or 50 days. It's to cover the hospital's operating expenses for admitting the patient (eg nursing, facilities, supplies, medications, etc...) Anything left over will be profit for the hospital.

E/M refers to professional fees billed by the individual physicians for their services and is separate, and translates to RVUs. For example, a typical Level 3 Inpatient H&P (99223) is currently worth 3.86 wRVUs as assigned by CMS. Obviously the more you admit the higher your RVUs should be, and you would be paid on the amount per wRVU as specified in your contract. For example if your contract specifies that you $5 per wRVU for all of your wRVUs then that admission would get you an extra $19.30 on top of your base salary.

 

[aafisahar]

easier to just admit than to argue and fight about it. the last time i fought an admit was like pgy-2 and it took me like 2.5 hours arguing. any half-decent resident can bang an admit out in <1 hour. now when I moonlight, I can bang an admit out in like 20-30 minutes (notes, orders, interview).

 

[Osteoth]

DRG refers to the lump sum the hospital gets paid for an admission and is largely fixed at time of admission based on admitting diagnoses, and the amount doesn't usually change if the patient stays for 1 day or 50 days. It's to cover the hospital's operating expenses for admitting the patient (eg nursing, facilities, supplies, medications, etc...) Anything left over will be profit for the hospital.

E/M refers to professional fees billed by the individual physicians for their services and is separate, and translates to RVUs. For example, a typical Level 3 Inpatient H&P (99223) is currently worth 3.86 wRVUs as assigned by CMS. Obviously the more you admit the higher your RVUs should be, and you would be paid on the amount per wRVU as specified in your contract. For example if your contract specifies that you $5 per wRVU for all of your wRVUs then that admission would get you an extra $19.30 on top of your base salary.

So I guess my question is what is a fair way to structure hospitalist wRVU bonuses? I know that hospitalists are often subsidized by hospitals for throughput reasons, but from a group standpoint what is a fair amount, per RVU, to expect in compensation as a hospitalist?

I have seen numbers like $5 or $10 per RVU above an arbitrary amount but considering the RVU conversion factor is $32, shouldn't hospitalists demand more like $15?

 

[chessknt]

So I guess my question is what is a fair way to structure hospitalist wRVU bonuses? I know that hospitalists are often subsidized by hospitals for throughput reasons, but from a group standpoint what is a fair amount, per RVU, to expect in compensation as a hospitalist?

I have seen numbers like $5 or $10 per RVU above an arbitrary amount but considering the RVU conversion factor is $32, shouldn't hospitalists demand more like $15?

There is no one answer to this question. It depends on the payor mix to some degree but also how much the hospital is being subsidized and how hard it is to recruit. In an ideal world if you are truly 'being subsidized' by the hospital they should openly agree to 85-90% collections for all billing + covering medmal and maybe other benefits with no other stipend but you would want to know what payor mix you are getting before agreeing to that.

More commonly it is either fixed with no productivity incentive or a low bonus that has no floor (eg $5/wrvu) or a higher bonus that starts at a median level (eg 35/wrvu > MGMA 50%). Don't kid yourself too much though--if the hospital is losing money on you then you are going to get replaced as soon as possible (with a midlevel or a teleHospitalist or even a trained golden retriever if they can get away with it) because hospitals are not about providing care for patients, they exist to generate money for shareholders (or C suite executives if 'non-profit'). The pandemic has absolutely shown us that.

 

[Osteoth]

There is no one answer to this question. It depends on the payor mix to some degree but also how much the hospital is being subsidized and how hard it is to recruit. In an ideal world if you are truly 'being subsidized' by the hospital they should openly agree to 85-90% collections for all billing + covering medmal and maybe other benefits with no other stipend but you would want to know what payor mix you are getting before agreeing to that.

More commonly it is either fixed with no productivity incentive or a low bonus that has no floor (eg $5/wrvu) or a higher bonus that starts at a median level (eg 35/wrvu > MGMA 50%). Don't kid yourself too much though--if the hospital is losing money on you then you are going to get replaced as soon as possible (with a midlevel or a teleHospitalist or even a trained golden retriever if they can get away with it) because hospitals are not about providing care for patients, they exist to generate money for shareholders (or C suite executives if 'non-profit'). The pandemic has absolutely shown us that.

