Life in the 467th Group


Anonymous has commented “You are not costing the government any money. Hospitals are paid on a DRG basis. Which means the hospital you are in is eating the cost of your stay beyond any diagnosis related treatment days.”

In the first place, I did not say I was costing the government any money; I said I was costing the citizens money.  My neighbors are paying for me under Medicare and Medicaid.  When we stop thinking about “the neighbors” and start calling them “the government” then we distance ourselves from reality.  “The government” sounds like some detached third-party payer.  No.  It is you.  Call it what you will, the money is coming out of your pocket.

At the time that I wrote “Not Sick, Just Gonna Die” (https://annecwoodlen.wordpress.com/2013/05/31/not-sick-just-gonna-die/ ) I doubt that the hospital was “eating the cost.”  I have searched “Hospital DRG” and gotten Wikipedia and a very interesting education.  A DRG is a “diagnostic related group” and, as I understand it, it is the juncture where money meets medicine, at least as related to hospitals (http://en.wikipedia.org/wiki/Diagnosis-related_group).

“Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups. The 467th group was ‘Ungroupable.’

“A central theme in the advocacy of DRGs was that this reimbursement system would, by constraining the hospitals, oblige their administrators to alter the behavior of the physicians and surgeons comprising their medical staffs. Hospitals were forced to leave the ‘nearly risk-free world of cost reimbursement’ and face the uncertain financial consequences associated with the provision of health care.”

I think this is why, when I was in the Observation Unit at St. Joseph’s Hospital, Dr.Tucker said that “Administration” would not let him admit me, and I understood that to mean that St. Joe’s would not be reimbursed by Medicare for me occupying a bed.  Maybe Dr. Tucker didn’t know about the 467th group, or maybe St. Joe’s is blocking admissions under that group.  I don’t know.  What I am sure of is that “lithium poisoning” and “immune dysfunction, type unknown” are not in the first 466 groups.  (And Dr. Tucker, as a director of hospital services, probably is part of “Administration” and probably should have recused himself from my case on the basis of conflict of interest.  If he had not been a director, just my family physician, how would he have behaved differently?)

My reading of “constraining the hospitals, oblige their administrators to alter the behavior of the physicians” is simply this:  instead of letting doctors treat their patients appropriately and then send a bill, “the government” (in the name of the citizens) is going to demand that hospital administrators—who may not be physicians—force their doctors to not treat their patients right.  “Alter the behavior,” my ass.  The administrators are now working for the government, not the physicians, and they are going to order them not to treat.  And how does that play out, I wonder?  If the doctor refuses to obey the administrator, then what happens?  How much pressure can a doctor put on an administrator before the administrator breaks?  How much pressure can a doctor withstand before she loses her hospital admitting privileges?  And all this is played out in conference rooms and offices to which the patient has no access. 

Then there’s the Big Player:  “the government” that is telling the administrators that they won’t get paid for the time the patient is in the bed, which, at Crouse, is $1639 per day.  So what it all comes down to is that the citizen-patient is getting screwed because the government has gotten so big and strong that it is unresponsive to the citizens; “the government” has acquired a life of its own and, frankly, we should be afraid—very afraid.

So let’s go back to Anonymous, who is usually wrong and who said the hospital is eating the cost “beyond any diagnosis related treatment days.”  Fact:  I was admitted under a diagnosis of hyperglycemia and urinary tract infection, which surely is covered under one of the first 466 groups.  Attempts were made to treat but they failed, so yesterday I was put on ALC or “alternate level of care,” which basically means that the patient is alright for discharge but no place can be found to discharge to where the patient will remain alright. 

It is highly probable that now the hospital has to eat the charge.  This would be one way for the government (Medicare and Medicaid) to motivate hospitals to deal with the discharge problem.  Crouse’s Care Management team, which does discharge planning, has struck me as being the worst department that I’ve run into at Crouse—nursing, dietary, housekeeping and so forth.  Yesterday I met Barbara (sorry, don’t remember her last name) who is the new head of Care Management.  She’s been here less than a year and is working hard to fix Care Management but it takes time to retrain or replace the employees.  I would give her two years before judging her effectiveness, and I’m betting she’ll get the job done.  Barbara struck me as being highly competent.

Meanwhile, back at St. Joseph’s Hospital, in 2000 I spent four months on ALC while they worked on a discharge plan.  By 2013, St. Joe’s had come up with a solution:  kick the patient out without a discharge plan.

Crouse Hospital is doing what St. Joseph’s failed to do; I think Crouse should bill St. Joe’s for my time here.

About annecwoodlen

I am a tenth generation American, descended from a family that has been working a farm that was deeded to us by William Penn. The country has changed around us but we have held true. I stand in my grandmother’s kitchen, look down the valley to her brother’s farm and see my great-great-great-great-great-grandmother Hannah standing on the porch. She is holding the baby, surrounded by four other children, and saying goodbye to her husband and oldest son who are going off to fight in the Revolutionary War. The war is twenty miles away and her husband will die fighting. We are not the Daughters of the American Revolution; we were its mothers. My father, Milton C. Woodlen, got his doctorate from Temple University in the 1940’s when—in his words—“a doctorate still meant something.” He became an education professor at West Chester State Teachers College, where my mother, Elizabeth Hope Copeland, had graduated. My mother raised four girls and one boy, of which I am the middle child. My parents are deceased and my siblings are estranged. My fiancé, Robert H. Dobrow, was a fighter pilot in the Marine Corps. In 1974, his plane crashed, his parachute did not open, and we buried him in a cemetery on Long Island. I could say a great deal about him, or nothing; there is no middle ground. I have loved other men; Bob was my soul mate. The single greatest determinate of who I am and what my life has been is that I inherited my father’s gene for bipolar disorder, type II. Associated with all bipolar disorders is executive dysfunction, a learning disability that interferes with the ability to sort and organize. Despite an I.Q. of 139, I failed twelve subjects and got expelled from high school and prep school. I attended Syracuse University and Onondaga Community College and got an associate’s degree after twenty-five years. I am nothing if not tenacious. Gifted with intelligence, constrained by disability, and compromised by depression, my employment was limited to entry level jobs. Being female in the 1960’s meant that I did office work—billing at the university library, calling out telegrams at Western Union, and filing papers at a law firm. During one decade, I worked at about a hundred different places as a temporary secretary. I worked for hospitals, banks, manufacturers and others, including the county government. I quit the District Attorney’s Office to manage a gas station; it was more honest work. After Bob’s death, I started taking antidepressants. Following doctor’s orders, I took them every day for twenty-six years. During that time, I attempted%2
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