When the Supreme Court hands down its decision on whether or not the Patient Protection and Affordable Care Act is constitutional, Glen Stream, MD, FAAFP, MBI, president of the American Academy of Family Physicians (AAFP),  hopes he'll be in meetings and not making rounds in his clinic in Spokane, Wash.

That's because he wants to be available to respond to the flood of calls anticipated from the media—and even his fellow physicians. The high court is expected to decide this month whether the healthcare reform law should be overturned in full or in part, or remain intact. Stream, for one, is ready to give his opinion.

And that's in the middle of the road.

Stream is unlike a lot of his physician colleagues who detest the law and would love nothing better than to see it completely trashed by the Supreme Court.

Stream's AAFP, which represents 105,000 doctors, has supported the health care law. His association certainly isn't a cheerleader for it, though. The executive board supported the act, passed two years ago, though "somewhat reluctantly on the whole," Stream tells HealthLeaders Media. "It was controversial among membership; it was imperfect, and incomplete."

While the AAFP half-heartedly gives its approval of the act, a growing number of physicians seem to be more upset about the law. Surveys and polls conducted periodically over the past two years show doctors expressing a steady and increasing dislike of the reform effort, indicating a widening gap between those who endorsed healthcare reform and those who did not.

In 2011, the year after the law was adopted, a HealthLeaders Media industry survey found that 30% of physicians thought the law was positive, 30% were neutral, and 10% were very negative. Earlier this year, another Health Leaders Media industry revealed that 53% of physicians believe the current state of the healthcare industry is "on the wrong track."

The disapproval numbers are getting higher. A new survey released this week by Jackson Healthcare, a physician staffing firm based in Alpharetta, Ga., shows 68% of physicians disagree that the law will have a positive impact on physician/patient relationships. Only 12% of physicians say the law provides the needed healthcare reform for the country.

In a report, the company says that physicians gave healthcare reform a letter grade of  "D," says Richard  L. Jackson, chairman and CEO of Jackson Healthcare. "It's worse than before," Jackson tells HealthLeaders Media, of physician attitudes about healthcare reform.

"Simply put, they don't like healthcare reform. They don't want to be handcuffed [as to] how they practice medicine. Whether it's real or not, I think they feel they don't want more government control. And I don't think it's just a political issue."

The nearly 2,500-page ACA is so multi-faceted that it is broken down into distinct parts or sections.  Physicians may embrace or reject it in total, but many others may like some of it, or dislike some, with partisan preferences playing a role, Stream concedes.

"Even among this very intelligent segment of our population, physicians, I think many of the folks are subjected to the same sort of partisan rhetoric as the rest of the population," Stream says.

"You can ask them, ‘What part of the Affordable Care Act don't you like? Are you against insurance reforms, such as coverage for young people to 26, or no pre-existing conditions?' They are all in favor of that. Are you in favor of getting more primary care doctors and having them paid more? They say, ‘Yes.'"

Not surprisingly, Stream sees the individual mandate provision of the law, which goes into effect Jan. 1, 2014 and requires virtually all Americans to obtain insurance or pay a fine, as a major sticking point and cause for disagreement among physicians. It will certainly be a prime focus for the highest court.

The Supreme Court is expected to decide the constitutionality of the individual mandate, which also impacts other provisions of the law, including a requirement health insurance companies provide insurance coverage for those with pre-existing conditions. Disagreements are reflected in internal polling of the physicians group, in which 19% showed they wanted a complete rejection of the law, and—at the other end of the spectrum—18% didn't believe it "went far enough" in insurance coverage.

"The (individual) mandate is the one piece that people legitimately have fundamental differences of opinion (about)," Stream says. "The other provisions, I think, pale in comparison. But our policy for 20 years is that everyone should have access to health insurance coverage of some kind. I have not seen anybody making a convincing argument that you can get everybody covered, without a mandate. Is a mandate the ideal thing? No."

So what happens if the Supreme Court doesn't touch the law, or just overturns a few sections, and not the individual mandate? With so many more physicians opposing the law, there is certainly going to be more disappointment spread around.  For some older doctors who hope the Supreme Court strikes down the measure, a court decision to uphold it means they will exit the world of being a provider that much sooner.