So payer mix matter because the conversion factor is for Medicare, private pays better and Medicaid pays worse.

Doesn’t every hospital lose money on their hospitalists though? I read the average subsidy per hospitalist nationwide is like $100k/yr

 

[collegestud2013]

So payer mix matter because the conversion factor is for Medicare, private pays better and Medicaid pays worse.

Doesn’t every hospital lose money on their hospitalists though? I read the average subsidy per hospitalist nationwide is like $100k/yr

Depends on how much they're paying the hospitalists, what patient volumes they're seeing, and the patient payer mix. But $100k subsidy per hospitalist per year seems a bit high. The Medicare rate for codes commonly used by hospitalists pays about $52 per wRVU in 2021 so that's a good place to start as an average at most places. Private insurance usually pays higher per wRVU and Medicaid pays lower. And they probably won't get much of anything if the patient is uninsured. For example, In the southeast states, there tends to be a much higher rate of uninsured patients (probably 10-15%) while in the Northeast it's only like 3-4% so you'll probably have to see a bit higher patient volumes in the Southeast to bring in the same amount or require a higher subsidy from the hospital (unless you work in a facility such as LTAC or rehab where everyone has to have insurance to get admitted there).

And the "fair" amount for an RVU bonus depends on the patient volumes you're seeing. There's usually an approximate break-even volume of patients; above that they profit off you and below that their are losing money. But since most hospitalists get a base salary, the RVU bonus is almost always below $52 since they need to use some of money to pay your base salary. And if there are midlevels helping, some of of the RVU money that they bill under you has to cover their pay as well (and they usually get paid 1/3 to 1/2 the rate per hour as the attendings).

 

[efle]

Problem is not all ED admissions are profitable for both the hospital and the physicians. It's only profitable for the hospital if the patient has at least decent insurance and they can be discharged very quickly. If the patient doesn't have insurance, hospital is probably going to take a loss on it so it's even worse if it's for a patient that didn't need to be admitted (major problem for hospitals located in areas with high rate of uninsured population).

Even if they do have insurance, if the patient is there mainly for a dispo issue and the length of stay ends up being excessively long to place them and the admitting diagnoses are low billing diagnosis (which is often the case for patients that don't really have a medical reason to be admitted), the physicians can make easy money with their E&M by writing almost the same note everyday, but the hospital (which is paid by DRGs) will probably still take a loss on admission. The issue is even worse when the hospital is near full and you don't have the staffing resources to care for the patients that are actually sick.

Very interesting, thanks for explaining. Suddenly a lot of things I witness as a resident make more sense. Low threshold for unnecessary diagnostic cards workup, cuz that's printing cash with a quick discharge after ACS is ruled out. Yet they never want to admit the sickle cell pain crises who will get nothing besides IV dilaudid for a week unless they have to. I feel like if I had a full picture of how cashflow in the hospital worked I'd end up too cynical to function.

 

[CCM-MD]

Depends on how much they're paying the hospitalists, what patient volumes they're seeing, and the patient payer mix. But $100k subsidy per hospitalist per year seems a bit high. The Medicare rate for codes commonly used by hospitalists pays about $52 per wRVU in 2021 so that's a good place to start as an average at most places. Private insurance usually pays higher per wRVU and Medicaid pays lower. And they probably won't get much of anything if the patient is uninsured. For example, In the southeast states, there tends to be a much higher rate of uninsured patients (probably 10-15%) while in the Northeast it's only like 3-4% so you'll probably have to see a bit higher patient volumes in the Southeast to bring in the same amount or require a higher subsidy from the hospital (unless you work in a facility such as LTAC or rehab where everyone has to have insurance to get admitted there).

And the "fair" amount for an RVU bonus depends on the patient volumes you're seeing. There's usually an approximate break-even volume of patients; above that they profit off you and below that their are losing money. But since most hospitalists get a base salary, the RVU bonus is almost always below $52 since they need to use some of money to pay your base salary. And if there are midlevels helping, some of of the RVU money that they bill under you has to cover their pay as well (and they usually get paid 1/3 to 1/2 the rate per hour as the attendings).

