Authors: Julie Salamon
Hospital (15 page)
“The right leaders have to see it in real time,” he said. “We have twenty-eight people waiting for beds, average wait time is twelve and a half hours.”
When this digitized vision of chaos popped up on Lili Fraidkin’s computer, she shrugged. “The emergency room is a pot of gold,” she said in her unflappable way. That was Brezenoff’s theory: Contrary to prevailing popular wisdom, that ERs were money losers, he recognized early on that the emergency room didn’t just fulfill the hospital’s civic responsibility, it offered a way to build volume. Sometimes the ER brought in those who couldn’t pay at all, like Zen, but more often they drew in people with some kind of insurance—or for whom some kind of insurance could be gotten.
The variables may have been different, but the essential economic assumptions were the same in Lincoln, Nebraska. Chuck Gregorius, David’s father, said the system reminded him of a popular bar and grill in Lincoln called P.O. Pears, with a menu that was decidedly not Borough Park, offering items such as the Jiffy Burger, a hamburger covered with peanut butter, bacon, and jack cheese. “You go up to a window to order, and the window looks like a big old pair of lips,” he said. “On those lips it says, ‘We lose a little on each sale but make it up in volume.’ Sometimes in health care, because of the constraints on money, we have to spend on health care, sometimes it feels like they are using the P.O. Pears approach. Sometimes in health care, that’s the way it comes out.”
Fraidkin may have been unperturbed by the snapshots Ramsay e-mailed her way, but she didn’t like the last part of his message: “We have three hours of diversion,” meaning three hours in which patients were sent to other hospitals. For the ER to be a pot of gold, it needed constant refilling. But more patients meant more stress on the system.
David Cohen, senior vice president, clinical integration, whose office was just down the hall from Lili Fraidkin’s, had come to Maimonides six years earlier, after a career in public hospitals, including ten years as the medical director at Bellevue. He and Brier were friends, and she urged him to come there to help streamline the hospital’s unwieldy systems. Brier’s husband, Peter Aschkenasy, called Cohen the living embodiment of “think Yiddish, dress British,” by which he meant someone who was practical, smart, a man of the people, but who also aspired to a certain gentility. Cohen lived on Manhattan’s Upper East Side and was a theater fanatic; he and his wife on occasion would fly to London for the weekend to catch the latest shows. In a hospital where everyone said what they thought as the thought occurred, Cohen revealed little.
Cohen saw the hospital, all of it—David Gregorius, Mr. Zen, the crazy ER, the pregnancies and deaths, the rabbis and the politicians—as Brownian motion. It was typical of his erudite sensibility to connect the glatt kosher institution in Borough Park with the nineteenth-century Scottish botanist Robert Brown, who found his place in history when, studying pollen grains under a microscope, he noticed they were gyrating in a strange, jittery way. Brown’s name became linked to small, random movements that weren’t apparent from the surface, a concept that became valuable to Albert Einstein in thinking about the atomic nature of matter and to David Cohen about the management of big-city hospitals.
Cohen had strong ideas about the hospital’s place in the community, and he wasn’t sure if Maimonides—if any nonpublic hospital—was right for him. But when Brezenoff and Brier beckoned, he went.
Shock number one: Unlike those at Bellevue, where almost all the physicians were employed by the hospital, a substantial number of Maimonides patients were treated by private physicians (like the Bashevkin group). “There seemed to be an awful lot of concern by the medical staff of finances in terms of their own compensation,” said Cohen. “That was a surprise. I kind of felt that . . . I looked at the place as . . . this is so quotable I don’t want to say it.” But he did anyway. “It looked to me like a little factory for Jewish doctors to take care of their patients and make lots of money. I was much more interested in the role of a hospital in the community and advancing medicine and clinical practice and care. I just didn’t think I was going to be happy or comfortable here.”
Even Cohen, who kept his emotions under wraps, wasn’t immune to the weird, compelling pull of the place. He began to see a desire to adapt and transform as the hospital struggled to find its place in the intersection between individual well-being and public health care, between expensive, efficient high-tech medicine and the human needs and demands of a community. “I think the place has changed considerably, and I know I have as well,” he said. “It’s hard to say which is which. I think it’s both.”
