Medical Industry Regulations and Practical Care Challenges.

It's no secret that I'm an unabashed fan of GeriPal blog. And here's one reason why: an excerpt from today's post on care challenges for two individual patients that lets us layman in on the challenges the medical industry and regulations pose to patient-friendly, affordable, quality care:

A gentleman I see on housecalls with hospice has clearly stated his desire to not be hospitalized. With his level of frailty and the excellent palliation through hospice, this didn't seem to be an issue until his nephrostomy tube came out. While he has been preparing himself to die within a matter of months, he wasn't ready to die from urinary obstruction and renal failure in a matter of a few weeks. His first great grandson had just been born. We had a long discussion and he chose to have the nephrostomy tube reinserted. With the hospice medical director's agreement, I made arrangements for him to be transported to the local hospital for the procedure. Our plan was to transport him in, have the tube replaced, and to bring him right home where he had excellent caregiving. Unfortunately, in order for the hospice to be reimbursed for this intervention, he had to be admitted as an inpatient for an overnight stay. My patient asked me why he had to stay overnight. It reinforced for me how ludicrous some protocols and requirements are under current DRG/inpatient-driven reimbursement processes. As such, what could have been a simple, cheaper, more patient-friendly few-hours event was drawn out into a more costly, more resource-heavy, and assuredly less patient-friendly 24h stay in a hospital.

Similarly, another patient I care for with dementia recently fell and broke her hip. After a series of discussions with the family,orthopedic surgeon, and anesthesiologist, we agreed on non-surgical management to preserve what cognition she has left as she was, remarkably, having minimal pain from her fracture. The care plan for convalescence and subsequent rehabilitation to teach slide board transfers and possible weight-bearing transfers after 6 weeks was discussed with the orthopedist prior to discharge. It took considerable coaxing and authorizations for us to arrange for the SNF as they at first declined since hip fracture rehabilitation is normally only covered post-surgery. And, now safely convalescing at the SNF, the patient is being asked to see the orthopedic surgeon to get an "OK." The situation leaves me frustrated on multiple levels: a) orthopedic surgeons understandably don't make housecalls/SNF visits and so this would require gurney transport to clinic, b) we had already made decisions for non-surgical care and the orthopedist had 'signed off' in the hospital so an outpatient visit to the orthopedic office was rather useless in this situation, c) that rehabilitation-potential is defined so narrowly for our frail geriatric patients that they must have surgery after a hip fracture rather than considering the potential that non-fixed hip fracture patients may still have to sit up, slide, or transfer into wheelchairs for mobility and to interact with others.

Helen Kao concludes:

Patient's experiences with illness are fluid. But care delivery is (literally) broken--and, frankly, often seems haphazard. How would it be if we reformed health care delivery to truly be patient-friendly, to provide care in the settings patients wish to be in (especially when it is feasible and cheaper!) and to reduce the divide we have created over time between inpatient and outpatient care? What if we dispelled regulations that require patients to have "qualifying stays" in the hospital or qualifying procedures in order to access the myriad intermediate and home-based options that exist and could be better integrated to care for our patients?

I've repeatedly pushed the idea that giving patients more flexibility of choice was one way to combat resource challenges and rationing. We've been given regulations by the medical industry that limit both flexibility and choice because of "best practices" procedures implemented not necessarily with the patient's best interest in mind. The fractured system decreases our quality of care, raises over-all costs, and most importantly, limits patients' choice of care options.