This is an old article. Adjusted for inflation, the avg subsidy is likely higher now.

 

[aafisahar]

View attachment 346514

This is an old article. Adjusted for inflation, the avg subsidy is likely higher now.

admin so dumb that this is the way they think

nevermind if no hospitalists = no hospital and hello tons of violations, fines, fees, and possible shutdown. admin must push the narrative that hospitalists cOsT tHeM mOnEy.

 

[CCM-MD]

admin so dumb that this is the way they think

nevermind if no hospitalists = no hospital and hello tons of violations, fines, fees, and possible shutdown. admin must push the narrative that hospitalists cOsT tHeM mOnEy.

I dislike admin as much as anyone but 300k+ benefits going to each hospitalist is not coming from the 20 patients they see that are partially uninsured. There is an out of pocket cost to having hospitalists, nocturnists are an even higher cost because of even less billable activity at night. And hospitals could function with internists rounding and leaving as they did historically. It obviously makes sense for administration to pay for hospitalists but thinking that admin is making money off hospitalists is a lie - they are a cost.

 

[aafisahar]

I dislike admin as much as anyone but 300k+ benefits going to each hospitalist is not coming from the 20 patients they see that are partially uninsured. There is an out of pocket cost to having hospitalists, nocturnists are an even higher cost because of even less billable activity at night. And hospitals could function with internists rounding and leaving as they did historically. It obviously makes sense for administration to pay for hospitalists but thinking that admin is making money off hospitalists is a lie - they are a cost.

it's not a cost, just like electricity isn't a cost. literally cannot have a modern hospital run without hospitalists.

most hospitals are chartered with a certificate of need and there are expectations to provide care for patients. if hospitals stopped admitting people (which would technically save them money as most inpatients lose money), they could risk their charter and be forced to shutdown, jeopardizing all revenue.

i think we are saying the same thing, but I'm arguing that this isn't a cost but more of a necessity of doing business.

 

[CCM-MD]

it's not a cost, just like electricity isn't a cost. literally cannot have a modern hospital run without hospitalists.

most hospitals are chartered with a certificate of need and there are expectations to provide care for patients. if hospitals stopped admitting people (which would technically save them money as most inpatients lose money), they could risk their charter and be forced to shutdown, jeopardizing all revenue.

i think we are saying the same thing, but I'm arguing that this isn't a cost but more of a necessity of doing business.

Private internists can admit patients and do everyday where I work. No hospitalists involved.

Electricity isn’t a cost?! What’s this bill I pay a bill every month!

 

[efle]

Makes sense the general hospitalists aren't a revenue source themselves, it's all the business they refer to the surgeons/proceduralists and other specialists that the hospital makes most profits on, no?

 

[CCM-MD]

Makes sense the general hospitalists aren't a revenue source themselves, it's all the business they refer to the surgeons/proceduralists and other specialists that the hospital makes most profits on, no?

They add value by making the hospital efficient, being available in house the whole day, reducing length of stay, discharging faster etc. They aren’t really a referral source, that would be like calling the ER a referral source.

 

[Nocturnist]

At my current hospital site all the residents are explicitly forbidden from any kind of pushback against ED admits. This leads to some pretty absurd stuff - for example I recently admitted a patient in the ED who was already improved to baseline s/p IVF, just to be told to write their discharge about an hour later when the attending saw them at the floor. Another example would be a LOL in NAD denied at their usual hospital because they "dont accept admits for placement"...admitted here. Multiple admits for ACS ruleout this week with negative trops, normal EKG and no cardiac history but still having their "weird chest feeling" after GERD treatment.

At the other hospitals I've rotated through theres usually some ability for residents to push back on this kind of thing to stop the unwarranted admission in the first place - what's your experience been like? Anyone else out there with a strict policy to accept any and all admits?

I push back on at least a couple admits a week. I'll have to go see the admit and put in a consult note detailing why I'm comfortable sending them home and what the discharge plan will be. I'll discuss it with the ER and they'll do the discharge directly from the ED.

