Case: Another Reason Why Healthcare is Going Down the Toilet

An 88 year-old man traveled from the Silicon Valley to visit friends up here in Rural. After dinner and a couple of glasses of wine, he tripped on a flagstone and broke his right proximal humerus and his right femoral neck. My little hospital had the great pleasure of admitting him.

Almost immediately, his three daughters started calling Med-Surg, providing phone numbers of his primary care doctor, cardiologist, and vascular surgeon. One of them made reference to two episodes of "torsades," although she really didn't know what that meant. They were obviously worried about the prospect of surgery to repair the hip. What was unspoken but equally obvious was their concern about his having surgery at "what's-that-hospital-called?" here in Rural.

I took all the information and released the medical record hounds, and pretty soon we had records from his home hospital and cardiologist. He had well-compensated CHF, rate-controlled atrial fibrillation, and some bronchiectasis from a remote smoking history that didn't cause much trouble but ended him up in the hospital once a year with "pneumonia," although reading between the lines it was pretty clear to me that some of these pneumonias were nasty viral URIs.

I discussed the situation with our orthopedist, who recommended surgery if I thought the man was medically OK for anesthesia. Based on the info I had, I didn't see why not. We get a couple of hip fractures a week on our service, and we've gotten more than a few medically tricky patients back on their feet. We agreed to recommend ORIF to the family.

The daughters arrived. They lived in various affluent suburbs of Silicon Valley and you could tell they were not from Rural. They wore expensive casual clothes and good make-up and diamond wedding bands. They had not a hair out of place. And when I walked into their father's room, I could tell they were appalled by my little hospital, with its worn linoleum floors and hallways populated by men wearing cowboy hats. (Visitors, not staff members.)

I suspect they also weren't too pleased to see the hospitalist wearing slightly threadbare L.L Bean casuals. Or maybe my unmade-up face is the wrong poster child for Rural. Who knows?

Anyway, in the nicest, politest way imaginable, they suggested Dad should be transferred back to his hospital in San Jose. They suggested his cardiac history was too complicated to be managed by doctors unfamiliar with him. One of them asked, "What happens if we move him to a bigger hospital?" It was clear to me they thought we were too small and too backward to take care of their father.

I reassured them that we were more than capable of taking care of a hip fracture of this kind, in a person with Dad's history. But they kept approaching the nurse's station and hovering in the hallway and nagging the discharge planners that I began to think my life would be a bit easier without these people. I had a moderately large but very acute hospitalist service at the time, and I kept getting pulled away from much sicker patients to deal with the condescension of old King Lear and his three wealthy and entitled daughters.

So I made no objection when they asked to have Dad transferred back to his home hospital. I made it clear to them that there was no medical necessity for the transfer, so they would be liable for the entirety of the cost. Dad had Medicare and a private secondary insurance, and neither of them would pay for the cost of transfer without a statement of necessity.

One daughter asked if his previous cardiac conditions didn't make transferring to a larger, private hospital necessary. I explained that we'd managed much more severe cardiac patients than Dad through orthopedic procedures.

Another daughter asked if there was anything I could say that might help Dad persuade the insurance company and Medicare to pick up the ambulance tab. I said the most I could do was say that he might be better served at a hospital where he was already known.

The third daughter looked at me with what I suppose was meant to be an entreating gaze. "We just don't want to empty out his little wallet," she said.

There was a pause during which I'm pretty sure I failed to suppress a look of pure disdain. "I can say he might be better served at his own hospital," I said with a certain hauteur. "But I can't say anything that would be fraudulent."

Feeling like Robespierre, or at least one of his revolutionaries, I made it clear in my note that this was an elective transfer and I hoped that the family got stuck with an enormous bill. The discharge planner told me the local ambulance company quoted a ground transportation cost of $6,300 and an air transport cost of $7,500, which was not as great a difference as I expected.

I spent the better part of a morning glued to a telephone trying to identify a doctor in San Jose who would accept the patient in transfer. I felt I was neglecting a number of other, much sicker patients by being stuck on hold for so long. Finally I had an accepting physician and an air ambulance at the ready, because the accepting hospitalist wanted the patient to arrive before 5pm so that the H&P and ortho consult could be done expeditiously.

When I entered the room, the three sisters were talking to our house supervisor, who looked at me and said, "They want him to go by ground because of the cost difference." The expression on his face spoke volumes. Then the sisters began to pipe up.

"It's almost $4,000 difference," one of them said.

"I thought it was only $1,200," I said.

The house supervisor explained the difference was due to med administration in the air versus on the ground, a distinction I don't understand at all.

"If it were only $1,200," said the daughter, who was obviously the financial genius of this family, "I wouldn't hesitate. But it's $4,000."

I didn't know what to say. If Dad's comfort and well-being were worth $1,200, why weren't they worth $4,000? I guesstimated that two of the sisters were wearing a couple thousand dollars worth of designer clothing and accessories.

The house supervisor and I explained, as nicely as we could, that we couldn't guarantee that the hospital would accept the patient the next day. We explained that accepting a transfer was a courtesy on their part. What we didn't explain, what we should have explained, was that several hours of staff time, not to mention my time, had already been totally wasted on this project.

I suppose if I had been in a position to bill $2,800 for my wasted time and for cost savings that time might have made in the care of the other patients at the hospital on the same day, then these three sisters might have been more inclined to accept the air transport. As it was, we negotiated an agreement with the accepting hospital to take the patient the following morning, and with the ambulance company to pick her up at 5am to make it to San Jose by 3pm.

