30 March 2009

University of Chicago in more trouble

WhiteCoat has a reasonable rundown on the events surrounding last month's death in the waiting room at University of Chicago Medical Center -- as well as a satisfying but spurious idea of how UCMC should respond.   The news is that now CMS is looking into this as an EMTALA violation, which, based on the facts as presented, it almost certainly is.   The headline is that Medicare could pull its certification of the hospital, which is technically accurate, but terribly unlikely.

UCMC is in trouble.   There's no mistaking that fact.   They're being crucified in the media over their ER, and with good cause -- their ER is a nightmare, even for an inner-city academic center.   It seems to be a self-inflicted problem caused primarily by bad senior management -- not of the ER, but of the facility.

I've spoken and corresponded with some people with direct knowledge of the situation there.  The problem is that the hospital does not want to provide basic medical care as its sore mission.  They want to focus on their "Programs of distinction," and to the degree that general medical care is an impediment to that mission, they are willing to throw it under the bus.

The administration of UCMC portrays this as a financial necessity, which is half true.   Their motivations are clearly in part economic -- oncologic and surgical subspecialty services lines are far more profitable than general inpatient medicine, apart from the more favorable payer mix such referrals tend to bring.   However, to claim this is a necessity is an absolute sham -- UCMC has had operating income of >$80 million annually for the past two years running, with a better than 8% margin.  This is a staggering feat in the world of hospital finance.  Even in these difficult times, they managed to retain a 1.8% margin in the fourth quarter of 2008.

How to they do this?   Put simply, they ration care provided to the local community.   Although the medical center has over 590 beds, only 50 beds are available to medical patients admitted through the ER, and only 9 ICU beds are available to ER patients.   This in a facility with over 80,000 ER visits annually!   When a patient presents to UCMC's ER needing admission, if there are no "ED beds" available in-house, or if there are but the ER resident cannot convince the medicine resident that the patient "needs the university," then the patient cannot be admitted to the hospital, and must be transferred.   The ER residents spend more time making phone calls with neighboring facilities trying to arrange tranfers than they do providing direct patient care.

I can see some people saying, "Fine, I can see the logic in that, where's the problem?"  There might not be one if there was a receiving hospital right across the street that would take all transfers, no questions asked.   But that's not the case, and patients needing admission languish in the ER for many hours (and days) while the ER staff seeks an inpatient facility that will take them.   This reduces the number of beds in the department that are avilable for assessment and care of new patients.   The UCMC ED is already undersized, at 30 beds for 80,000 patients (generally, one bed is good for 1,500 annual visits, and at 2,000 visits per bed, an ER is considered over capacity), and if there are seven beds taken out of service, then the capability to move new patients through the department is hamstrung, as the department capacity is reduced by 25%.

The result?   Seven-hour waits to be seen, a LWOBS rate of 10-20%, and people dying in the waiting room.

And it gets worse.   UCMC recently closed its fast track and laid off its mid-level providers who had staffed it, many of them fifteen-year veterans of the facility.    If, as has been claimed, the crisis at UCMC was caused by a deluge of patients with minor conditions, then it makes no sense to close fast tract, but to expand it to streamline the flow of minor patients without consuming ED resources.   Unless, that is, your strategic goal is to eliminate the ED as a service line, in which case the next logical step would be to downsize the ER by a third, and reduce the inpatient beds available to ED patients by half.   Which is exacly what they planned.   After 190 of their doctors (mostly housestaff, it seems) signed a letter of protest, the university may have partially backed off of this plan.

But the message is clear: the University is actively trying to get out of their obligation to provide emergency services and is trying to position itself as a purely referral-based provider of specialty care.   They would probably close the ER entirely if the Illinois Department of Health would allow them -- which might almost be better than the tragicomic sham of an ER they are currently supporting (or, more accurately, failing to support).   In this, I don't blame the doctors and nurses staffing the ER at UCMC.   I've been at institutions where the administration did not support the ER, and there's no way to turn that around until there's a change of management.  I'm sure the clinical staff are doing the very best they can in the shameful situation their hospital has placed them.

There are a lot of factors nationally which place the emergency care safety net in jepaordy; this is not a case of the national picture on the small scale.   This is a case of a crisis caused by willful and deliberate mismanagement.

So with the firestorm of negative PR, condemnation by medical specialty societies, and now a death in the waiting room, is it finally time for UCMC to pay the piper?   It's encouraging that the trifecta of CMS, IL DOH, and TJC are displaying interest.   Whether real reforms come out of this will depend on exactly how aggressive the regulators' approach is.   I've been a victim subject of these agencies' tender mercies in the past, and they commonly take a very adversarial position in these matters.   Given the egregious nature of the policies UCMC has put forth, I have some cautious optimism that the regulators will hold their feet to the fire and demand real changes.  

8 comments:

  1. I can see the money grubbing logic...but have they though about the bad PR and whatnot that would drive their well insured customers away?

    I can see why a hospital could be an anti-emtala advocate....but to do that, you need to actually invest in the ER by creating a superduper triage protocal to "train" the community.... And then dump the ER.
    They have tried to do this in a month, wtf.

    I could not work for an organization like that. When people die for the bottom line...

    WTF

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  2. You mean they don't want to provide goods and services to people who don't pay for them? I'm shocked.

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  3. Nice analysis. You're right on the money -- obviously got past the UCMC Press releases. Anyway, the actions of the administration make much more sense when you realize that Dean Madara is trying to transform the hospital into a specialty clinic for well-heeled (if not healed) patients from the burbs.

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  4. Hmmm, a for-profit hospital?

    If this works for UCMC, will many be far behind?

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  5. thanks for finding the data

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  6. At the same time the UChicago Hosp. execs are withdrawing inpatient beds, urgent care, and ER space allocated to the local community Michelle Obama (a $300,000+ newly hired pr job) is out front stating ""We have an obligation, to ensure that we use our resources on behalf of our neighborhood and our city." I do not claim that she understood what was really happening; rather, her job was, in part, a sham.

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  7. I love this post, as it gets to the heart of the matter. I'm an academic ER physician here in Chicago. And my question is: What is UCMC going to do? Even if all these agencies want a change, there needs to be a change from the top, ie, the hospital needs to make a commitment to the ER. Open (medical and ICU) beds up for admitted patients. But then, you get a large portion of non-paying and poorly reimbursing (Medicaid) patients. If you stop taking Medicare/Medicaid patients, you lose your training physicians/residencies, and your top academic standing (research money etc). Now, if you build 2 hospitals, one research, one specialty care, (both non-profits) then you may be going somewhere. There are places this exist (NIH, MD Anderson). U of C needs to start thinking outside the box. It's going to be tough, though given their bad press and worse, the state of their current ER.

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  8. This sound very similar to UWMC (University of Washington Medical Center, Seattle). Terribly run ED. The department itself falls under direction of Internal Medicine. Strange, but perhaps why the UW LOST it's Emergency residency program, and pushes undersupervised internal med residents through each month.

    On that note, I enjoy your blog!

    Katie

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