Chasing Two Rabbits

It's said that when one attempts to chase two rabbits at the same time the only sure outcome is that both will escape. And for all our talk about busy-ness, multi-tasking, and juggling, to the point that these come to seem normal if not praiseworthy, the fact remains, with an increasing body of supporting data, that one cannot do two things at one time and do them justly and well. Even Jesus of Nazareth said no one can serve two masters, yet in healthcare we're expected to do it every day.

"Lucille" is 93 years old and in August went to the Emergency Department with back pain that turned out to be due to a compression fracture of one of her vertebrae. This means that one of the bones in her back had collapsed, a problem that occurs fairly often in advanced elderly patients who have thinning bones. She was admitted to the hospital to undergo a procedure that restores the height of the collapsed bone and then cements it in place so it doesn't collapse again.

The next day the manager of the orthopedics department called me. Lucille wants to go home, he said, but she lives alone in a second floor walk-up apartment and has homemaker services only fifteen hours per week. While her granddaughter and grandson-in-law live downstairs, they both work outside the home and so aren't available to help except in the evenings and on weekends. Lucille was doing well after her procedure the previous day, but the manager was concerned. "Will you go talk with her and see what you think?" he asked.

On a personal note, August was a bear for me. Property taxes for half the year were due, a painful bite in excess of five thousand dollars. At the same time, the car developed a two thousand dollar problem, and two of the dogs ran up a nearly thousand dollar tab for the vet. The mortgage, utilities (including summer air conditioning expense), and routine expenses ranging from groceries to gas all had to be paid as well. Some months just are like that, but darn! they're tough when they happen.

One of the professional hats I wear is that of home healthcare liaison to an area hospital, where I help to transition patients from hospital to home, being sure that they have the supplies, equipment, and services they will need once discharged. I meet with patients and their families or other helpers before they leave to answer their questions, assess their needs, and evaluate whether there may be safety or caregiving issues at home while the patients recover or as they cope with chronic illness. I review the medical record and discuss each case with the hospital providers, and then send pertinent information to the home health agency so services can be initiated. Roles of this nature have been around for a long time, but too often these days their focus has shifted.

Originally liaisons were service providers whose job was as described above. However, with the rise of for-profit healthcare there has been increasing pressure to turn liaisons into sales people whose job is to secure new business (read: "patients") for the home health company. When I took this part-time gig I said very clearly that I would be there to serve and not to sell, except to the extent that good service and outcomes themselves generate business. Nonetheless, there is a provision for bonuses attached to my employment agreement, whereby I receive a four-figure bonus any month in which I generate a specified number of referrals, a designated percentage of which have Medicare as the primary payer. (Medicare is the best payer for home healthcare.)

So there was Lucille, 93 years old, home alone most of the time, stairs to her apartment and probably dated fixtures and accommodations within it, with a broken back and a wish to go home. And Sue, with eight thousand dollars in new and due bills superimposed on the usual monthly expenses, and happening to be within striking distance of earning a bonus for the month of August.

Rabbit #1: Lucille's health and safety
Rabbit #2: Sue's sorry finances that month
Rabbit #3: A for-profit hospital and for-profit home health agency with stockholders who expect a good return on their invested dollars

No clinician ever should be in a position where his or her personal financial interests come up against the health interests of his or her patients, while a corporate entity looms over them all with an eye to maximizing investors' returns.

But it happens every day, many, many times a day, in ways great and small.

Lucille turned out to be a very alert, spunky senior with a sparkle in her eyes, a smile that would melt a stone, and determination that would move the rock of Gibraltar. She had walked to the bathroom by herself that morning, she told me, and then dressed herself. And she was eager to go home, having told the ortho manager very clearly that she wanted no part of any inpatient rehabilitation setting. I explained what home healthcare is and what we do, assured her that whenever she went home we would be there to provide those services, and said that she and her doctors would be the ones to determine when that happened and if any intermediate steps were needed. And I told the manager that I had done just that.

Lucille went to inpatient rehab, I never saw her again, and I earned no bonus that month. In fact, I'm proud to say that in the two years I've been doing this job I never have earned that bonus. To do so would require meeting an absurdly high quota, which in turn would require aggressive selling, promising services I know wouldn't be delivered, and pushing patients like Lucille towards home and home healthcare despite it being clear that they would be best served in another setting.

When I walk into a patient's room, in my white coat with my name tag bearing not only my credentials but also a large, easy-to-see attachment that says "NURSE," that patient must be able to know that I am there to advocate for his or her best interests. The day that doesn't happen is the day I've sold my soul to the devil.

Today, every day, in innumerable ways, every provider faces these situations. Some are blatant and glaring, others so subtle that they could be overlooked.