Hal Scherz, MD, a 57-year-old urologist in Georgia, who founded an organization Docs4 Patient Care, in part, to fight the law, is adamant that the high court's approval would be a turning point in his career. "My time horizon will truncate," he says, noting that he would quit the profession sooner than he would have anticipated. 

"I love what I do and I could easily practice until my 70s, but I am just fed up with all the government overregulation. They have every intention of slashing more revenue, and with the amount of money spent on liability insurance, at some point it just won't be worth practicing. I may be a consultant, and educate myself in healthcare policy."

Certainly there are other physicians who, like Scherz, are "fed up." Many who don't quit certainly may grumble to their colleagues and to themselves if the law is upheld, or even if parts of it are.

But it's not a time to create "silos" of physician opinion on this matter. As healthcare has shown in recent years, physician teamwork for improved patient care is especially crucial, but it may be even more difficult if the Supreme Court goes against the wishes of many doctors. Indeed, physicians' ability to cooperate may be tested further.

Doctors, like others healthcare professionals, need to look beyond the court action, because there are events and a movement of care that will not remain static, no matter what is written by the court. "A river is flowing toward more efficiency and accountability," says Lucy Savitz, director of research and education of Intermountain's Institute for Health Care Delivery and Research,  based in Salt Lake City, Utah. The group is working with hospitals and physicians to engage in a "culture of continuous improvement."

Stream agrees. Whatever the Supreme Court decision, the health reform law hardly touches many watershed issues such as improvements in medical malpractice laws. Or it completely ignores them, such as the SGR (Sustainable Growth Formula), "which continues to rear its ugly head," Stream says. These overarching issues must be evaluated and considered by physicians, as well as lawmakers, he adds.

"Regardless of the politics and view of the (Affordable Care) act, we recognize there are limitations of our healthcare system," he adds. "We pay too much for too little quality and safety, and we need to do better. There's no doubt about that. There are initiatives for improvement that predate the act, and they are going to move ahead regardless of the Supreme Court action."

For improved healthcare, there can be no languishing in middle ground, Stream says.

This article appears in the May 2012 issue of HealthLeaders magazine.

Aside from a patient, perhaps no element of a hospital system is as in need of emergency care as the emergency department itself.

Health systems know this and are working to overcome ED bottlenecks by initiating improved throughput systems. They are imposing fast-track, split-care programs to improve patient flow and decrease wait times by caring for patients with lower acuity in one area, freeing up beds for those with more severe illnesses.

It may seem like a dizzying array of models, but hospitals don't have much time in the we-can't-wait-much-longer ED world to improve patient flow and provide safer access to care.

Hospitals are improving coordination among nurses and physicians to ensure that the sickest of patients are seen quickly, working with primary care providers to develop different care for too-frequent ED users, and installing electronic medical record systems to hasten and coordinate care through outpatient centers as well as in the hospital. 

Hospitals have been systematically revamping and implementing changes in the wake of a 2007 Institute of Medicine report that called the ED a growing national crisis, citing not only delays of care, but also diversion of ambulances to other hospitals and inadequate capacity to handle a large influx of patients requiring boarding. The IOM described in the report "a widening gap between the quality of emergency care Americans expect and the quality they actually they actually receive."

Moving toward ED improvements is a bumpy journey, but one of slow, steady progress if properly managed, with health systems finding direct throughput gains not by singular, but collective changes, hospital leaders say. The 455-licensed-bed Holy Cross Hospital in Silver Spring, Md., like many hospitals, uses a variety of approaches to ED throughput "to make sure the sickest of the sick gets to see a doctor immediately," says James Del Vecchio, MD, FACEP, CMIO and medical director of the department of emergency medicine at Holy Cross.

To improve patient flow, the work begins as soon as a patient enters the hospital and is seen by a clinician, instead of sitting around and waiting to be registered. And quickly, the hospital separates patients having serious conditions from those who do not. By evaluating patients having "minor sore throats" for instance, "the hospital can siphon off 20% of 240 patients going to the ED on any given day," he says.

"Theoretically," Del Vecchio says, "those patients could have been seen at an urgent care clinic or have gone to a primary care physician, but may not have had one," he says. By redirecting patients who don't need ED services to an in-hospital urgent care center called Express Care, the hospital has a quicker response for patients with conditions, such as severe stomach ailments or potential appendicitis cases, who should be seen in the ED.

