Pressure to admit

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yesboss572

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I am a hospitalist at a community hospital. For the past few months, I have noticed that the hospital administration has begun to pressure the ER providers and other hospitalists to admit a high number of patients regardless of medical necessity.

I am assuming that they have many empty beds that need to be filled and want to maximize revenues. I would say some of these patients that I am called to admit can simply be discharged with outpatient follow up.

Conditions that I have been asked to admit for: insomnia, chronic pain management, hypothyroidism with no evidence of myxedema coma, alcohol abuse with no evidence of hepatitis, withdrawal or intoxication, atelectasis, mild volume overload, common cold, chronic venous stasis, chronic rate controlled atrial fibrillation, broken suction equipment for a trach patient, CKD with no evidence of acute worsening, migraines, need for outpatient hospice to be set up, medical clearance for psych placement, mild uncomplicated non-gallstone pancreatitis, don't have a ride home (but live too far away for a paid taxi) and homelessness. I have been also called to admit people who simply came to the ER for "medication refills".

I have discussed this with the ER medical director and he says he has to "maintain a 20% admissions rate from the ER". Sometimes when I try to admit these people, they are bewildered and upset as to why they have to spend a night or two in the hospital. When I discharge them from the ER, I have gotten complaints from administration as to why I did not admit a particular patient. Case managers have asked me to "come up with a diagnosis" to justify the admissions.

So when I admit them, their insurance companies start questioning medical necessity. The funny thing is I get calls from the case managers to perform a "doc to doc" to convince their insurance carriers to consider the admission as inpatient and not observation. Then there are truly sick patients in the ER who are waiting for a bed for hours and hours; since the beds upstairs are occupied. Also, admitted patients are at risk for developing hospital acquired infections, delirium, pressure injuries and falls.

I have worked at other hospitals and never saw such meddling by management.

Any thoughts on this?

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Omg... I can't believe this ... good luck dealing this this OP. I'd be careful, I'd rather lose my job than be accused by insurance companies of fraud (which could happen if u stay at such a toxic place). I think it's time to get the heck out of there.
 
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Omg... I can't believe this ... good luck dealing this this OP. I'd be careful, I'd rather lose my job than be accused by insurance companies of fraud (which could happen if u stay at such a toxic place). I think it's time to get the heck out of there.

This!!!!

We constantly get told my case managers that since patient has to go to SNF we have to keep them in-pt for 3 MNs which is medical fraud.
Your allegiance is to your patient and yourself (the order of it is debateable to some) and I totally agree with hello1234, that this is a lawsuit, complaint, medical chart review waiting to happen.

If there truly is no chance of a cultura change then you need to start looking for a new job if at all possible
 
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I am a hospitalist at a community hospital. For the past few months, I have noticed that the hospital administration has begun to pressure the ER providers and other hospitalists to admit a high number of patients regardless of medical necessity.

I am assuming that they have many empty beds that need to be filled and want to maximize revenues. I would say some of these patients that I am called to admit can simply be discharged with outpatient follow up.

Conditions that I have been asked to admit for: insomnia, chronic pain management, hypothyroidism with no evidence of myxedema coma, alcohol abuse with no evidence of hepatitis, withdrawal or intoxication, atelectasis, mild volume overload, common cold, chronic venous stasis, chronic rate controlled atrial fibrillation, broken suction equipment for a trach patient, CKD with no evidence of acute worsening, migraines, need for outpatient hospice to be set up, medical clearance for psych placement, mild uncomplicated non-gallstone pancreatitis, don't have a ride home (but live too far away for a paid taxi) and homelessness. I have been also called to admit people who simply came to the ER for "medication refills".

I have discussed this with the ER medical director and he says he has to "maintain a 20% admissions rate from the ER". Sometimes when I try to admit these people, they are bewildered and upset as to why they have to spend a night or two in the hospital. When I discharge them from the ER, I have gotten complaints from administration as to why I did not admit a particular patient. Case managers have asked me to "come up with a diagnosis" to justify the admissions.

So when I admit them, their insurance companies start questioning medical necessity. The funny thing is I get calls from the case managers to perform a "doc to doc" to convince their insurance carriers to consider the admission as inpatient and not observation. Then there are truly sick patients in the ER who are waiting for a bed for hours and hours; since the beds upstairs are occupied. Also, admitted patients are at risk for developing hospital acquired infections, delirium, pressure injuries and falls.

I have worked at other hospitals and never saw such meddling by management.

Any thoughts on this?