Cynicism and sentimentality are common enough in hospitals, but something about Maimonides brought it all to the surface. Winnie Kennedy, a senior nurse in psychiatry, told me she thought the exaggeration of all feelings had to do with jamming so many cultures into such a tight spot. “It’s like the yeast in bread,” she said. “It gives the place its rise.”
Brier depended on Cohen to keep the dough from overflowing the pan, to rationalize an irrational system. He was in charge of the front end and the back end, checking patients in and helping them find care after they left the hospital—the transition points. He described how things had changed since he’d trained as a physician thirty years earlier. In those days the crucial nexus for patients and physicians came in the first twenty-four hours: get a history, make a diagnosis, set up a therapeutic plan, carry it out. Then everyone could take a breath, because the patient would stay for two weeks. Convalescence was still part of the plan. There was time for reactions to medication to manifest themselves, or for the patient simply to regain strength.
In 1983, Medicare began linking payment to DRGs, Diagnosis-Related Groups, about five hundred categories determined by disease, age, gender, and possible complications. This formula eventually became the standard payment for all patients. Reimbursement was set not by individual but by group. Thus began the push for hello/good-bye. Discharge planning began almost simultaneously with admission. It wasn’t a bad idea in theory; hospitals were dangerous places full of infectious diseases, even when the staff did remember to wash hands. But, often, speed was achieved more readily than were efficiency and coordination. Even little things that got lost in the shuffle could have a big impact. For example, patients might come into the hospital taking one set of medications and, while in the hospital, be prescribed a similar medication with a different name. If the patients wasn’t made fully aware before they left, they might fill the prescription for the new medication, the one with the different name, and then unwittingly double the dose when they get home.
The entire system had changed. More and more care took place outside hospitals—though patients ejected from hospitals often found they were stranded. As recuperating patients were shoved out the door earlier and earlier, hospitals increasingly resembled intensive-care units. The cottage-industry model, where doctors went back and forth between their patients and their offices, was becoming obsolete. Patients increasingly were handed off by their primary-care doctors to hospitalists like Todd. “Team approaches” and “interdisciplinary models” were meant to maximize efficiency, because everyone had less and less time to spend with each patient.
That’s why the charts were so thick. Every new person who took a look also took a history and made a new notation. That’s why the potential for mistakes increased. Who had time to read all that and get to the next patient in time? And that was assuming you could read the notations, which was rare. Even at a computer-savvy place like Maimonides—one of the one hundred “Most Wired” hospitals—electronic records (outside the emergency room) were still used primarily to relay lab results and to place orders for medication. Patient progress was still scribbled into charts.
“It’s about teams, not lone rangers practicing anymore,” Cohen said. “It’s not even about who’s the captain of the team anymore. It’s about teams, one component of which is strictly medical care. There’s no captain. Someone has to be coordinator, but at each point somebody else is going to have to take charge.”
Cohen described his day.
“By about ten, ten-thirty, I get a list of expected discharges, and I can match them with patients coming in. Probably about sixty discharges a day, actually more. In medicine it’ll be fifty-to-sixty range; that doesn’t include critical-care units. Drop-offs on the weekend. Total surgical-medical discharges are in sixty-to-eighty range. Busy busy. If you consider a seven-hundred-bed hospital minus psych and maternity beds, you’re talking about turning over about one-fifth of the hospital.”
The potential for tension was there every step of the way.
“Before, it would take us ten minutes beginning to end to clear an admission. Now it’s forty-five minutes to an hour,” said Maria Ferlita, vice president in charge of admitting, medical records, in-patient insurance verification. Ferlita was another Maimonides character, Italian-born, a compact woman with long dark hair and dramatic eyebrows who wore snug-fitting skirts and spike heels. Her gravelly cigarette voice issued thoughts as decrees with the rapidity and punch of machine-gun fire.