Of those patients sent to Express Care, the hospital counts 87% of those patients as "written for discharge at Express Care in 90 minutes," says Del Vecchio. "We are aiming for 90%, but still, it's pretty good," he says.

Hospitals like Holy Cross use other techniques to improve patient flow. For example, Holy Cross empowers nurses to begin taking tests on potentially more serious conditions, such as severe stomach pains or potential appendicitis cases. It stations a physician in an area near the ED for at least 11 hours a day to, in effect, conduct ED business without interfering with the ED, Del Vecchio says. "It's doing waiting room management so patients can be seen but not interrupt the flow." In the meantime, a multidisciplinary team coordinates other areas of the hospital, whether it's lab staff or housekeeping, to free up bed space and, Del Vecchio adds, to effectively reduce wait times.

Hospitals are trying new programs to deal with increasing numbers of patients visiting the ED and the resulting impact on wait times. From the moment patients enter an ED until they are discharged from the ED, the average time spent in waiting rooms nationally was 4 hours and 7 minutes in 2009, an increase of 4 minutes compared to 2008 and 31 minutes more than the national average in 2002, according to Press Ganey 2010 ED Pulse Report.

Hospitals don't see the situation easing any time soon. At least 32 million people who are currently uninsured will have coverage under PPACA—and hospital leaders can hope those patients get nonemergent care from a primary care physician and not the ED. But the country faces years of primary care shortages. The United States has about 350,000 primary-care physicians, but about 45,000 more will be needed by 2020, according to the Association of American Medical Colleges.

"My concern is if there are going to be enough primary care providers in place for them to go for appropriate healthcare," Del Vecchio says. "There will be an ongoing and worsening of the problem of the ED if there is a lack of primary care physicians."

Success key No. 1:  Taking pressure off the ED
For many hospitals, the time from the afternoon to the evenings is one of overcrowding and nervousness inside the ED, and it has been no different at the 713-bed Memorial Regional Hospital in Hollywood, Fla., and its 72-bed ED, says Maggie Hansen, RN, BSN, chief nursing officer.

"We have our saturation point [beginning] in the afternoon," says Hansen. "Usually, it is Monday through Thursday, from 3 p.m. to 1 a.m."

The hospital has launched special programs to deal with overcrowding and potentially dangerous situations. One of its most effective ways of reducing the number of patients using the ED has been working with local community centers that provide patient care beyond the hospital, says Hansen.

Like many healthcare systems, Memorial has a high percentage of patients—about 20%—who do not have a primary physician or medical home, Hansen says. While Memorial's ED volume increased rapidly from 2005 to 2010, Hansen says, it has "stabilized" in the past year, increasing from 91,000 in 2009 to 92,000 in 2011.

Hansen attributes the relatively small increase to the hospital's community health services ED discharge program, "which seeks to provide primary care in South Broward for residents who qualify," she says.

"We have also worked diligently with many providers in the community to partner with them regarding patients who are considered high ED utilizers to develop specific plans of care to meet their needs on an outpatient basis," Hansen adds.

The hospital has an ED discharge clinic that provides follow-up care for recently discharged patients. It also has an ED diversion clinic to establish "quick care" for patients who were unable to schedule an appointment with their primary care physicians.

"There are a lot of people who don't have a payer for healthcare. It's our mission to care for people regardless of their ability to pay," Hansen says. "But we don't want them to overutilize the ED services because they don't have a primary care physician. If they come to our ED for an illness—say, heart failure—we can refer them to a community health service so they can be followed up, so they have a medical home."

Having working relationships in the community must be connected with the hospital's own "patient flow team" that evaluates its staffing each day for the ED unit, which includes 62 acute care beds and focuses on patients who leave the ED without treatment, against the advice of hospital staff, Hansen says.

Hansen says that only 1.8% of ED patients leave without being seen, which is better than the national average of 2.5%.

The patient flow team, which includes physicians and nurses, "looks at all components that impact patient flow to identify challenges and barriers, and work on ways to remove them," Hansen says.

The hospital has a "split flow" design in which ED areas are separated into acute care, quick care, and "super-track," depending care the patient may need, Hansen says. The average treat-and-release time for all ED patients is 210 minutes, but for those seen under quick care the time is 110 minutes.