I know of a tertiary care teaching hospital in the northeast where something similar to this occurs frequently. The ER is encouraged to consistently admit patients that don't require hospitalization. It is always a "code bed". Sick patients that actually require hospitalization are frequently stuck in the ED waiting for beds and patients that don't need to be there are constantly frustrated because they are in a hospital and don't need to be in a hospital. Because the patients are frustrated the staff is frustrated. It is extremely frustrating for residents to admit someone to the hospital that has no true indication for hospitalization.

It is a money making scheme and a blatant abuse of healthcare dollars, and hospitals that are playing this game need to be held liable for doing this. Unfortunately, I think this is only going to get worse over the next several years as the "hospitalism" of medicine continues.
 
I've never heard of this before. At the 3 hospitals I trained at in residency, I'm used to the case managers pushing to discharge the pt, never the other way around.
 
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I've never heard of this before. At the 3 hospitals I trained at in residency, I'm used to the case managers pushing to discharge the pt, never the other way around.

You are missing the money making scheme here. Hospitals are paid for admissions often based on DRG. The ER is pushed to admit, and medicine is pushed to discharge. More admits lead to more $ and even if some of these claims are deemed by the insurance as being medically unnecessary, a majority of them are still paid for.

Mild CHF exacerbation? You could probably be safely discharged with an extra dose of PO Lasix. But the ER is encouraged to admit, and they are more than happy to. Less liability. Once the patient is admitted, the hospitalist service is encouraged to discharge the patient in 1-2 days. The hospital is paid for the admission, and after the patient is admitted it is in the hospitals interest to discharge the patient quickly.

It's obviously much more complicated than this but I know for a fact that this is what is happening at a few hospitals in my area.
 
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If you have empty beds lying around; why not fill them with "observation" patients. These patients don't need to be "observed" but the insurance companies would rather pay for observation rather than for inpatient care. Hospital exec's have taken advantage of this fact. Random ER patients are then admitted to fill these beds. They are then "observed" and then discharged in a day or two. The hospital receives a few thousand dollars for this "observation". Cycle repeats.

I am already looking to find another employer.
 
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If you have empty beds lying around; why not fill them with "observation" patients. These patients don't need to be "observed" but the insurance companies would rather pay for observation rather than for inpatient care. Hospital exec's have taken advantage of this fact. Random ER patients are then admitted to fill these beds. They are then "observed" and then discharged in a day or two. The hospital receives a few thousand dollars for this "observation". Cycle repeats.

I am already looking to find another employer.

Don't be surprised if your new employer is doing a slightly different (or more discrete and calculated) version of the same thing.
 
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If you write "no medical necessity to remain as an inpatient" they will stop asking you to admit dubious pts...but they may also ask for you to leave as well...

The other is admit to obs...or bill a level 1...:)
 
Can other hospitalists here comment on how pervasive this practice is?
 
Can other hospitalists here comment on how pervasive this practice is?

I've never encountered a situation like this. This is pretty bad and for me, would make me question if I want to continue working for a company who placed money/finances blatantly over what's right or wrong for the patient. It also reiterates to me one if the frustration of being a hospitalist in general: lack of respect for our speciality. Do the same administration tell the surgeons who they must operate on? Do they tell the interventational cath attendings who they cath or CC docs who they must intubate? Highly doubtful.

Now, have I heard of ED docs say that they go in seeing a patient assuming they will admit everyone and must find a reason to discharge them from ED....Yes. But it wasn't coming from hospital admin but more from a poor ED culture where there was no penalty for admitting someone who didn't need to be admitted. Good luck.
 
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My current hospital admits a lot but they at least have good staffing so I have a night cap of 8 pts and a closed ICU so if the pt is sick I call the intensivist and it’s off my hands. So I never argue about all the BS admissions I get , they are easy patients who take me 20 minutes to admit. Just admit the chronic migraine with q2hr dilaudid and let the day hospitalist figure out how to get the pt out.
 
My current hospital admits a lot but they at least have good staffing so I have a night cap of 8 pts and a closed ICU so if the pt is sick I call the intensivist and it’s off my hands. So I never argue about all the BS admissions I get , they are easy patients who take me 20 minutes to admit. Just admit the chronic migraine with q2hr dilaudid and let the day hospitalist figure out how to get the pt out.

Aren't you an intensivist?
 
Aren't you an intensivist?
I am. But I used to be a nocturnist hospitalist and still help them out when their nocturnist goes on vacation and they need help. It’s a welcome change of pace. I admit I would struggle to discharge a pt but I haven’t lost my admitter skills.
 
