In and Out

OK, so I promised a further discussion of diabetes, but we're going to take a little detour to answer the Iconoclast's questions, because it raises several interesting topics, all of them pertinent to healthcare today.
First off, the Iconoclast asks if the sequential toe/foot/leg amps that occur with these diabetics is part of the high re-admission rates that are currently blamed for the high costs of medicine. The answer is: Yes. And No. Hey! That's dodging the question. Actually, what it means is that this population group of poorly controlled diabetics is a huge drain on the healthcare budget due to frequent admissions and significant complications, both with their diabetes as well as with their other medical conditions that are made worse by the diabetes. It's not necessarily the sequential amps that lead to readmission, but rather a continuous spectrum of problems that could often be managed as an outpatient in the general population. And that's something I need to clarify here, as well. When I dicuss diabetes, and diabetics, from a surgeon's perspective, what I'm talking is that group who do not maintain tight control over their disease. As a surgeon, the only diabetics who practice tight control of their blood sugars I know are social contacts and those that show up in my office for an appendix or gallbladder. Diabetics who monitor their blood sugars frequently throughout the day, and maintain their sugars in a very tight range approximating normal, don't have diabetic complications, certainly not at the level of the poorly controlled diabetic. This brings up the whole topic of self responsibility, but I'll save that for another time -- It has so many implications. Anyway, the sequential amputation of the diabetic is variable in it's progression, sometimes a toe every year or two, and ten years to the finale, other times, it's the massive debridement and a BKA less than a month later. So much depends on the patient's compliance with management, just how poorly and for how long they've been diabetic, how many other health problems they've got, and finally (but certainly not least), the patient's socio-economic support system. Sad but true, wealthy diabetics fare much better than poorer diabetics. While we have healthcare for everyone, there's still a lot of cost that isn't covered by any insurance or aid.
The Iconclast's second question is broader:

"what are the issues of readmission from your point -- poor hospital care, insurance/Medicare/Medicad refusing to pay for longer initial stays, poor followup by the home health care folks (part of the insurance issue probably), etc.?"

How about all the above? Poor hospital care is probably the least of all the reasons, at least in my world. Poor care from either the hospital or the doctors generally is a manifestation of external pressures, ie insurance carriers, pushing to have the patients out faster, sooner, quicker. Hospital readmissions were rare because we would keep the patient that extra day to make sure everything was working right. I've discovered a little line in the litany of the insurance providers from several of my battles to get the proper care for my patients. When I ask the medical director (a physician) his/her name, because I'm going to transfer care to them, since they are telling me what to do with the patient, their response is, "I'm not telling you what to do for the patient. You can do whatever you (and the patient) want to do. We're just not going to pay for it. " No fault insurance. They're not interfering with the management of the patient in any way. Of course, we all know the prices are so astronomical that you have no choice to follow their lead, but they're not telling you what to do.
Poor follow up by home health is generally not a reason. These people are dedicated to what they do, and as a general rule, their care is excellent. The actual care providers are in this for the same reason the hospital providers are in it, because they like caring for people. If anything, I say their strong devotion to duty and attention to detail may contribute to readmission just by seeing critical issues and alerting the docs in a timely fashion.
The third reason for high readmissions goes back to the poorly controlled diabetic we discussed earlier. Patients who don't take responsibility for themselves. These are self declared victims, and expect the world to serve them. "why didn't you get your prescription filled?" "The hospital didn't call it in." Or, our favorite, "I couldn't afford the ($4) copay" (while smoking 2 packs a day @ $4/pack). The other day, a patient in my office told me she hadn't been taking her meds because the pharmacy hadn't called the doctor for a refill, even after she had checked back twice. I asked her if she had called the doctor herself. Of course not. That's not her responsibility. Well, hell, if she's not going to take responsibility for her health, why the hell should I? Well, because I'm required to by law, for one thing. When she shows up in the ER, sick from her own irresponsibility, I will come in, no matter what the hour, and bust my ass to save her, and know that she's going to be in the hospital for weeks, on my dollar, because of her failure to take responsibility for her own health care. And that is the doozer of hospital readmissions, usually thru the ER, that contributes to the high cost of medicine.

And on that note, I will sign off, good readers.

Good night, and farewell.