Generally speaking the ER attendings just care about dispo and covering their derriere, not to win any fights or keep scores. The paper trail shows they've recommended admission and the hospitalist didn't agree. Their hands are washed clean. It saves me a couple minutes on admit orders and documentation, I still get to bill for the consult, and the hospital keeps a bed open.

 

[CCM-MD]

I push back on at least a couple admits a week. I'll have to go see the admit and put in a consult note detailing why I'm comfortable sending them home and what the discharge plan will be. I'll discuss it with the ER and they'll do the discharge directly from the ED.

Generally speaking the ER attendings just care about dispo and covering their derriere, not to win any fights or keep scores. The paper trail shows they've recommended admission and the hospitalist didn't agree. Their hands are washed clean. It saves me a couple minutes on admit orders and documentation, I still get to bill for the consult, and the hospital keeps a bed open.

You're taking on a lot of solo liability if the discharged patient drops dead for any reason. Especially when EM physician feels like the patient should have been admitted.

 

[NITRAS]

You're taking on a lot of solo liability if the discharged patient drops dead for any reason. Especially when EM physician feels like the patient should have been admitted.

I try not to push back on much, but seriously, some of our ED docs haven’t cracked a guideline this millennium. These are the idiots teaching residents . . .. . .

Some of the my systems stuff is so screwed up. A clinic doctor or NP gets a call for “new onset” atrial fibrillation on an ekg drawn for no particular reason, who sends them to the ed. The ED doc draws some labs, which are normal, sees rate controlled atrial fibrillation, and calls me for admission.

The patient has had 2 encounters with doctors who have prescribed no medication or added anything to the patient’s care but adding charges.

 

[VA Hopeful Dr]

it's not a cost, just like electricity isn't a cost. literally cannot have a modern hospital run without hospitalists.

most hospitals are chartered with a certificate of need and there are expectations to provide care for patients. if hospitals stopped admitting people (which would technically save them money as most inpatients lose money), they could risk their charter and be forced to shutdown, jeopardizing all revenue.

i think we are saying the same thing, but I'm arguing that this isn't a cost but more of a necessity of doing business.

I think the phrase you're looking for is "cost of doing business".

 

[aafisahar]

I think the phrase you're looking for is "cost of doing business".

i purpsefully avoided that phrase because a cost of doing business means you will look to every avenue to cut that cost. Cutting costs with hospitalists doesn't save money.

 

[VA Hopeful Dr]

i purpsefully avoided that phrase because a cost of doing business means you will look to every avenue to cut that cost. Cutting costs with hospitalists doesn't save money.

Doesn't it?

If you cut hospitalist pay/benefits by 25%, you're saving money.

 

[Nocturnist]

You're taking on a lot of solo liability if the discharged patient drops dead for any reason. Especially when EM physician feels like the patient should have been admitted.

I suppose, but I'm talking about some pretty low hanging fruit. Uncomplicated divertics they gave one morphine to 8 hours ago and so now it's an admit for pain control, cellulitis that took 2 doses of keflex and now its outpt treatment failure, even low risk/non cardiac chest pains or copd that arent wheezing by the time I see them. Its no more liability than a same day admit and discharge, except its logistically simpler for me to drop a consult note and have the ED take care of the rest. The patient gets a full history and physical by a board certified internist, with a plan and return instructions. 6 years working 2 FTEs and knock on wood haven't been sued or had a bounce back yet.

 

[CCM-MD]

I suppose, but I'm talking about some pretty low hanging fruit. Uncomplicated divertics they gave one morphine to 8 hours ago and so now it's an admit for pain control, cellulitis that took 2 doses of keflex and now its outpt treatment failure, even low risk/non cardiac chest pains or copd that arent wheezing by the time I see them. Its no more liability than a same day admit and discharge, except its logistically simpler for me to drop a consult note and have the ED take care of the rest. The patient gets a full history and physical by a board certified internist, with a plan and return instructions. 6 years working 2 FTEs and knock on wood haven't been sued or had a bounce back yet.

Lawsuits are for bad outcomes, not bad medicine. It only takes 1 post discharge death that the ED wanted to admit. People die all the time, and even if its from an unrelated reason, it will be very easy to make it look like you're at fault. Physicians have been successfully sued for less. Discharging is high liability as is, add in another physician disagreeing with it and its just crazy.