Can other hospitalists here comment on how pervasive this practice is?

I wouldn't say my hospital pressures the ED to admit but they do make it easy because we have an obs unit and dedicated obs doctors. Low risk chest pain, non-septic cellulitis without outpt treatment (and don't forget bilateral cellulitis!!), missed dialysis and similar ilk frequently get admitted. It sucks somedays 'cus the obs docs have a pt cap and the remaining obs admits flow to the inpt guys, so there are days i can get 4 obs admits that are questionable at best. Bear in mind, first job out of residency so IDK if this is just how the real world is.
 
Man this thread makes me want to puke. I wonder if there have been any studies about how much questionably necessary or downright unnecessary admissions contribute to heathcare spending. Or maybe an ED metric should be percentage of patients you admit that are discharged the next day when a resident admitted, excluding obvious short stays like ACS rule outs.
 
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Man this thread makes me want to puke. I wonder if there have been any studies about how much questionably necessary or downright unnecessary admissions contribute to heathcare spending. Or maybe an ED metric should be percentage of patients you admit that are discharged the next day when a resident admitted, excluding obvious short stays like ACS rule outs.

Why do you need a study? Everyone has plenty of stories about bs admissions. My favorite was the "multifocal pna". I'm like uh just change their antibiotics and discharge, they're fine. The midlevel would insist that multifocal pna is an indication to admit and I'm like ok fine whatever. So I admit and copy/paste my admission into the discharge summary with the new abx. Patient gets discharged as soon as the attending sees them. The ED's main job is to triage patients but for some reason they seem to struggle with it.
 
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I am a hospitalist at a community hospital. For the past few months, I have noticed that the hospital administration has begun to pressure the ER providers and other hospitalists to admit a high number of patients regardless of medical necessity.

I am assuming that they have many empty beds that need to be filled and want to maximize revenues. I would say some of these patients that I am called to admit can simply be discharged with outpatient follow up.

Conditions that I have been asked to admit for: insomnia, chronic pain management, hypothyroidism with no evidence of myxedema coma, alcohol abuse with no evidence of hepatitis, withdrawal or intoxication, atelectasis, mild volume overload, common cold, chronic venous stasis, chronic rate controlled atrial fibrillation, broken suction equipment for a trach patient, CKD with no evidence of acute worsening, migraines, need for outpatient hospice to be set up, medical clearance for psych placement, mild uncomplicated non-gallstone pancreatitis, don't have a ride home (but live too far away for a paid taxi) and homelessness. I have been also called to admit people who simply came to the ER for "medication refills".

I have discussed this with the ER medical director and he says he has to "maintain a 20% admissions rate from the ER". Sometimes when I try to admit these people, they are bewildered and upset as to why they have to spend a night or two in the hospital. When I discharge them from the ER, I have gotten complaints from administration as to why I did not admit a particular patient. Case managers have asked me to "come up with a diagnosis" to justify the admissions.

So when I admit them, their insurance companies start questioning medical necessity. The funny thing is I get calls from the case managers to perform a "doc to doc" to convince their insurance carriers to consider the admission as inpatient and not observation. Then there are truly sick patients in the ER who are waiting for a bed for hours and hours; since the beds upstairs are occupied. Also, admitted patients are at risk for developing hospital acquired infections, delirium, pressure injuries and falls.

I have worked at other hospitals and never saw such meddling by management.

Any thoughts on this?
First bolded in your post is the issue - other bolded areas I could easily see be admitted at my local community/rural hospital.

I’ve always found quota driven medicine to be appalling and leads to borderline fraud. There are certain healthcare systems - the VA being the most notable, with rural hospitals in there as well, where the “pop drop” is very common.

If I were in your shoes, I would document and admit (obs vs inpt) as I saw fit. If admin gave pushback, I would ask them to communicate their concerns through email so at least there was documentation of their (and your) responses - or you could be snarky and tell them to drop a note in the chart as to why they feel the pt should be admitted (oh wait - they can’t because they don’t have the clinical privileges).

Depending on how your ED is setup, if the ED calls for admission you can’t refuse, but I haven’t seen any cases yet where if the Hospitalist wants to d/c from the ED then so be it. In community settings however, inpt workup is much faster of course than in the outpatient world - neuro workup and consult takes 24hrs compared to a outpatient neuro referral which takes 3 months in my neck of the woods.

