RACs and Quality of Care

I’ve written before on the nonsense of trying to make a recipe card define quality heath care for patients, emphasizing that expert knowledge is not rule-based.  The numerous attempts by various oversight entities to measure “quality” in medical care always involve taking patient symptoms out of context and counting them. Whether it’s the much-touted “standard of care” or attempts by Medicare to try to find some way to avoid paying for services physicians provide, this checklist process often has little to do with genuine quality of care.

Much of my perspective on the problems of the checklist mentality in health care can be supported by what physicists have learned about complexity, what has become known popularly as Heisenberg’s Uncertainty Principle. Others see the same problems with check lists and health care. In Canadian Family Practice, Dr. Diane Kelsall’s article, “Uncertainty Principle,” provides a good summary of the problems in measuring complexity in health care:

Physicists had believed that it was possible to predict the behaviour of a system infinitely, provided that the initial system had been measured with infinite precision. In contrast, Heisenberg stated that the more precisely the position of a quantum particle is determined, the less precisely the momentum is known in that instant. In other words, because it is impossible to measure the initial state of the system with unlimited precision, we cannot calculate exactly what a quantum particle will do in the future.

Yet the bean-counters continue to count isolated incidents of this or that to come up with some sort of number they insist measures quality.  Let’s be blunt here.  Such tabulating of symptoms is a measure of many things, but it often has little to do with quality of care and usually much more to do with finding reasons to deny payments to hospitals or physicians for the good care they provide.

If Medicare or health care reformers truly recognized quality of care when they saw it, they would not deny care, often needed care, to save money. Yes, there are good studies showing how many mistakes are made in patient care, and this information is valuable in creating processes which avoid future mistakes. But preventing medical errors is not the only variable in quality of patient care.

In the practice of medicine, the reality is that all patients react differently to standard medical care. This makes checklists helpful to practitioners, but such checklists should not be construed as the only available option for quality care. Some patients actually respond better to safe, but non-standard care. There is no mistake in the decision to provide care the patient responds well to. But trust me.  Someone somewhere is taking the successful but non-standard treatment out of context and counting it as a mistake regardless of whether the outcome was good or bad.

Most patients do not know about the Recovery Audit Contractors (RAC) reviewing patient care in hospitals to ferret out “mistakes” in billing. On the surface, this looks reasonable. In practice, this review process is about as reasonable and friendly as the Spanish Inquisition. Presently, only hospitals undergo this review, but if physicians admit patients to hospitals, their patient care is automatically reviewed as part of the hospital patient’s chart.

The American Hospital Association has filed a suit against these reviews.  Frankly, it’s about time.  This is about having someone unfamiliar with the patient or the circumstances of the hospitalization review the patient’s chart, sometimes two years or more after the fact, selecting some detail in the chart, and using that out-of-context detail as an excuse to take back payment made by Medicare. There is much that is draconian in how physicians are forced to practice today, but the RAC system is one of the most perverse of any of the schemes used to deny payment to hospitals and associated physicians for the quality care they provide.

Once again, in theory, the review process seems reasonable. However, the public and most patients are unaware that the money taken back in this RAC review is in large part because patients have been admitted to acute care beds instead of observation beds. Medicare pays hospitals less for patient care in observation beds than in acute care beds. Hence Medicare is very interested in taking money back from hospitals if a patient is admitted into an acute care bed instead of an observational one.

So what’s so hard about a physician being able to tell the difference between an acute care patient and an observation patient when they admit someone to the hospital? When patients appear in the emergency room (ER) for care and are admitted to the hospital from the emergency room, the physician in the ER may not know enough about the patient’s condition to render a definitive diagnosis.  The patient may to the physician be obviously acutely ill, but only a stay in the hospital can provide the lab and radiology results needed to pinpoint the underlying cause of a patient’s condition.

In the medical field, the diagnosis reached as a result of the period of hospitalization, the most accurate diagnosis, is given in the patient record at the time of the patient’s discharge. In effect, Medicare is requiring the admitting physicians to know the discharge diagnosis—and whether this merits an expensive acute care bed or a less expensive observation bed—upon the patient’s entry into the hospital.

If the idiocy of this mentality has escaped understanding so far, let me provide an example.  My physician husband had a patient come into the emergency room with Addison’s disease, hypothyroidism, lupus, and MRSA. The patient was admitted from the ER to an acute care bed in the hospital. Anyone with any sense would recognize that with multiple chronic diseases, much less MRSA, the acute care bed would be a reasonable choice.

The RAC reviewer designated the admission of this patient to an acute bed instead of the cheaper observation bed an error. The reason?  The Milliman Care Guidelines indicated “it appears the observation/lesser level of care versus the acute inpatient billing would be the most appropriate.”  Neither Milliman nor this reviewer knows whether the less expensive observation bed is more appropriate than the acute bed. Note the use of the word appears.  The mere appearance of some sort of minor detail which is likely to be irrelevant in the overall care of the patient means the entire payment is taken back by Medicare.

Physicians have 20 days to contest a RAC decision. The first attempt at appeal simply puts the physician in contact with an RN. If that fails, the physician can contest the decision in a letter. This letter is put in front of the same reviewer who made the decision in the first place. That is, this appeal does not take the review to another level, but simply back to the original reviewer, who is unlikely to change the decision. At this point, no one is overseeing the decisions of these reviewers. There are numerous additional levels of review, all designed to eat up so much time that no reasonable person would see the appeal to the finish.  Physicians don’t have this kind of discretionary time.

The newly found emphasis on patient-centered care does not address the recipe dance physicians have to constantly skirt in order to provide the kind of care they know their patients need and deserve. It is beyond the comprehension of most reasonable people that any process as damaging to the delivery of quality health care to patients as the RAC system should be touted as a great money saver by Medicare. Quality, patient-centered care can only become a reality when physicians are given back their ability to make medical decisions in cooperation with their patients.

No one attempting to assess quality in patient care has been able to come up with any real means of measurement because it is “impossible to measure the initial state of the system with unlimited precision.” It’s time Medicare and those talking about medical reform admit there is no way to effectively measure the complexity of genuine quality of care. It’s time Medicare admitted that the billions of dollars it claims the RAC system has saved the federal government has little to do with genuine quality of care—and often not even real errors—and everything to do with mean-spirited ways to avoid paying providers for caring for their patients.

Bring on the Heisenberg Uncertainly Principle! But I’m not sure those trained to take phrases out of context to justify the unjustifiable have the ability to understand quantum anything.




Some young HR person once looked at my CV and asked me, quite seriously, if I had really done everything I had listed there. Well, yes. Because I am someone who can't sit in a Morris Miller cubicle every day, much less for any great stretch of time. Once the problem is solved, I get bored and I'm ready to move on to the next challenge. This hasn't afforded me any great stability in my work life. I simply arrive in places about ten years ahead of time. So far, at least, that penchant for early arrival hasn't been accompanied with a pocketbook full of door knobs.
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