Demystifying Medicine One Month at a Time

Push or Pull?

Chances are if you’ve never been admitted to a hospital, you know someone that has.  If that admission was unplanned, you likely waited a long time in the ER before you or your friend/loved one was transported up to the hospital floor.

If hotels ran like hospitals, they’d run themselves out of business.  Imagine the desk clerk, instead of giving you your room key (swipe card?), telling you, “I’m sure your room will be ready in the next 2-4 hours, or at change of shift, Mr. and Mrs. Cunningham…”

What is it about hospitals and all this waiting?

For one thing, hotels have the tremendous advantage of their customers planning their departure dates.  All the hotel has to do is enforce a “checkout time,” after which a guest is threatened with paying for another day’s stay–voila!–let the march of checker-outers begin!

Hospitals wish they could do the same thing, but there are major differences.  The main difference is that you and I aren’t paying directly for the hospital bed–insurance is.  So there’s no personal incentive to get out quickly.

Also, there are too many moving parts when it comes to executing a checkout (in hospital-speak, a “discharge”).  Nurses can’t discharge patients from a hospital floor without a doctor’s order.  Doctors are frequently busy caring for sicker patients, so they sometimes make discharges a lower priority (though this has changed with the focus on efficiency and attention to–hold your nose!–‘throughput’–getting patients in and out of the hospital as quickly as possible).

To understand why throughput has become such a dominant concept in hospital operations, it helps to understand a bit about the economics:

Since 1984, hospitals in the U.S. are paid for inpatient stays (a hospitalization) under the Diagnosis Related Group [DRG] system.  This was a Medicare innovation. Under the old system (purely “fee-for-service”), the longer someone stayed in the hospital, the more charges the hospital rang up.  And the more money the insurance paid.  [Now you see why politicians sometimes call Medicare a “headless check-writing machine using taxpayer dollars.”]

The folks running Medicare could see where this was headed–with no incentive to move people along, patients could stay in the hospital indefinitely, until they were, well, better!

How quaint.

Now we admit patients, diagnose them, set them on a treatment plan and discharge them to home or another facility [like a rehabilitation hospital] usually within 72 hours.  Hospitals have become patient-churning factories.  With tight margins.

For the last quarter century, the longer a patient stays in hospital, the longer they stay in the hospital.  Typically it results in no higher payment to the hospital (that is, unless there are ‘complications’ requiring further treatment or that involve alternative diagnoses).

If you have pneumonia, the hospital gets the same payment whether you’re there for two days or seven.  Suddenly, you can see the logic of the shorter admission.

In such a system, the hospital stands to keep more of what it’s paid the faster they can get you out.

The irony is that it’s harder to get you out if they can’t get you in.

Hospitals have shed beds over the last two decades as they’ve looked to run closer to capacity.  Empty beds don’t bring in revenue, so staffing for them is a fixed cost that needs to be ratcheted down if at all possible.

Yet running closer to capacity strains everyone.  It makes the beds more scarce, so it’s tougher to get that patient from the ER or the operating room admitted to a bed if all the beds are full.

Plus, there’s no incentive for the staff caring for the patients that are currently hospitalized to discharge one patient and bring in the next one.  Admitting and discharging patients require inordinate amounts of paperwork on the part of the nursing staff.  Caring for the patients that are there is the path of least resistance.

When I worked in administration, I was charged with solving this problem:  How could we make the nurses hunger to bring in the new patients faster?

The obvious answer was to provide incentives to help grease the wheels of healing and commerce.  But this ran afoul of the collective bargaining agreement with the nurses’ union.

I called around to other hospitals, and was surprised to find that this problem exists almost universally.  Some places call it “holding” time, some “wait” time, some “time to transfer.”  Call it what you will.

It means that the patient, the sick one, winds up waiting until a bed is opened, cleaned, and re-assigned.  Then the patient has to be transported to the room.

How long should this take?

I called the largest for-profit hospital chain in the country, figuring they must have developed a solution.

The executive with whom I spoke was extremely kind, and willing to share all kinds of information with me about this topic.  “Improving patient care is not proprietary information,” I was told. I liked this attitude.

Unfortunately, the for-profit world is no better at solving this dilemma than we are.

“Get back to me when you have something that might work!” the for-profit administrator begged me.


  1. Dr. Grumpy

    I don’t have any answers. Have you looked into how this is done in other countries, such as Canada? I don’t know if they have a different system for handling patient turnover. Although the payor system is different, the inner working of hospitals are similar.

  2. Adam

    You are correct that there is no solution under the current status quo. The government expects the private sector to provide health care but then sets up a huge number of constraints and restrictions that prevent the private sector from succeeding.

    Either a fully private system (like the US used to have) or a fully public system (like Canada has) offer a major advantage, namely that the decision-makers have flexibility and control and can make hard decisions.

    The current US system of ambiguity between gov’t, hospitals, insurance and individuals is not the recipe for success. It is the recipe for a unending political battle.

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