What will be interesting though is when population DRG takes place - the goal is to keep the pt out of the hospital for your CHF/DM/CKD/COPD pts. Don’t know how fully this will work out with your non-compliant pts, but current fee for service model is an eat what you kill - the weak are meat and the strong do eat...unfortunately
 
Why do you need a study? Everyone has plenty of stories about bs admissions. My favorite was the "multifocal pna". I'm like uh just change their antibiotics and discharge, they're fine. The midlevel would insist that multifocal pna is an indication to admit and I'm like ok fine whatever. So I admit and copy/paste my admission into the discharge summary with the new abx. Patient gets discharged as soon as the attending sees them. The ED's main job is to triage patients but for some reason they seem to struggle with it.
I just see this as a really big problem for why costs are so high, and ideally it would be nice to change that rather than talk about many of the other maybe unnecessary cost cutting measures. Like this isn't talked about much except by hospitalists/IM residents.
 
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I recently quit this job after administration made it "mandatory" to admit everyone that the ER provider deems needs to be admitted. I fought tooth and nail and discovered that this was a losing battle. It's all about $$$. I have heard my CFO say "lets keep these beds full". From what I understand, a patient in "observation" is more profitable than an empty bed. I brought this issue up with the department Chairman and he told me "its the physicians doing it not administration"

The hospitalists are now longer allowed leave a consult in the chart and discharge the patient from the ER under their own liability. The ER providers unfortunately are pressured to admit a lot. This thus transfers upon the hospitalists. Recently I was asked to place in obs, a woman having nightmares. A dialysis patient that came to the ER for knee pain that was benign; was recommended to be placed in observation for "inpatient dialysis". A man with a chronic wound that needed outpatient wound care setup was recommended to be admitted for IV antibiotics and inpatient wound care. Again, I am no longer allowed to say NO.

Insurance companies have decreased reimbursements to hospitals. Hospitals are now fighting hard to maintain a decent operating margin (profit margin). So the shift now is to "admit as much as possible".

This is gross deviation from the standard of care. I know medical boards are targeting physicians ordering unnecessary care. CMS and insurance companies need to come down hard on these hospitals for defrauding their patients.
 
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I recently quit this job after administration made it "mandatory" to admit everyone that the ER provider deems needs to be admitted. I fought tooth and nail and discovered that this was a losing battle. It's all about $$$. I have heard my CFO say "lets keep these beds full". From what I understand, a patient in "observation" is more profitable than an empty bed. I brought this issue up with the department Chairman and he told me "its the physicians doing it not administration"

The hospitalists are now longer allowed leave a consult in the chart and discharge the patient from the ER under their own liability. The ER providers unfortunately are pressured to admit a lot. This thus transfers upon the hospitalists. Recently I was asked to place in obs, a woman having nightmares. A dialysis patient that came to the ER for knee pain that was benign; was recommended to be placed in observation for "inpatient dialysis". A man with a chronic wound that needed outpatient wound care setup was recommended to be admitted for IV antibiotics and inpatient wound care. Again, I am no longer allowed to say NO.

Insurance companies have decreased reimbursements to hospitals. Hospitals are now fighting hard to maintain a decent operating margin (profit margin). So the shift now is to "admit as much as possible".

This is gross deviation from the standard of care. I know medical boards are targeting physicians ordering unnecessary care. CMS and insurance companies need to come down hard on these hospitals for defrauding their patients.

This is happening in so many hospitals.
 
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I recently quit this job after administration made it "mandatory" to admit everyone that the ER provider deems needs to be admitted. I fought tooth and nail and discovered that this was a losing battle. It's all about $$$. I have heard my CFO say "lets keep these beds full". From what I understand, a patient in "observation" is more profitable than an empty bed. I brought this issue up with the department Chairman and he told me "its the physicians doing it not administration"

The hospitalists are now longer allowed leave a consult in the chart and discharge the patient from the ER under their own liability. The ER providers unfortunately are pressured to admit a lot. This thus transfers upon the hospitalists. Recently I was asked to place in obs, a woman having nightmares. A dialysis patient that came to the ER for knee pain that was benign; was recommended to be placed in observation for "inpatient dialysis". A man with a chronic wound that needed outpatient wound care setup was recommended to be admitted for IV antibiotics and inpatient wound care. Again, I am no longer allowed to say NO.

Insurance companies have decreased reimbursements to hospitals. Hospitals are now fighting hard to maintain a decent operating margin (profit margin). So the shift now is to "admit as much as possible".

This is gross deviation from the standard of care. I know medical boards are targeting physicians ordering unnecessary care. CMS and insurance companies need to come down hard on these hospitals for defrauding their patients.

