Life is full of things that cause negative feelings. These feelings need to be discharged, and unfortunately some of us do so in perverse ways. The victim of a crime may be blamed by the authorities. After all, if the victim had not come forward then there would not be an unsolved crime. Shooting the messenger has always been a simple response to hearing bad news.
Why should patients be immune to this? A recent article in The Wall Street Journal discussed really sick people who cost a lot of money and that someone has to pay. As one might expect, payers and the government want that “someone” to be someone else. This position manifests itself as insurance companies refusing to pay for mental health services because they are not “real” illnesses. And policy makers who advocate that insurers, private and public, should not pay for the consequences of obesity, smoking, drinking or other “sinful” behaviors. They believe the sinners should pay! When physicians and payers are evaluating patients, medical calculators can help to assess risk and complications that might arise from harmful lifestyle choices.
The Centers for Medicare and Medicaid Services (CMS) have determined that the only explanation for expensive problems such as readmission or post-operative complications is poor care delivery. As physicians, we know that the care and response of each patient is nuanced and there is no one explanation for why a patient’s condition may deteriorate. We can’t control patient compliance, patient lifestyle choices and habits, patient care both in and out of the hospital, and many other factors that can result in readmission and complications. The new CMS approach attributes all of these unknown factors to sloppy care and their rules demand that the responsible hospital and and/or physician should pay.
Tools Reduce Hospital Readmissions
Medical calculators incorporate lessons learned from years of evidence in clinical practice and can be put to use to reduce readmissions by identifying risks early.
While poor care may contribute to complications, it does not explain everything. Really sick people often are really sick. An insurance policy that might be relevant for a brand new car does not apply to rebuilding an old car on grandpa’s farm. Stating categorically that there are only black and white causes expands the opportunity for healthcare providers to shoot the messenger. For patients and healthcare providers, simply accepting this approach without questioning may have unanticipated consequences.
If I, as a physician am taking care of a patient, and there’s a chance of not getting paid for doing something, then why would I do it? This means that only patients with a high probability of complete recovery and low probability of problems will get certain types of care. You can be sure that a lot of people having expensive surgery today will not be offered this surgery in some future tomorrow.
The spin doctors will be working overtime to give reasons why it is better for you to stay in your home rather than to go to the hospital. Telemedicine will be “almost” just as good. There is the risk of exposure to superbugs in a hospital. Informed consent will contain so many potential complications that no one in their right mind would give consent. All of this will be for the patient’s good, not the hospital’s bottom line. And by the way, physicians are now employed by the hospital and are no longer independent advocates so are they really looking out for the patient’s interests first?
These calculators can help mitigate risks in some of these situations:
One consequence of government changes is already evident. Certain billing codes flourished when they were rewarded by extra reimbursement. Those same codes are now being used much less. One explanation could be that health systems have implemented effective interventions to prevent their occurrence. Another explanation is that coders aren’t using them anymore since their use is penalized. Coders are only supposed to use relevant codes, but miscoding is hard to prove. If the costs to the payers go down, then don’t expect a whole lot of questions to be asked. And, really sick patients won’t be around to ask them. We’re seeing these effects already with cancer patients, who sometimes can’t get coverage at the hospitals they want.
As cost burdens shift from insurance companies and the government to providers, medical calculators can help to reduce the financial and health risks and improve outcomes for patients and providers.