I ask you, how does it reflect upon American culture today when obviously affluent families try to persuade doctors to defraud Medicare? How are we going to cut costs in an era of so-called consumer-driven healthcare which implies that patients and their families are the ones directing care? It is cases such as this one that really make me angry when the public blame doctors for inflating healthcare costs. For every doctor out there who orders too many tests, there must be a dozen patients who show up in exam rooms demanding chest CTs, lumbar spine MRIs, Lyme titers--or expensive unnecessary transfers from one medical center to another. If people really want to overhaul the healthcare system, they'd better begin with their own expectations.

Addendum: The next day, at 4:30am, when the ambulance arrived, the night house supervisor received a call from the San Jose hospital. They had no beds, so they couldn't accept Dad in transfer. So much for saving on air transport. I hope the affluent sisters get nailed for the entire hospital bill.

Comments

[Theresa]

San Jose finally took him, but much later, so either their hospitalist had to accept him after 5pm or they had to go by air after all. I dont' know. I'd washed my hands of the whole situation by then. Thanks for stopping by!

[Dr. Dredd]

Ouch! So what happened to the patient when the San Jose hospital couldn't accept him in transfer? It would add insult to injury if you had to take him back!

[Dragonfly]

Good post, though in my opinion Australians and others do the same thing. People of lower socioeconomic status can do the same though...my personal favourite are those who call an ambulance to take them to the emergency department to get more cough syrup. And the bill to the taxpayer keeps growing, essentially taking money away from more cost effective health measures, including the social determinants of health, in the next years budget.

[Dr. Val]

Excellent and exasperating post. You may appreciate my own foray into VIP aggravation territory: http://www.revolutionhealth.com/blogs/valjonesmd/vip-syndrome---a-no-w-2857

All of this dispo planning that we docs do is such an inefficient use of our training and skill sets. Maybe we could simplify this process with IT? One can always dream...

[AnnR]

I think money is one of those things that is so peculiar to a family and it's interactions that you really need to leave it alone.

Unless you grew up in that family you can't really know what the whole sub-text is.

I have been running Fidelity Investment's retirement calculator, and if the stock market doesn't behave itself for me I may be running out of funds as I hit those late 80s birthdays (I sure hope I live to see that!). According to the Wall Street Journal that's a common time for retirees to have a money crunch.

Asking you to do something fraudulent is wrong, wrong, wrong and they should be ashamed of themselves for pressuring you!

[IVF-MD fertilityfile.com]

"I ask you, how does it reflect upon American culture today when obviously affluent families try to persuade doctors to defraud Medicare?"

This is more a reflection on human nature in general rather Americans specifically. The spectrum of selfishness ranges on a scale from 1-10 with perhaps Mother Teresa being a 1 and narcissistic sociopaths being a 10. I'd say most Americans are from a 4-8. We can't change human nature. What we CAN do (in theory at least) is change the system back to one where personal accountability helps motivate people into making the decisions that are best for society overall.

As for the above comment stating "My personal observation is that the more money someone has, the more he/she tends to haggle over costs.", I disagree totally. There are many with money who DON'T haggle and many without money who DO haggle.

I'll never forget during med school being on the MICU team taking care of a comatose elderly grandmother with end stage CA. The family (on public assistance) was adamant that "EVERYTHING BE DONE" to prolong her life each additional day, even thought they realized there was less than a 1% chance she would wake up before she passed. However, they later were under the impression that it would cost them out of pocket, something like $25 rather than having the government foot the entire daily bill. With that bit of information, they decided it was best for grandmother to pass away in peace.

Human nature. Great post, Theresa.

[Theresa]

Hi PJ, Mack, and friendly Anonymous:

I see this is not an isolated phenomenon. I also see I shouldn't get so huffy about it, but I'm STILL mad at this family. I guess I'm small-minded.

I think the entire "rate your doctor/hospital" movement is going to make this type of situation worse, because small rural hospitals won't even register on the ratings, so--in the minds of affluent suburbanites--won't be "good enough."

Anonymous has an excellent point--I could have made the family arrange the whole thing. But they gave me all the phone numbers and I confronted the following problems: the PMD was out of town, the (semi retired) physician covering for him didn't know how things work when it comes to facilty-to-facility transfer and sent me on a wild goose chase, I couldn't get in touch with the physician covering for the PMD's hospital patients, and when I called the hospitalist in San Jose, she wasn't all that pleased to be taking a patient in transfer for a group of PMDs with whom the hospitalist group OBVIOUSLY has a tenuous relationship.

And then they insisted on ground transport.

I have to let this go.

[anonymous]

they aren't going to like the results if they delay the surgery for too long, i imagine. i also work in a rural area. maybe i'm an a-hole, but when they tell me they want to transfer i have them call the primary and let them work out the details. i don't have time to know who to call in a city hundreds of miles away.

[Mack]

Great post. I can totally identify with your story. I'm an internist in rural Illinois and I occassionally get this type of patient (and family) visiting from Chicago. People want "cadillac care" without them having to pay for it.

[PJ]

Good grief.

My personal observation is that the more money someone has, the more he/she tends to haggle over costs.

When the daughter says they don't want to empty out Dad's little wallet, I bet the subtext is, "We want to inherit as much of Dad's money as possible." But maybe I'm just being cynical.

The sad thing is that for every family making these kinds of unreasonable demands, there's probably someone else who doesn't even have these options because they don't have the ability to pay.