Call it the riddle of the revolving-door recuperation. Why are so many Maryland patients spending only one day in the hospital?
Maryland hospitals on average discharge more people after one day, as a portion of their total business, than those in almost any other state.
The reason might not be what you think. It has to do with delivering too much health care, not too little.
Solving the puzzle shows yet again the difficulty of containing medical costs and how Maryland employers, insurers and patients pay millions for what are probably unnecessary services. It also demonstrates why Maryland hospitals are worried about looming, intensive Medicare audits designed to uncover unneeded treatment.
Experts say Maryland hospitals aren't necessarily discharging patients who ought to be staying longer. Rather, lucrative reimbursement schedules induce hospitals and doctors to admit many patients who likely don't need to be there.
"It's fair to say that some hospitals have admitted patients for the extra revenue that gives them under the current system," says Hal Cohen, a consultant who does work both for Maryland hospitals and insurers, including CareFirst BlueCross BlueShield.
Maryland hospitals seem to be very good at it.
Last fiscal year, 24 percent of all Maryland hospitals stays were for one day only, according to data from the state's Health Services Cost Review Commission. At some hospitals, the portion was a lot higher - 34 percent at Upper Chesapeake Medical Center in Harford County and 31 percent at Union Memorial in Baltimore.
The national average for one-day stays is about 17 percent of admissions.
No wonder Maryland hospitals worry about Medicare auditors who have been going across the country reclaiming money billed for what they say are unneeded one-day admissions. Based on what Medicare did in other states, Maryland hospitals could have to give back $42 million, says Marty Brutscher, a health care finance consultant with McBee Associates.
Hospitals deny knowingly taking patients who don't need to be there. It's the doctors who admit, not hospital administrators, they say. And given the difficulties of diagnosis in pressure situations, they add, it's not surprising that they sometimes admit patients who turn out to be not that sick.
Dr. Stuart Bell, Union Memorial's vice president of medical affairs, attributes his hospital's high score for one-day stays to its cardiac practice. Often, people getting coronary-artery clearance or stent implants spend a night as inpatients.
Upper Chesapeake focuses "not on how long a patient stays, nor the potential revenue associated with their stay, but the quality of care," says hospital spokeswoman Martha Mallonee.
OK. But the best way to explain economic activity is usually to look at incentives. The incentives for Maryland hospitals to admit patients who might not need to be admitted are powerful and, combined with admissions statistics, suggest hospitals are gaming the system.
Medicare pays flat fees (more or less) according to diagnosis and symptoms. Unless there are complications or surgery, somebody admitted with chest pain earns the hospital just as much whether he stays one day or five.
So why not just admit the guy who ate a bad oyster, pocket the revenue and send him home the next day? Or the stent patient who didn't really need to spend the night, either?
Maryland's unique setup, in which private insurers pay hospitals in the same fashion as Medicare, only increases the payoff for admitting mildly ill patients. (Of course, a fear of getting sued is also a factor behind over-treatment, whether for one day or 20.)
Jim Reiter, spokesman for the Maryland Hospital Association, notes that for all admissions, the average length of stay in Maryland is lower than across the nation. But he acknowledges that the Maryland system offers incentives to admit patients with questionable illnesses for short stays.
Medicare auditors authorized by a 2003 law have clawed back nearly $1 billion in hospital "overpayments" in other states, much of it for one-day stays. Brutscher, who works with hospitals, insists that much of the reclaimed money is about incomplete paperwork, not patients who weren't seriously ill.
Auditors now have Maryland in their sights. They're expected to begin going over years of local Medicare claims in the next few months.
That's probably why hospitals have agreed to negotiate with the state's medical cost agency on changing the payment setup. They're talking about setting up half-way stations to observe patients who don't seem ready to go home but who don't obviously need admission. That care would be reimbursed at less than inpatient rates.
It would be one victory in the fight to fix America's overpriced, overutilized medical system. Only 99 more battles to go.
Meanwhile, be careful in the emergency room. They might not let you go home.