The no seatbelt/helmet argument is a weak one: "I've been driving/riding for the last 6 years and never wear a seatbelt/helmet. I'm doing just fine."

 

[NITRAS]

Haven’t had a bounce back in 6 years?!!?

Our patient populations must be incredibly different.

 

[Neopolymath]

This is probably the dumbest part of the short time during TY year I'm on IM but honestly I prefer it. Yeah, I'll admit the purely surgical patient and get the quick work done so it counts toward an admission and the cap. That's way better than the alternative. Heck, the other day I admitted someone (aka surgery didn't want to write the H&P) for a patient with vonWD supposedly under the impression I would be managing that disease if nothing else but then the orders were already done by surgery. I didn't look a gift horse in the mouth. There is no point in arguing with the ED, attendings or subspecialists in training unless it will cleary harm the patient. IM is probably the best example of the waste of time that would be.

 

[NewYorkDoctors]

Very interesting, thanks for explaining. Suddenly a lot of things I witness as a resident make more sense. Low threshold for unnecessary diagnostic cards workup, cuz that's printing cash with a quick discharge after ACS is ruled out. Yet they never want to admit the sickle cell pain crises who will get nothing besides IV dilaudid for a week unless they have to. I feel like if I had a full picture of how cashflow in the hospital worked I'd end up too cynical to function.

It’s the medical industrial complex . It’s not medicine itself . It’s capitalism .

Consider opening your own private practice and waiving copays/coinsurance one day.

I mean you can only wink wink be generous like that if you have your own private practice.

 

[cardsperson]

Very interesting, thanks for explaining. Suddenly a lot of things I witness as a resident make more sense. Low threshold for unnecessary diagnostic cards workup, cuz that's printing cash with a quick discharge after ACS is ruled out. Yet they never want to admit the sickle cell pain crises who will get nothing besides IV dilaudid for a week unless they have to. I feel like if I had a full picture of how cashflow in the hospital worked I'd end up too cynical to function.

ACS can kill the patient and a missed MI is going to be a huge malpractice payout in the right patient. Sickle cell crisis doesn't kill anyone, and you could make a very strong argument that we harm patients by admitting them for IV opioids for an uncomplicated crisis, not to mention the complex psychosocial issues that these patients often have around narcotics given that they are on them since childhood. In African nations, which have far higher prevalence of sickle cell than the US, IV opioids are almost never used for sickle cell crises (even PO is generally not used).

 

[Nocturnist]

Lawsuits are for bad outcomes, not bad medicine. It only takes 1 post discharge death that the ED wanted to admit. People die all the time, and even if its from an unrelated reason, it will be very easy to make it look like you're at fault. Physicians have been successfully sued for less. Discharging is high liability as is, add in another physician disagreeing with it and its just crazy.

The no seatbelt/helmet argument is a weak one: "I've been driving/riding for the last 6 years and never wear a seatbelt/helmet. I'm doing just fine."

It only takes one insurance fraud claim on a patient that didnt meet admission criteria too?Cynicism and hyperbole aside- Respectully, that's just not true, and no its not that easy.

In the United States, the patient alleging medical malpractice must generally prove four elements or legal requirements to make out a successful claim of medical malpractice. These elements include: (1) the existence of a legal duty on the part of the doctor to provide care or treatment to the patient; (2) a breach of this duty by a failure of the treating doctor to adhere to the standards of the profession; (3) a causal relationship between such breach of duty and injury to the patient; and (4) the existence of damages that flow from the injury such that the legal system can provide redress.

Not only are lawsuits for a bad outcome and bad medicine- they explicitly need to prove I practiced bad medicine, AND that my bad medicine directly led to said bad outcome, AND that said bad outcome led to the damages. The bar in actuality is quite high.

