Thursday, December 18, 2008

Economy and Waste in Health Care

Let me start by saying that I think there are many valid points of view about what causes health care costs to be so dramatically high and to rise so dramatically fast. Doctors see different things from patients, and both may see different things from accountants who see different things from insurors and lobbyists and etc. So I fully acknowledge that even the sum total of all I see or could see from my perspective is only one viewpoint and not the whole.

However, there are things that certainly make one wonder. A new patient came into the inpatient hospice unit recently. This patient has had some serious diagnoses for quite awhile and everything kind of came together in a perfect storm a couple months ago. The patient was in and out of the hospital, in and out of intensive care. A couple weeks ago the patient, who could in layman's terms be described as "held together by chewing gum and baling wire," was discharged from the hospital to a skilled nursing facility (SNF) for "rehab." This lasted about 24 hours, whereupon the patient was returned to the hospital in critical condition and went back to ICU. And back onto a ventilator.

Now, obviously, cost is minimized when patients get the appropriate level of care in the appropriate (that is to say, cost-effective) setting. And to be sure nothing is gained by keeping a patient in a hospital who doesn't need to be there, but really? Two ambulance transfers in 24 hours? With all the coordination and paperwork and orders and etc. that are required to transfer someone to another care facility? How much money did THAT save? The patient is now in hospice, the last acute crisis having pretty much shown everyone that the prognosis is simply awful, the patient is suffering terribly, and it's time to quit with the invasive curative stuff and look for comfort.

I really am annoyed by expense that is disguised as efforts toward efficiency. Such as, holding meetings every single day to browbeat department leaders about why they are not more cost-effective. If the meetings degenerate into repetitive exhortations to "do better," and, in the industries where I've worked that tends to be the case, then they become, themselves, a huge waste of money as well as a morale-destroyer. I suppose you could call that efficiency: wasting money and ruining morale in a single meeting. I'm sure Scott Adams has explored this theme in the Dilbert strip and books.

A death early this morning, and our wild and crazy mortuary driver appeared. I warned him the deceased was a good-sized fellow, not tall but sort of stocky. He sighed. "They're all big, today," he said. He'll be more chipper in a couple more days when we have some snow and ice for him to drive through.

Oh, and here is a GOOD rant: I was present at a death of a gentleman of middle age. His mother and sister were attending him. A brother had died recently, so this mother had lost two sons in, I think, less than a year. The earlier death had happened in some sort of care facility and unfortunately a new age romantic had attended the family. The romantic had told the mother that she should not have her hands on the body of her dying son because "It would hold him back spiritually" and "She needed to let him go." She had tears in her eyes as she said, "I didn't get to hold my son..." and wondered about THIS son. Who, as it happens, had curled his fingers around my hand when I touched it. I'd transferred his hand pronto into his Mom's hand, where he continued, although profoundly unresponsive, to curl his fingers round hers. "LOOK," I said to her. "There just is not one rule for all. Your SON will tell you what he needs, and you will know. If he gets agitated when you touch him, you will know he is asking you for a little space. But, see, he is curling his fingers around your hand. It looks to me as if he LIKES having you touch him. You're his MOTHER, you know him, you stay here and do what you know will help him." He died less than thirty minutes later. With his mother and sister holding him. The way they wanted, the way he wanted, the way they didn't get to do thanks to the romantic, the last time. Blech. Now, I suppose it is possible that the previous son was agitated and the caregiver wanted to diminish the stimulation around him, that can happen. But the way it was phrased, that's mean, and I call it every bit as much abuse of power as if the caregiver had told the mother her son would go to hell if she didn't get him to say the sinner's prayer.

When we have agitated patients and they need calm, I would ask the family to try giving the patient a little space and emphasize that as a way for them to help, which is what they are yearning to do, rather than lay some sort of trip about "holding back spiritually."

Enough grumbling, time to walk Big Fuzzy!


Blogger Mary Beth said...

So glad to have you doing the work you do.

3:19 PM  

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