Quick care is a separate area within the ED staffed with a physician and nurses who see patients who "will not need a lot of resources and can be out soon," Hansen says. The super-track room, located outside the ED, where a physician extender sees patients having the "most minor of complaints," Hansen adds. "A patient can be out in 38 minutes," she says. "You can't even go to a doctor's office and be out that quickly."

To keep patients from returning to the ED, the hospital also has a disease management program "especially for those people who don't really have a primary care physician or payer source to have their healthcare managed by a physician or nursing staff. The idea is to help them care for themselves by showing them how to make appointments, take medications," Hansen says. "We help them with following appointments and answer questions they need."

The program is connected to the community health service "to avoid unnecessary ED visits, focusing on preventing readmission of congestive heart failure in particular," Hansen says.

Success key No. 2: EMR in the ED
Hospitals are using electronic health systems to improve coordination and care in the ED, but first they have to recognize one caveat: These systems may not be more efficient, at least initially, than paper records.

The 265-licensed-bed MidMichigan Medical Center in Midland, Mich., turned to an EMR system primarily due to federal mandate, but the transition has become a slow process that involves working with physicians to improve their handling of the records. Hospital officials found that it was important not to just wait for everyone to adapt to the EMR, but to introduce other changes in the ED, as well.

"When the EMR was rolled out at our institution in March 2011, it led to a marked increase in our wait times and throughput times," says Danny Greig, MD, emergency physician at MidMichigan Medical Center. "We were the first people to switch to EMR before the rest of the hospital came on board. It was a huge struggle, just the learning curve, and initially that cut our productivity at least 40%. Initially, a lot of docs were fighting it and wanted to do paper."

As the hospital physicians struggled to deal with the EMR, there were other ramifications, such as a decrease in patient satisfaction, "as waiting times are the major complaint from patients who visit the ED," he adds.

The hospital leaders didn't wait for everyone to come around on EMR.

Because of those early difficulties with the EMR, the hospital could not simply rely on electronic innovation to improve its throughput. Instead, hospital administration and Midland ER Corp. relied on other strategies, such as adding overlap physician shift coverage for afternoons and evenings on a rotational basis, he adds. Essentially, the hospital increased physician coverage from having four to five 10-hour shifts each day.

In addition, the hospital instituted an expedited care model, leaving rooms open for patients with more minor complaints and a nurse staffed to focus on them to move them quickly through the department.  From adding the extra shift and expedited care, overall ED wait times were reduced from 236 minutes to 215 minutes, Greig says.

"I think we're putting all the pieces together," he says. "The hospital is getting patients out of the ED, up to the floors when they need to be admitted, and not boarding them in the ED for six or eight hours or occupying beds that can be used. In the meantime, they are beefing up x-ray, EKG, and lab services to use with the ED. Patients aren't waiting a half hour or 45 minutes to get an ankle x-ray or blood drawn."

More of the doctors are seeing improvements in working with EMR.

"Becoming facile with the EMR is almost completely a function of time," Greig says. "We saw a great improvement at about 2 months, and by 6 months physicians have generally become as good as they are going to get with the technology—again never getting quite as efficient as before it was instituted.

"I embraced it, and it's no question that EMR is the way to go," Greig adds, citing the potential of "improved patient outcomes, the reduced drug errors, the completeness of discharge instructions, in the long run."

Success key No. 3: Frequent fliers
For EDs nationwide, one of the biggest problems is "frequent fliers," those patients who repeatedly use the ED as an alternative to primary care. Many of those patients need psychiatric services or should be seen for alcohol or drug abuse conditions.

Too often, those patients are dismissed by their primary care physicians for failure to follow instructions—and are "fired" by the practitioners, says R. Corey Waller, MD, a specialist in addiction and emergency medicine and director of the Spectrum Health Medical Group Center for Integrative Medicine. Most of the patients have been diagnosed as having mental health or substance abuse issues or poorly controlled medical issues, such as diabetes, or pain issues that "were never fully vetted or diagnosed," he says.

Spectrum Health, based in Grand Rapids, Mich., had initiated the program in late 2011 after identifying nearly 1,000 patients who used the ED at 847-licensed-bed Spectrum Butterworth and 284-licensed-bed Blodgett hospitals more than 10 times in a year. By focusing on these patients, Spectrum has channeled them to cheaper care programs and away from the ED, with hundreds of thousands of dollars saved, Waller says.