I'm not practicing cowboy medicine.
I'm fully/competently evaluating the patient infront of me and coming to my own conclusion supported by standard of care, major societal guidelines, and good documentation (and of course, education and shared decisions making). If that divertic's pain is controlled after and oxy and they're eating- they go home. If that young healthy non cardiac chest pain with a negative mibi 4 months ago has a negative dimer, normal ekg and trops- I have no further urgent testing to offer them and no amount of time in the hospital will change that- home they go. The nonpurulent nonseptic cellulitis can keep their leg up and give keflex a couple days to work- go home, come back if you're not better.
Its not worse medicine or higher risk than discontinuing antibiotics and instead diuresing the volume overloaded patient they wanted to bring in for pneumonia.

You can say I'm driving without a seatbelt, I can equally at the opposite end of the cynicism spectrum say it's a little extra not getting in a car first without a seatbelt, helmet, fire resistany suit and scuba gear. But we all practice the medicine we're comfortable practicing. My practice is if a patient doesn't meet admission criteria when I see them, they go home. Nothing wrong with either approach.

 

[Nocturnist]

Haven’t had a bounce back in 6 years?!!?

Our patient populations must be incredibly different.

I'm an admitter not a rounder. I discharge very infrequently and a very select population I'm completely comfortable with doing so. Still, I'm not referring to 30 day any cause readmissions- I'm strictly referring to them popping up again on my census a few days later with a complication directly related to the issue I sent them home for. As far as I can recall- no, not to my knowledge.

 

[CCM-MD]

It only takes one insurance fraud claim on a patient that didnt meet admission criteria too?Cynicism and hyperbole aside- Respectully, that's just not true, and no its not that easy.

In the United States, the patient alleging medical malpractice must generally prove four elements or legal requirements to make out a successful claim of medical malpractice. These elements include: (1) the existence of a legal duty on the part of the doctor to provide care or treatment to the patient; (2) a breach of this duty by a failure of the treating doctor to adhere to the standards of the profession; (3) a causal relationship between such breach of duty and injury to the patient; and (4) the existence of damages that flow from the injury such that the legal system can provide redress.

Not only are lawsuits for a bad outcome and bad medicine- they explicitly need to prove I practiced bad medicine, AND that my bad medicine directly led to said bad outcome, AND that said bad outcome led to the damages. The bar in actuality is quite high.

I'm not practicing cowboy medicine.
I'm fully/competently evaluating the patient infront of me and coming to my own conclusion supported by standard of care, major societal guidelines, and good documentation (and of course, education and shared decisions making). If that divertic's pain is controlled after and oxy and they're eating- they go home. If that young healthy non cardiac chest pain with a negative mibi 4 months ago has a negative dimer, normal ekg and trops- I have no further urgent testing to offer them and no amount of time in the hospital will change that- home they go. The nonpurulent nonseptic cellulitis can keep their leg up and give keflex a couple days to work- go home, come back if you're not better.
Its not worse medicine or higher risk than discontinuing antibiotics and instead diuresing the volume overloaded patient they wanted to bring in for pneumonia.

You can say I'm driving without a seatbelt, I can equally at the opposite end of the cynicism spectrum say it's a little extra not getting in a car first without a seatbelt, helmet, fire resistany suit and scuba gear. But we all practice the medicine we're comfortable practicing. My practice is if a patient doesn't meet admission criteria when I see them, they go home. Nothing wrong with either approach.

Any physician who thinks they won't get sued because they "did everything right" needs to think again. As someone who does peer review and expert witness work, I can tell you that all that elaborate criteria doesn't need to be met. 99% of the time cases end in a settlement so there is very little "proving I practiced bad medicine".

Case: non-hemodynamically significant PE in a middle aged firefighter. Patient was admitted to telemetry, next day codes and dies. Patient was appropriately anti-coagulated and no one did anything wrong. Everyone was named, including the residents. It went on for 5 years before it was settled.

Patient dies after being discharged when another physician recommended to admit? Forget about the suit, just sign where they ask you to.

 

[BorntobeDO?]

View attachment 346514

This is an old article. Adjusted for inflation, the avg subsidy is likely higher now.

BS, they get all the facilities fees and subsidies. They arent subsidizing a hospitalist 130k a year, between the facility RVUs (not just wRVU) they are billing out like 2 million a year for average hospitalist. The whole '130k' subsidy is a BS accounting trick. We make money, not lose it.