Then your name comes up in the new york times as a fraudulent physician as we take the hit for hospital administrator greed
 
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Unfortunately admissions are a necessary evil for many community hospitals. A big name brand hospital where the rich schedule their revenue generating expensive surgeries do not have this need to admit. They don’t depend on their ED so much. But smaller community hospitals have to get by with medicine admissions. The weak stuff that gets admitted bags everyone a few $$ and helps the hospital scrape by. And gets a little pressure off the patient family / nursing home.
Hospitalist jobs wouldn’t be this plentiful if we admitted only the really sick stuff.
Admit, code well, capture all chronic conditions with mild acquittal , IV abx for a day, get the DRGs and discharge a day later. We will all remain in the black.
 
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Or you could all go to my home country (a poor 3rd world country) where there is no health insurance and every patient is self paying and comes to you with max $50 in his pocket in which he expects diagnosis and treatment. Then you have to really spend 10 minutes with the patient on diagnosis and try to avoid any tests or imaging and use clinical judgement. There is little to no need for malpractice and documentation but there is only $50 in it for you. If you can’t get the job done in $50 he will go to the next physician down the road and tell his entire extended family not to visit you as well.
 
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I recently quit this job after administration made it "mandatory" to admit everyone that the ER provider deems needs to be admitted. I fought tooth and nail and discovered that this was a losing battle. It's all about $$$. I have heard my CFO say "lets keep these beds full". From what I understand, a patient in "observation" is more profitable than an empty bed. I brought this issue up with the department Chairman and he told me "its the physicians doing it not administration"

The hospitalists are now longer allowed leave a consult in the chart and discharge the patient from the ER under their own liability. The ER providers unfortunately are pressured to admit a lot. This thus transfers upon the hospitalists. Recently I was asked to place in obs, a woman having nightmares. A dialysis patient that came to the ER for knee pain that was benign; was recommended to be placed in observation for "inpatient dialysis". A man with a chronic wound that needed outpatient wound care setup was recommended to be admitted for IV antibiotics and inpatient wound care. Again, I am no longer allowed to say NO.

Insurance companies have decreased reimbursements to hospitals. Hospitals are now fighting hard to maintain a decent operating margin (profit margin). So the shift now is to "admit as much as possible".

This is gross deviation from the standard of care. I know medical boards are targeting physicians ordering unnecessary care. CMS and insurance companies need to come down hard on these hospitals for defrauding their patients.

The problem is that this encourages the conglomeration of healthcare in to mega health systems and reduces competition which drives salaries down for everyone except upper level administrators. It's happening all over as the larger health systems buy up these small hospitals, gut the staff, and farm referrals.

I'd much rather work at a pokey hospital even if they need me to do pointless admissions than watch it get swallowed up by the tertiary system and make it impossible to get anything other than urgent care in that community any more as specialists bail out over the precipitous drop in salary. A lot of small town people are distrustful of big city hospitals and can't make the trip to be with them regularly
 
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We doctors tend to talk about how the system is all messed up and that we practice defensive medicine and do a lot of excess labs/imaging/unnecessary hospital admissions. How we all are paying for it out of our taxes and how Medicare will go bankrupt and the system will collapse. What we forget is that the same defensive medicine, hospital admissions drive the heath care economy and pay our bloated salaries. Otherwise we would be like European countries with doctors making about $70,000 like teachers and be just middle class. And that would probably be the case if we move to a single government payor because the government would quickly clamp down on doctors salaries/hospital costs/pharmaceutical drug prices. They would also get rid of med malpractice in a flash because it would drive down the costs. Doctors would have no stress and no money either. But since AETNA, CIGNA and Blue Cross foot the bill and Medicare only pays a certain amount no one gives a damn. And if 25% people mooch off the system and another 5% get driven into medical bankruptcy no one gives an f’’’ either.
 
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Or you could all go to my home country (a poor 3rd world country) where there is no health insurance and every patient is self paying and comes to you with max $50 in his pocket in which he expects diagnosis and treatment. Then you have to really spend 10 minutes with the patient on diagnosis and try to avoid any tests or imaging and use clinical judgement. There is little to no need for malpractice and documentation but there is only $50 in it for you. If you can’t get the job done in $50 he will go to the next physician down the road and tell his entire extended family not to visit you as well.

At least you get respect for it and don't have the kind of headaches doctors have in this country. Medicine is getting worse and worse here, year by year.....
 
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