Under the program, physicians ask the patients if they would agree to coordinated care treatment; most of the nearly 200 patients contacted early this year said they would. The center's treatment team uses addiction specialists, RN case managers, and medical social workers to evaluate the medical issues, such as pain or diabetes, but also addiction or alcohol abuse that may be driving patients to the ED.

"Of the patients in our system, more than 60% have been preidentified as having been engaged in our local mental health system and substance abuse service," Waller says. Those patients accounted for more than 20,000 total visits and up to $50 million a year in costs to the hospital system. The program was started after he began seeing the same type of patients and it became frustrating, Waller adds.

At least 40% of the patients are neurobiologically addicted to some substance. Through a regimen that combines medication and behavioral therapy, at least 90% have stayed clean since starting treatment, he adds.

When patients "show up here, we have a four-hour initial visit in which they see a case manager, a social worker, and myself," Waller says. "We look over the last five years or more of their records to determine what's been done, what hasn't been done, what's been missed, what's been diagnosed."

Over time, Waller encourages the patients to work with primary care physicians, beginning with phone consultations. Often, those physicians can "identify previously undiagnosed illness," he adds.

"The hardest part is getting these people placed into appropriate therapies," he says. "The goal is to come up with a screening tool so we can identify them and get them the social or psychological or medical services they need before they turn into a high-frequency user of the ED," Waller says.

In that way, he says, the cycle of patients going to the ED is curtailed.

Success key No. 4: Collaborating competitors
A major frustration for hospitals has been trying to access information from previous treatments at other hospitals that could be helpful to avoid redundant or unnecessary tests.

But that is changing in Maryland where competing hospitals are sharing information as well as among doctors' offices. Doctors can access operative notes, discharge summaries, consultations, lab reports, and x-rays from a surgery that took place a short time earlier at a different hospital, with the impact of improving care for ED patients, says Del Vecchio.

The Chesapeake Regional Information System for Our Patients is formally designated as Maryland's statewide health information exchange and has also been named Maryland's Regional Extension Center for Health. The nonprofit membership corporation works to help healthcare providers use EHRs in a meaningful way and to enable providers to share clinical data with other providers and hospital systems across the state.

"From a throughput perspective, the biggest impact of this is when you have medical records to review," says Del Vecchio. "Traditionally you would have to get a signed release, fax it to the other facility, and hope that someone is available to pull the records and send them to you. You try to find the necessary information. The whole process could take hours. Now you automatically find a patient's visit from another hospital using a medical record" available 24 hours a day.

Del Vecchio says that the exchange program is particularly useful in thwarting unnecessary tests. He cited the example of an exchange of data that was particularly helpful related to a patient with abdominal pains who had been in a motor vehicle accident two days earlier and treated at another ED in Maryland, so there were x-rays and CT scans. "I found all her lab results and other clinical information quickly, and that they had done a thorough workup," Del Vecchio says. "That process could have taken hours—if I was lucky enough to get the reports faxed over. By not having unnecessary tests or procedures, you've already improved throughput and patient care."

This article appears in the May 2012 issue of HealthLeaders magazine.

Reprint HLR0512-7

In April, the U.S. House Ways and Means Committee sent letters to 70 physician and healthcare organizations seeking their input to find a "long term solution" to—or at least viable options for—the existing Sustainable Growth Rate formula that doctors desperately want to change.

"Republicans and Democrats alike agree that continuing to do temporary, short-term patches is a less than ideal way to deal with the physician payment issue," a House Ways and Means spokeswoman told HealthLeaders Media. She declined to be identified here.

"Steps must be taken toward a permanent legislative solution, and that requires gathering the input of the stakeholders most affected on the front lines—our physicians and the patients they treat," the official added.  The letter "is an important step toward securing the input of these stakeholders and will be instructive in how the process moves forward."

The House letter invited physicians groups to offer their guidance and suggestions concerning various financial structures for improved care.  In response, physician groups asked Congress to scrap the SGR and replace it with flexible payment options that reward quality and efficiency.

Under the current SGR structure, Medicare physician payments would be reduced 30.9% on Jan 1, 2013, unless, of course, Congress can be counted on to stop it—which they have continually done, in a one-step, two-step for years. The ongoing threat of reduced payments, while the physicians groups' payment needs increase each year, destabilizes their business operations and planning, as long as the formula stays in place.

