EXCESS COSTSHOW MUCH CAN BE SAVED?

Doris, an 80-year-old white female, had been previously healthy. Her mother had a history of hip fracture. Doris was told to take extra calcium to prevent osteoporosis, but she was never tested or prescribed any treatment.

One Saturday morning, Doris fell in her home and landed on her hip. She lay in pain for about an hour before she was able to reach the telephone and call for help. The ambulance took her to the nearest hospital rather than the hospital she had requested. The doctors at the hospital had none of her medical records and did not realize that she was allergic to penicillin, which they prescribed because of the deep skin abrasions she suffered in the fall. Within minutes after receiving a shot of penicillin, she experienced anaphylaxis, a severe allergic reaction, and required an emergency team to be called to provide immediate resuscitation.

Doris was admitted to the intensive care unit on a Friday night. She underwent X rays and was seen by five teams of doctors over the weekend. The doctors determined that she had a hip fracture and needed surgery as soon as possible. No surgeons were available to see her until Monday morning, at which time surgery was scheduled for Wednesday morning.

While Doris was in the hospital, the physicians decided to do a work-up for gallbladder disease because gallbladder disease is very common in her age group. The scans did show gallstones, and she was initially advised to have surgery for her gallstones. A consult recommended that rather than surgery, she seek health care if she ever had pain in the area of the gallbladder.

The physicians who took care of Doris in the hospital decided to treat her aggressively for osteoporosis using the newest and most expensive medication. The medication was covered by Medicare because Doris was in the hospital. The medication could be given by an injection and lasted for a year.

After discharge, Doris was supposed to receive physical therapy to be sure that she was ambulatory and did not develop blood clots in her legs. Unfortunately, the wrong telephone number and address were provided to the physical therapy team, and it took a week before the physical therapists were able to locate Doris to begin physical therapy.

Doris began the therapy, but on the second day in the middle of the treatment, she became short of breath. The physical therapist recognized the signs of a pulmonary embolism, or a blood clot traveling to the lungs. She immediately called the ambulance, which took Doris to the same hospital where she stayed before.

The hospital staff recognized that Doris had been discharged less than one month earlier and were concerned that Medicare might not pay the bills for her readmission. They decided to transfer her to the hospital that she had originally requested. She was successfully treated for pulmonary emboli and was followed up as an outpatient on a weekly basis for several months.

Doris received over 40 mailings related to the billing for her hospitalization, many of which said, This is not a bill. She did receive 10 separate bills, including ones from the two hospitals, three laboratories, the physical therapy group, and four different doctor groups. The bills for her care totaled $215,000, $212,000 of which was covered by Medicare or her Medigap policy. The bills included a $50,000 bill for the orthopedic surgery, which was fully covered, and a $1,000 bill for transportation to the second hospital, which was not covered by Medicare.

When Doris inspected the 10-page bill from the hospital, she noticed a bill to Medicare for equipment for three blood transfusions. No one told me about that, she said to herself, so she called the hospital to confirm whether she in fact had had blood transfusions. The billing clerk checked with the hospital administration, let Doris know that this was a mistake, and apologized. A week later, Doris read in the newspaper that a large number of Medicare patients were being charged for equipment for blood transfusions they never received.

Discussion Questions

1. Identify ways that each of the IOM categories of excess costs played a role in this case.

2. Identify ways that excess costs could be reduced in this case.

3. Discuss ways in which a reduction in the costs of health care in the United States could affect the quality of health care favorably.

4. Discuss ways in which a reduction in costs of health care in the United States could affect the quality of health care unfavorably.