- Most of what we do is a waste of time or delays time
- No diagnosis can be trusted
Look, what I am about to say does not reflect, in any way, my respect for physicians and the institutions they work for. In fact, I in no way expect any person to be perfect, and therefore it's not possible for every thing they order to be necessary, nor every diagnosis to be accurate.
What is my evidence? Why is this true? Yes, I will get to the answers.
I've written enough about useless breathing treatments on this blog to choke a cow, so I don't want to get into that too much here. But any respiratory therapist is taught to assess a patient before and after every treatment. When three treatments are ordered 20 minutes apart, and the patient is breathing normal after the first and still breathing normal before the second is due, that the second one is not needed.
But the Quality Assurance people will cry on your shoulder if you did not do the second two treatments, because the patient required three failed breathing treatments to qualify for admission.
So, while doctors sometimes order breathing treatments because they "think" they will help, or because they will make the patient "feel like we are doing something" or because "it can't hurt." Many more now appear to be ordered just so the hospital gets paid.
Now I don't know if it started with ICD-10 or DRGs, but most diagnosis' now appear to be incorrect as well. Long ago a coworker of mine showed me a diagnosis of pneumonia. He went over the patient's chart with me and said there is no evidence here that the patient has pneumonia at all.
"Look," he said, "the x-ray is normal, there is no elevated white blood cell count, and the patient is not having trouble breathing. The only reason this patient was diagnosed with pneumonia is because the patient was too sick to go home and needed a reimbursable diagnosis."
From then on I paid attention every time a diagnosis of pneumonia was written, and, on many occasions, there was no evidence of pneumonia.
Recently a doctor came to me and asked me a logical question. He said, "How do you, as a respiratory therapist, define hypoxemic respiratory failure? Or, worded another way, what do they teach about it in respiratory therapy school?"
I said, "Well, the easiest way to diagnose it is a CO2 greater than 50 and a PO2 less than 60. Why?
He said, "I just find that hypoxemic respiratory failure is often written as the diagnosis and there is no evidence of it. Most of these patients do not even have a blood gas."
I said, "Keep in mind that a patient can be in acute respiratory failure and have an SpO2 of less than 90 and still be diagnosed with it. During some such episodes there is not time for a blood gas."
He said, "True. But in most cases, that is not the case, and yet patients are still getting diagnosed improperly. I'm getting tired of it."
I said, "I see your frustration. I think most doctors have no clue what a bronchodilator is and when they are needed. I think that most doctors order albuterol because they think it will do something for pneumonia, and there is no reason why it would. And this has gotten so out of hand that CMS requires albuterol for the patient to meet admission and reimbursement criteria."
He said, "I agree. If I don't order albuterol I have QA people knocking on the back of my head saying, "Hello. Hello. We need albuterol ordered on this patient. We need a diagnosis of pneumonia. We need a diagnosis of asthma. We need a diagnosis of COPD. Those are much more reimbursable than what you wrote. We need a diagnosis of hypoxemic respiratory failure."
I said, "It's sad."
He continued to show me examples. He opened the chart of a cancer patient. Her charting showed the following:
- Respiratory Assessment: Dyspnea noted
- Breath sounds; rhonchi
- SpO2: 98% on 2lpm
- Temperature: 98.5
- White Blood Cell Count: normal
- ABG: pH 7.4, PO2 95% on 2l, CO2 35
- Diagnosis: hypoxemic respiratory failure; also pneumonia, lung cancer
He said, "An accurate diagnosis is exacerbation of COPD secondary to pneumonia or lung cancer. You see how this is not a good diagnosis. It throws off statistics, and it also causes the doctor to seek medical solutions that are not best for the patient. It causes the doctor to treat what doesn't need to be treated, wasting money and resources."
I said, "I agree."
He gave me another example.
- Respiratory Assessment; no respiratory distress, coughing spasm
- Breath sounds; rhonchi
- SpO2: 98% on room air
- Temperature: 100.5
- White blood cell count: normal
- ABG: none ordered
- Other: patient has peg tube
- Diagnosis: hypoxemic respiratory failure, aspiration pneumonia, sepsis
He said, "First, there was no ABG done. Second, the physician charted that the patient was in no respiratory distress. So how could he diagnose hypoxemic respiratory failure?" It's simply wrong.
I said, "Agreed."
He said, "So I charted that I disagreed with the above diagnosis, and entered that the patient had probable aspiration pneumonia. The next day the QA officials was all over me. She said, 'That's a difference of $20,000 in reimbursement.' I said, "It's also fraud, and why healthcare costs are so high.' So she was mad at me. The other doctor was mad at me, and I proceeded to explain to her why I was right and she was wrong. It was a learning experience for her. But the next day I worked I saw that she had written, 'I respectfully disagree with the other doctor's diagnosis.' Fine. And you wonder why the healthcare profession is so screwed up. QA officials are so concerned with making money for the hospital that they are trained, encouraged to falsify, or exaggerate, diagnosis. It has caused doctors to become lazy. Rather than think, they just chose a diagnosis from a list of ten most reimbursable."
I said, "The same happened with asthma. Since DRG law was passed in 1978 or 1979 or 1980, asthma rates have skyrocketed. Did asthma rates really skyrocket, or was it because asthma is a reimbursable diagnosis?"
He said, "Agreed. It sucks."
It does suck.