On the surface, the mere focus of the letter on the SGR suggests immediate hope.

Don't believe it, insiders say.  It's probably illusory.

SGR reform absent from GOP's agenda
For one thing, it's summer and it's an election year—a double deal-breaker for advancing issues in Washington. Absolutely nothing will happen regarding the SGR, not for months, or possibly this year, I am told.  In addition, Republicans have a different healthcare focus, not the SGR: The GOP priority is getting rid of "Obamacare."

That push is reflected in a separate Washington D.C. document making the rounds. It's a memo from Rep. Eric Cantor, (R-VA), the House majority leader, sent to his GOP colleagues over the Memorial Day weekend. I received a copy. It makes no mention of SGR.

Instead, Cantor mentions what the GOP may tackle if the Supreme Court overturns President Obama's healthcare reform. The court is expected to consider challenges to the law sometime in June. 

"Independence Day to August, Americans will rightly be focused on the effects of the Supreme Court's ObamaCare decision when we return from July Fourth," Cantor writes. "Although we do not know how the court will rule, we are prepared to move forward to ensure that the whole unworkable law is fully reported."

"We have a busy legislative agenda planned this summer and our schedule will undoubtedly require further additions," Cantor adds. "I hope this memo provides you and your constituents with an outline of our pro growth plans for the months ahead."

Obviously, Cantor's agenda is not set in stone, nor is it reflective of what the House may do, although 240 Republicans and 190 Democrats are seated in this legislative session. But it does give an idea that the SGR is not a key consideration. "Hey," one healthcare organization official told me about Cantor's letter, "it's politics."

Payment reform requires flexibility
The House Ways and Means Committee's letter to physician groups, however, makes it seem that the committee is serious about looking into changes around the SGR, but offered no timetable as to when it would act.

The House letter invited physician groups to look into various financial issues faced by doctors, as well as organizational alignment strategies.

"Given the SGR situation and the long-term fiscal challenges faced by the Medicare program, this committee recognizes the urgent need to transform Medicare's physician payment system to one that preserves and promotes the patient-physician relationship and rewards physicians for the high-quality and efficient care they provide," says the committee's April 27 letter to physician groups.

"Experts agree that there is no 'one-size-fits-all' solution and that a reformed payment system will require some flexibility to account for the diverse needs of both beneficiaries and physicians," the letter adds. "As we continue to work toward a permanent, fiscally responsible solution for the SGR, we are seeking input from the physician community and other stakeholders."

Short-term fixes result in deficits
The committee noted that Congress has repeatedly enacted legislation to avert scheduled rate cuts since 2003.  It also said that the short-term fixes have resulted in deficits of $300 billion over the past decade.

In response to the House Ways and Means Committee letter, American Medical Association  CEO James L. Madara, MD, pointed to payment rules under Medicare Part A and Medicare Part B that have "not adapted to the increased use of physician services vs. hospital services."  The AMA adds, "This imbalance creates disincentives for physicians who are working hard to provide the most efficient and efficient care for their patients."

An official of the AMA, who also declined to be identified, commented later on the letter, saying, "Eliminating the formula remains a top priority for the AMA and this letter is one step in working with Congress to see that goal achieved."  The official noted that the Senate Finance Committee had a roundtable discussion on the SGR in March.

Physicians' groups offer payment models
Both the AMA and the Medical Group Management Association Medical Group Management Association  have offered the House Ways and Means Committee similar payment models to consider that would advance payment reform.

In her letter, MGMA President/CEO Susan Turney, MD, said she supported "looking at various payment reform models, and the MGMA supports the testing of new models that promote integrated care delivery and encourage cost-effective medical treatment" Options for evaluation include bundled payments, partial capitation, accountable care organizations, medical homes and "other hybrid approaches that couple fee for service payments with a risk based bonus opportunity," she adds.

But "first and foremost," Turney wrote, Congress must act to permanently "repeal the flawed SGR formula used to annually update Medicare physician payment rates."  In the process, Congress should test other payment and delivery models, she added. "Physicians should have the flexibility to adopt different approaches based on their composition, capabilities and community needs."

That all sounds fine. Whether the House Ways and Means Committee does anything remains to be seen.

A year ago last May, the House Energy and Commerce Committee's subcommittee on health conducted a hearing, "The Need to Move Beyond the SGR."

