I am a cancer patient who has been in and out of hospitals for the last decade. While I have received good care I have also been appalled by the amount of inefficiency, waste and just plain bone headed policies I have witnessed. Being a curious guy and a guy with a degree in Public Administration I have asked a lot of questions. The answers from the front-line folks have been pretty damning of hospital management. Basically it comes down to the fact that hospitals are generally for profit corporations pressured by Wall Street to show increasing profits. Anything that might adversely affect revenue, even temporarily, frightens them and they immediately start with the scare tactics. We cannot turn them back into nice little non-profit patient centered institutions.. to late for that... but we can make sure we get the best bang for our tax payer buck.

This is going to hurt large inner-city hospitals and university hospitals. I don't care how much reassurance is being given about that. I'm a nurse who has been associated with 2 large university hospitals and believe me, those hospitals get the sickest of the sick, the ones no other hospital is able or willing to take care of. And the idea of extending "efficiency" out 90 days is taking things too far. Up to 30 days, I can see. But nearly 3 months down the line, the hospital is supposed to be responsible for the care the patient gets? That just sounds punitive.

"The new measure of Medicare spending per beneficiary would include all these costs, which — federal officials say — could be reduced by better coordination of care and communication among providers."

No kidding! I will only offer anecdotal experience, as theory these days, breaks down into partisan speechifying almost immediately.

1) My father's quadruple by-pass kept him in the hospital for one week, most of it in intensive care. He was discharged and sent home with us with a list of instructions a mile long about wound cleaning, etc. I gave a week of my hard earned vacation to stay with him, taking shifts with my mother, and nonetheless he was readmitted with an infection. Discharged because of insurance limitations on the length of stay? Absolutely.

2) My general practicioner and my dermatolgist both require a liver function panel of blood tests. After going to give blood twice in one year (and having the insurance company pay for both), I decided I didn't much like being the vampire victim, and asked if they could share. They both said yes, and I now walk a single, annual report from one floor to another......

3) I had a laparotomy to check the nature of an ovarian cyst done on an outpatient basis; I was forced to stay awake after the procedure, being force fed fruit juice until I could battle the effects of the anesthesia and be escorted to the street to get a taxi home with my friend. A kindly nurse accompanied us to the curb offering some "barf bags" just in case. Would one night in the hospital to shake off the anesthesia be so terrible? Again, wound care at home, etc.

Something's not efficient, although the revolving door concept seems to be the prevailing one at this time to keep a good relationship with the insurance companies who, themselves are the medicare gatekeepers in many instances. I say, lift the corporate rocks and see what scurries away from the light. Or we might find that things are working as well as they can. Who knows?

I have always felt that this whole Medicare discussion is being approached from the wrong angle. My husband was in the hospital last year for a urinary tract infection. He had no surgery, MRI's, scans, etc., only a urinalysis. He was administered an antibiotic (Levaquin) and after four days was released. The bill was over $18,000.00, which, thank God, Medicare and our AARP paid for it but I was appalled at the cost. If this is typical (and I have no doubt it is) then no wonder Medicare is going broke!

Community hospitals, by their charters, are mandated to accept any/every patient. They do not have the luxury of accepting or cherry-picking low risk, higher income patients who traditionally have better education and will take initiative to follow medical advice post discharge. Additionally, until Medicare/Medicaid can negotiate with Big Pharma as the VA does, medication costs will stay high for hospitals and individuals. Time to get the Pols out of Medicine.

Why go after Medicare when Medicaid seems like such a much better choice? Why penalize old people who have contributed to this country for their entire lives when Medicaid gives handouts to the poor who are also being given food for their tables and housing to place that table. There is just about nothing more offensive to me than to see a morbidly obese medicaid recipient hanging outside a hospital emergency room smoking a cigarette. It is sad that we protect the poor better then we protect the elderly. Why?

Private insurers already "punish" hospitals who create avoidable injury. If a patient is admitted for surgery, contracts an infection, and has to prolong hospital stay, private insurers often penalize the hospital. Nosocomial infections can often be avoided, through proper protocols for effective outcomes, they reason.

So, why shouldn't this practice (and similar practices) be rationally implemented in Medicare reimbursement schedules?

Those who "cry wolf" every time the federal government changes policies have to think less emotionally and see the long-term benefits that could accrue from a carefully "tweaked" outcomes-based reimbursement policy.

The critics are correct. There is no point implementing "efficiency" standards until you define "efficiency."


The drive for "efficiency" standards cuts both ways. It could deter some providers from piling on futile and ineffective treatments on the assumption that the government (or the insurance company) will shell out. Not all doctors are greedy, but some are, and a fair number have a rather inflated sense of entitlement. I have a book on my shelf, "M.D.: Doctors talk about themselves," in which one anonymous physician noted that when his father practiced, the Buick was "the doctor's car." Now it's the beemer, the jag, the lamborghini. (When I tried to decline an expensive test once on the grounds that I couldn't afford it, and asked the doctor "do you know how much this costs?" he screamed at me -- yes, literally screamed with rage -- "I don't know! How would I know! I don't care!")


On the other hand, doctors and hospitals who want or need to keep their won/lost ratio on the plus side are likely to think twice before taking on a patient with a poor prognosis. When you see a doctor who loses a lot of patients, he may be a lousy doctor. He may also be the doctor of last resort, the guy who takes the patient everyone else has given up on or won't go near, the one who's willing to try a Hail Mary Pass.


As for the three-month measurement, this should, I think, be qualified or moderated, in that the analysis of costs obviously must take into account whether the post-hospital costs are directly related to the hospital stay. This is a complicated question. Say an 83-year-old who has had a small stroke is sent home, where he lives alone, despite balance and coordination problems; two months later he falls and cracks a hip. It would take some examination to determine whether the fall was related, that is, whether the hospital adequately addressed the coordination problems. (As to the impossibility of getting affordable home assistance that would prevent the fall and the rehospitalisation -- that is a whole other can of worms.)


(I haven't read the other comments, but I'm sure there will be a pretty good share of simplistic responses to the article, whether "death panels" or "greedy quacks." And before anyone points it out: yes, I know, not all doctors are male.)

Heed these developments if you are a younger physician.

You are going to be accountable for patient compliance on medication, and activities, 90 days out. You will not be able to open your own practice. You will be dictated to by insurance companies and malpractice insurance companies about how much you are worth. Everyone will expect you to fix their problems 100% and blame you for the costs.

There is no way in the world that any physician can control compliance with medications or diet regimens or activity levels 10 days post discharge, let alone 90.

Just don't do it. Forget the financial part of it. Just picture yourself spending a decade training, then treating someone or saving their life, only to be told you were a failure because 30 days after you saw them, there was a complication due entirely to the patient. Now rinse and repeat that over the course of a career, have a politician or actuary tell you that it is 'outcome measures' and ask yourself if the sacrifices you made or will have to make to get to that point are worth it.