Commentology: Improving Cost-Containment

Stephen J. Motew writes:

Surgical specialists practice under a slightly more regimented reimbursement model predominantly due to the global period payment for surgical procedures. The total care of the surgical patient for any procedure, including pre-op evaluation, the procedure itself, and all related care post-operatively including most complications is covered under a 90 day global pay period. This system has worked relatively well by containing costs to a specific 'disease' (or procedure) state. In addition, many surgical sub-specialties such as vascular surgery and oncologic surgery for example invest a large amount of time in overall disease-state management that may not even include a procedure. I believe this has allowed many surgeons to understand the concept of cost-containment and efficiency, disease management as well as outcomes-based practices.

A recent experience with a referral patient however, highlights the incredible gaps in cost-containment and disease management that can occur prior to surgical intervention. I have annotated each step in the process to demonstrate points where potential intervention may have occurred. I will leave it to the comments to discuss the reasons and realities of such a case!

An 85 y/o robust male had been seen by me over the past 3 years for an asymptomatic 4.8cm aortic aneurysm. The patient has previously had a CT scan showing that the aneurysm did not need repair, therefore the plan was to monitor every 6 months with ultrasound and consider repair only if significantly larger. [EHR/PM will schedule in reminder system, send reminder and letter to pt. automatically, follow-up test to be performed in certified vascular lab] Letters to this effect delineating plan was transcribed and sent to primary MD, but not sure if received or read. [EHR to enter this into portable PHR, transfer letter and note to primary MD electronically, confirm receipt available electronically].

Pt forgets to reschedule follow-up for ultrasound not sure if reminders sent. [Less likely with above reminder/scheduling system, alert shows failure of follow-up in specialist and primary MD e-mail] Pt reports to primary MD 18 months later on a Friday afternoon with vague mild abdominal pain, primary MD sends to local u/s facility, not a certified lab. [Poor access to accurate and quality controlled imaging] U/S suggests AAA now 5.8 cm. Although not symptomatic, primary MD very worried about this, has nurse tell patient to go to ED immediately [better education by specialists to primary MDs regarding disease process, accuracy of study questioned by using non-certified lab, defensive practice by MD/nurse causes immediate referral to high cost ED].

Pt admitted by hospitalist service, although recognize pt with minimal active process, re-orders tests including plain abdominal CT scan [PHR/EHR availability would allow review of current studies to avoid replication, knowledge of consulting MD would allow identification of specialty consultant familiar with plan to avoid unnecessary workup and ordering of correct CTAngiogram if needed]. Pt eventually seen by me as consultant in-house [additional E/M charge]. Pt sent home for follow-up in a few weeks with the HOPE that this process will not be repeated next week!

Unfortunately this scenario plays itself out almost daily, and at incredible cost, with the common failure being one of communication and to a lesser degree defensive medicine, and poor disease management. The bickering over HIT certification and complexity of 'meaningful use' may be distracting from the simplicity of basic systems that are be readily available now and in my opinion can contribute a first step to cost-containment. The identification of specialty disease management experts would keep unnecessary tests and hospitalizations to a minimum. Therefore, the primary impetus for health care cost containment must come from the physicians lest we lose the right to manage our patients to their best interest.

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4 replies »

  1. This case clearly shows that competent care can be undone by a non-compliant patient. It also illustrates that the use of some high tech equipment (the new fangled telephone) could have avoided the entire issue. Had the PCP simply called the vascular surgeon the admission might have been avoided. Of course, the current system provides no incentive for anything other than that which happened.

  2. The basic prblem was this robust patient was not taking responsibility for himself. If I tell you to do something and you don’t, it is your fault. Let the lawyers plow that.

  3. Seems like the basic problem was that no one was taking responsibility for managing the patient. This can happen with either paper or electronic records. If the original CT report with recommended follow-up is sent electronically to every MD the patient is seeing, there’s a good chance everyone will assume that someone else is taking handling it. The lawyers will have a field-day with this!

  4. I missed this comment wherever it first appeared, but this scenario sounds depressingly familiar, and the bracketed suggestions for improvement are dead on. As well as the EHR deficiencies, the scenario points out another weakness in our system – as I keep saying, if one wishes to shift more responsibility to primary care physicians, training of these physicians will have to change quite a bit so they can manage these issues better. Right now there is zero incentive not to cover butt (and go home on Friday afternoon) by sending the patient to the ER and letting them deal with it.

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