There are managers who receive bonuses for keeping costs down. By far, the biggest line item in a hospital budget is nursing services, so by cutting nurse staffing to a bare bones minimum significant dollars can be saved, and bonuses paid to managers and dividends to stockholders. Someone recently wrote that the appearance of nurses marching on the Capitol in Washington is the canary in the coal mine for healthcare. In May of this year nurses indeed marched, for safe staffing standards, and I'll tell you that the canary indeed is on its back and kicking very feebly. Nurses aren't agitating for better staffing because they want cushy jobs; most of us are terrible at sitting around and truly want to work and to serve. But a nurse cannot rightly attend to one critically ill patient while another who is just as ill waits, others whose needs are less urgent don't see a nurse for hours, and none receive instructions they can understand or the support they need to be able to care for themselves safely when they go home.

Last week a newly diagnosed diabetic patient with little command of English went home with insulin but no needles to inject it and no meter to measure his blood glucose. The doctor had written a prescription for insulin but not for needles, and the nurse was too busy to check to confirm that the orders written were complete. In two days the patient was back in the Emergency Department with a sky-high sugar level. Had he delayed any longer, he would have died.

Another day, at 3 PM doctors determined that a patient with a serious bone infection in his leg could go home with intravenous antibiotics. The infection was particularly difficult to treat, requiring two different and very strong drugs, and if treatment failed the patient would lose his leg and possibly die. Processing an order for home infusion takes some time, as a special infusion pharmacy must be contacted and someone must gather and send supporting clinical data for the pharmacist there to review and in turn complete and submit a request for insurance payment for the infusions. Once insurance coverage is confirmed any copayments that are required must be discussed with the patient and arrangements made to collect those. Then the drug must be prepared, all the supplies for maintaining the intravenous line gathered and packed, everything loaded onto a truck, and the order dispatched to the patient's home, which usually is many miles away and where someone must be available to receive it. Knowing this, I stood in front of the nurse and said, "Don't let this patient go until I tell you that arrangements for his home infusions are in place. He will need his last antibiotic dose for today here at the hospital before he leaves, as this late in the day there is no way to make a delivery to his home tonight." But the patient was discharged before he received the drug and without the blood test needed to assure that the dosage was correct, which meant the infusion pharmacy could not proceed with the home order at all because the dosage to be dispensed was unknown. There had been a discharge order, someone had arranged transportation earlier in the day, and when the van arrived the patient left, while the nurse was busy with another patient and didn't see him go. Mercifully, he was contacted and agreed to return to the hospital the next morning.

Physician colleagues regularly tell me that for-profit corporations are decimating their practice, adding layers and layers of paperwork and authorization requirements while cutting payment and denying services. Recently a paralyzed patient with bedsores was discharged from the hospital; since being home she has been unable to see a doctor because none will accept her "Medicare Advantage" insurance plan. The reason? That plan isn't paying even its own contracted physicians. Another of my patients is able to eat only small amounts of fruit and occasionally oatmeal because he is so sick from cancer spreading through his body and from the chemotherapy being used to treat it. He is skin-and-bones, and no longer able to climb the stairs to the only bathroom in his home. His "Medicare Advantage" plan refused to approve a request for a bedside commode. Excuse my language, but the insurance company that has taken his Medicare dollars for years will not give this man a pot to piss in. Literally.

A few years ago a senior physician with whom I worked for years at one of the university medical centers here shared his concern about young doctors graduating "with a mortgage but no house." Suffocating in debt for their medical education they cannot afford to practice in primary care and many other specialties, and often cannot afford to do the work they love, that which initially drew them to medicine. Instead they are casting about for any opportunity that promises to help pay the bills and keep their heads above water. Just this week another mid-career physician spoke of the reduction in payment and billing issues that soon will make it impossible for doctors in private practice to make a living at all, effectively forcing them into corporate or very "nontraditional" positions.

So the rooster is going to have to go to work for the fox guarding the hen house.

If car repair bills, veterinary expense, and property taxes could set someone like me in opposition to the best interests of patients like Lucille, what are these far more dire and ongoing circumstances likely to do to the lives and judgment of our doctors?

There are those among us who "tsk-tsk" and "cluck-cluck" about all of this, but think themselves somehow exempt. However, under their Armani suits or ragged jeans they are as vulnerable as anyone else when they land in an Emergency Department and find themselves looking up at name tags that say "NURSE" or "PHYSICIAN." And if the HMO didn't pay the doctor that month or the nurse had to come up with tuition dollars for a child and there is a dollar bonus attached to swaying patients' care one way or another, a burnout and fatigue factor operating from chronic understaffing, a pharmaceutical company ready to "take care of" a doctor who orders its drugs, and/or a ruthless insurance company out to serve its own interests, even the tsk-tsker and cluck-clucker are likely to experience first hand the consequences of pitting the best interests of patients and the best practices of clinical science against the greed of insurers, big pharma, and other corporate interests. And ultimately all will experience the fallout of simultaneously

Chasing Two Rabbits