"The committee sent a similar letter last spring (to that of the House Ways and Means Committee, soliciting physician input)" says a healthcare organization official. "And nothing happened."

A press release from the University of Maryland touts the findings of remarkable two studies: "Revenue-driven" surgery and poor planning apparently send some surgery patients home from the hospital prematurely.

Wow. Money was identified as an overriding driver of surgery discharges, and not what's in the best interest of patients' health?

I talked to Bruce Golden, PhD, a professor in management science at the University of Maryland's Robert H. Smith School of Business, about the two logistical studies he conducted. "Revenue-driven?" Pretty harsh, isn't it?

"Originally, I said 'incentive-driven,'" Golden told HealthLeaders Media, suggesting his comments were revised in the editing process. "Every incentive is aligned with performing," he says. "Economics and system-wide pressures dictate when surgery is done."

Whatever the word choice, one thing can be extrapolated from Golden's findings related to the studies of one large, unnamed hospital: Economics dictate how quickly some patients are released, if bed capacity is an issue.

Golden was principal researcher, with co-author David Anderson, also of the UMD Robert H. Smith School of Business, of two studies on this topic. They found that patients discharged from a large, academic medical center when the hospital was at its busiest, were 50% more likely to return for treatment within three days, compared to when the hospital was at lower utilization. That indicates that the patients' recovery was incomplete when first released, according to the report.

The studies examined the impact of hospital utilization on patient readmission rates, and the discharge practices of surgeons at a large medical center. They were published in the two most recent issues of the Health Care Management Science.

The researchers used surgical discharge data from fiscal year 2007, covering more than 7,800 surgery patients who collectively spent 35,500 nights at the facility. They tracked occupancy rates, days of the week, staffing levels and surgical volume.

"Surgeons adjust their discharge practice to accommodate the surgical schedule and number of available recovery beds," the report states. "We find higher discharge rates on days when utilization is high. Our findings suggest that discharge decisions are made with bed-capacity constraints in mind."

While the data shows that economics plays a role in when patients are discharged, Golden didn't wanted to give the impression that money was a key driver. Or the driver.

"You've got to keep in mind, these aren't 'greedy' doctors. Hospitals are really difficult, complex mechanisms, and if they don't bring in revenue, they have to close their doors eventually. The surgeon wants to operate; the patients don't want to be delayed. If a surgery is postponed, it has a ripple effect," he says.

"Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers," he adds.

Golden proposes four solutions:

1.Add more flexibility in post-operative room assignments. While there is a standard post-operative ICU in each service line, "there might be other beds in the hospital that would be able to take a patient and allow the patient to recover more fully," Golden's report says.

Since patients with co-morbidities, for example, may have higher readmission rates, "patients discharged from a highly utilized unit are more likely to be readmitted to the hospital after surgery. Because the discharge rates increase when utilization is high, extra time in the post-operative unit for these patients might help lower the probability that they are readmitted."

Though such procedures may increase costs in the short run, discharging patients who then quickly return to the hospital offers no long-term savings, and decreases quality of care, he says.

2. Create a checklist for bed usage. While many hospital systems have begun to use checklists, Golden suggests that surgeons use them, too, before discharging patients. A list of questions would "force the surgeon to think about whether they were discharging the patient for the right reason," he says.

He noted that the checklist approach, which has been espoused by Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, has been used successfully to reduce hospital bacterial infections. Golden says those procedures also can be applied in evaluating bed usage. "By standardizing the discharge process, it becomes more likely that each patient is fully ready to be transitioned out of the hospital at the time of discharge," he says.

3. Assign transition coaches.  These coaches can look especially at patients at high risk for readmission. "By standardizing the discharge process, it becomes more likely that each patient is fully ready to be transitioned out of the hospital at the time of discharge," he writes. Golden refers to previous studies that show hiring social workers to check on patients and to coach them on treatment and rehabilitation lowers the readmission rate.

4. Align a surgeon's compensation with a patient's health outcome. This would reflect the move toward value-based care. Currently, surgeons are paid for performing surgeries and having high operating room utilizations. "By incorporating readmission rates into the compensation formula, we might impact the discharge decision process in a way that would lower the readmission rate," he says.

Golden spoke with me about his proposals, but he best summarized his findings in the press release, after all. "Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment," he said in a statement.