Maybe this has been said in passing, but it should be stated more clearly: Increased outpatient care isn’t solely due to insurance. It’s also due to improved medical techniques.
A big example is the rise of laparoscopic surgery, which has much better patient outcomes in terms of bed rest needed post-surgically and post-surgical pain. Both of those factors push people out of the wards and back to their homes, because you don’t need a nurse just to handle uncomplicated dressing changes and a few pain pills. (And, yes, those pain pills would have been prescribed for outpatients anyway. You can’t have everyone with a bad back spend their lives in a hospital, and you didn’t have that kind of inpatient care even back in the Old Days.)
Another example is how little time women in labor spend in hospitals. I don’t know if that’s improved technology, improved knowledge (they didn’t need to be in the hospital that long even back then), or both.
Said by “Brendan Buck, former press secretary to Speaker of the U.S. House John Boehner, who was tapped this spring to be vice president of communications at America’s Health Insurance Plans” … Well duh he’d say that.
Of course, and as stated upthread, hospital and/or physician systems want the insurer to view them as a must-have … and the insurer wants to be able to pit systems against each more and have their contact be what the other side must have. From the same article:
Mind you I do not disagree with the thought: the motivation for large hospital systems is to have bargaining power and hospital systems are not the best agent of change to deliver cost-effective care. Physican-owned (or at least led) groups conversely are. Why?
No silver bullet that either … as that article points out the physicians need to develop a culture of medicine delivery as a team sport and with the patient being the population as well as the individual patient, they need to have (or hire out for) a developed and sophisticated IT and administrative infrastructure. Meaningful and believable metrics need to be available and wisely utilized. “Hey kids! Let’s put on an ACO!” won’t do it.
From the nurse’s perspective, what they’ve done is shift from determining discharge by nursing goals to determining discharge by medical goals. The schedule is determined by the doctors, while the nurses scramble to complete their checklists on someone else’s timetable.
My oldest teachers and mentors tell me that they spent days on patient education with new mothers. Feeding, changing, bathing, burping, circ care, infant development, nutrition while breastfeeding, schedule feeding vs. on demand (very out of vogue for a while, all the best scientific mothers trained their babies to a strict schedule!) …and the whole time they were doing it, they were doing nursing assessment for “baby blues” (what today would be considered postpartum depression) and the mom’s coping with her new role, as well as physical healing and watching for complications. That agrees with my grandmother’s tales of two weeks in the hospital after an uncomplicated vaginal delivery. She can’t even recall seeing the doctor for more than the delivery and one day after; all that time was spent on nursing care.
Now they have videos you can watch on the TV in your room, often on some sort of “Baby Channel”. Nurses are still monitoring for complications while you’re there, but not for long. And the time for all that teaching is really really cut short. They have checklists, but I know from two babies that they didn’t actually teach or find out if I was competent at all those things the paperwork said they educated me about. But I was medically stable, as far as the doctors and my insurance company were concerned, and so I was discharged.
I have almost never seen a client after a hospital discharge who even knew what their admitting diagnosis was, much less learned anything about how to manage their condition. Most of them aren’t even clear on what medications they should be taking at home. I don’t mind, it’s my bread and butter figuring it out and teaching them, but it’s definitely education that wasn’t done at the hospital, no matter what the checklist said. Not effectively, anyhow.
It seems from what I read that it’s a general tendancy in all western nations, except for some reason in Germany, where hospital stays are much longer than anywhere else.
It’s quite obvious to me when I talk with people who are/have been hospitalized. They get some serious surgery (say, kidney removal) and they’re out of the hospital three days later, while when I was younger I would have expected a couple weeks.
I wonder if it’s driven more by medical advances or by concerns over cost. Are surgery/post-sugery care/drugs so much better now that what was a concern back then isn’t anymore nowadays?
While cost may not be the only concern, it’s definitely a major concern. And I think it’s because Medicare (and therefore every other insurer) will reimburse a lump sum of X amount for a hospital stay for Y diagnosis, regardless of how long that stay is. So a hospitalization for pneumonia for 2 days and a hospitalization for pneumonia for 7 days will net the hospital the same amount of money.
Some of the “medical advances” are not better technology but better system approaches. A bit less of a doctor rounding once a day and deciding ad hoc for the next 24 and more established best practice procedures and order sets in place. More hospitals and medical groups now have doctors whose specialty is being on site and moving those protocols along. Better realization that people really do not need X day of antibiotic IV and that giving it by mouth works as well and the ability to give IV antibiotics at home if they do need it. The reality is that hospitals are great places to be when you absolutely need to be there and great places to get out of as soon as possible.
A current major driver of health system behavior right now is the Accountable Care Organization (ACO) model. ACOs are co-operating groups of hospital(s), physicians, and other providers, who are responsible for the care of large populations of individuals. If the group can deliver on meeting various quality care benchmarks and cut costs of care to the complete population while doing so by defined amounts they get to share in the savings. Obviously this is a major step different than a fixed reimbursement for an individual’s single admission; in this model getting the average length of stay (and thereby cost of care) for pneumonia down get the system, including the hospital, more money. Preventing pneumonias within the covered popultion in the first place gets the system, again including the hospital, even more. So far the model is giving modestly good results. Early days and early data.
The system is Medicare driven but as noted where Medicare goes the others follow. The system working however requires, as noted, a mindset and cultural shift among the different parts of the systems, not merely consolidating into a larger bargaining unit. It is a process.
I don’t know where you are located or how old you are, but normally breathing problems and chest pain in an adult bumps you to the front (or close to the front) of the line (behind chest trauma, obvious heart attack/stroke, and people spurting blood from a major artery). And sorry it takes a while, but when you have chest pain and breathing problems, part of treatment is keeping an eye on you to make sure you don’t get worse.
I’m asthmatic, and even on a busy Saturday night, it rarely takes more than fifteen minutes for me to be taken to the back; I normally see a doctor in 30-45 minutes. They do keep me around longer than I’d like, but it’s to make sure that I keep breathing and that my peak flow doesn’t drop again.
I also wonder how sick you are – sorry, but when my asthma flares up, the last thing I give a damn about is the décor. I could be getting treatment in a room with wallpaper from 1974 and dingy linoleum, and I wouldn’t give a rat’s patootie, so long as the oxygen, breathing meds, and sweet, sweet IV steroids and magnesium show up.
I’ve been in some really ugly ERs, and in some gorgeous, state-of-the-art ERs, and guess what? Care has been the same at both.
tl:dr – the ER is not there for a fashion show nor for privacy nor for your personal aesthetics; it’s there to save your life.
I’m also going to nitpick you. The photos referenced show an open design that easily allows for multiple people and lots of portable equipment to be added to the treatment area as necessary. Which means a patient undergoing a more serious event (that is noticed or develops while in the ER) can immediately be attended to without being moved to another location (which may be busy with other critical care patients). It also provides for easier sanitation and body fluids/medical waste cleanup.
It’s pure functionality. I grant you there is a noticeable lick of frolicking kitten posters, but this is an ER ward, not a family care office.