“That’s what’s put tremendous financial strain on the hospitals,” she said. “I would say on the patients as well. In the past we had five, six payers—Medicare Medicaid, Blue Cross, private, workmen’s comp, and unions. Now you have myriads of HMO companies, mandatory enrollment of the Medicaid population, which has affected hospitals adversely, fiscally. Medicare and Medicaid, very simple. You have documentation guidelines you need to meet. You meet the guidelines, you get paid. With HMO companies, much, much, much more challenging. These are private companies. Their goal, or what we’re finding—they deny a tremendous amount of admissions due to no authorizations. It’s a method of postponing payment to the hospital, and if the hospital doesn’t appeal these cases, there’s a time element, money in their pocket.”
No one was turned away if admitted through the emergency room, but Ferlita made sure her people did all they could for the hospital to be paid by someone. She knew that the system was a mess; her job wasn’t to fix it but to game it. “If there is a discrepancy—a doctor has booked a patient as an inpatient and managed care says it has to be ambulatory—we contact the physician and say, ‘If you want to book this patient as inpatient, you have to send more documentation.’”
NEW SUCK JOURNAL VOLUME A, ISSUE 7 OCTOBER, 2005Dudes,
Ok. Sorry it has been awhile. A resident gets busy sometimes you know. I think I worked like every day for the past month. I guess I had a few days off, but they were fake days off—I really don’t think you can count a day off after you just worked 27 straight hours (as you sleep the entire day), or when you have to go in to work that day at 7pm (as, again, you try to sleep the entire day). I just finished my month of Obstetrics, which I enjoyed, except for the fact I had to work (to some extent) every day, and had multiple 30 hour call shifts. Our hospital delivers 6,800 babies a year (about 20 a day)—the most in the country, so I was quite busy. But I gotta admit, Obstetrics is cool. For those of you who don’t know (I hope not many), Obstetrics and Gynecology is the medical specialty of Woman’s health/surgery/baby delivering, and such, and I nearly went into that specialty myself, as I really like it. I still think that it’s possibly the coolest job in the world, with the exception that it sort of sucks. The hours suck at least. Also we all know that the greatest job in the world is being paid to fish. Duh. Either way, I am done with OB/GYN for now (and perhaps ever?). But I got to deliver a lot more babies, in a lot more languages than ever before. I learned transiently how to count to ten and say “push” in Cantonese, Mandarin, Russian, and at least two other languages that I’m not sure what they were. But that is done now, the times with young healthy pregnant chicks and their babies is finished—it’s back to the ER and all the about-to-die old people . . .
Ok, until next time, carry on smartly
Love, Davey
“Fishing kills me exactly as it keeps me alive.” The Old Man and the Sea
Hi Dave,
Could I meet you at the E.R. on Tuesday around 11-11:30 and hang out for a few
hours, maybe find some time to talk, too?
Let me know.
hours, maybe find some time to talk, too?
Let me know.
Julie
Ms. Salamon-
If it is ok with my attending that day (not sure who it is yet), that would be fine. I’m not sure though. I think it would be fun. But if it is really busy and we start falling behind because i’m not seeing patients fast enough, i might get in trouble. I’ll figure out who is the attending that morning and if i see them before tuesday, I’ll ask them. If not, i’ll ask them that day. And as far as just “following around”, I’ll warn you that probably 50-60% of my time is spent documenting on the computer . . . not very fun to watch.
Dave
Madeline Rivera, associate vice president for case management, reporting directly to David Cohen, told me about the three calls that preceded my visit one day. “I’ve got one patient that wants to be taken off the vent and get out and one who isn’t ready to leave. The wife is upset. She’s eighty-seven years old, husband not doing well, he has to go to a facility. The managed-care company has already told them they’re denying. I’ve talked to our liaison from managed care, saying we have an eighty-seven-year-old who is trying to choose a facility and needs to take fifteen thousand dollars out of the bank, and she can’t do that in one day. Let’s give her until Monday to do that.
“There’s a child who is handicapped and needs placement, and we’re working with the mother, who doesn’t speak English, to help her understand she isn’t sending her child out to die, to reassure her she has visitation rights. She thought she would lose rights because she is of Mexican background, not legal. There are a lot of sad stories. Every day we deal with these things.”
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