I wrote a while back about the need for a social contract in healthcare. The essence of that contract is that I have a right to receive timely, quality and appropriate care. In return for that care, I need to take responsibility for my health and lifestyle as well as appropriately use healthcare resources.
I treated a patient recently that clearly elucidates this contract and how we need to modify our expectations if we are going to collectively improve and save our healthcare system, including care in emergency medicine.
The patient had a three month complaint of right upper quadrant abdominal pain. The nature of his condition caused me to suspect gallstones. The patient had baseline labs, a sonogram of his abdomen and pain medications. The pain was essentially resolved after one dose of medicines. His lab tests were normal including all of his liver enzymes and sonogram showed some stones but no evidence of acute cholecystitis. If it had, there would have been a clear reason to admit him for immediate surgical evaluation.
As a result of his evaluation I prepared him for discharge and follow-up as an outpatient for a surgical consult and likely elective removal of his gallbladder at a later date. That’s when the story got interesting. As I walked back in the room, his significant other informed me that she was a utilization review nurse. She said the the use of IV narcotics to control pain meant the patient met criteria for observation. She requested he be admitted for a surgical consult as he was just starting a new job and did not want to risk missing work. What I thought was a routine case had just turned curious.
There was really no reason to admit him. He was pain free, had normal labs and only stones on his sonogram. I told him that and that I also realized he wanted to be treated as soon as possible for this condition.
So what does this case have to do with the social contract? Quite a lot, actually. An observation admission costs the overall healthcare ‘system’ several thousands of dollars between the hospital and physicians charges. The patient’s responsibility would have been 20 percent even with insurance coverage due to the outpatient nature of the care. Meanwhile, a surgical consult in the office would probably be several hundred dollars. In addition, the surgical costs for an ‘emergent’ cholecystectomy would probably be higher than an elective one done as an outpatient.
We in America live in a society where now is often not good enough. That needs to change with health care. We need to reset many expectations on the limits of what we can do as a system. We need to talk more about personal responsibility and how we support those choices as a society. We also need to be more compassionate in the delivery of that care and considerate to the patients and families. It is a balancing act no doubt.
So what happened with my patient? I offered to call the on-call surgeon and arrange an appointment in the next several days. I was able to reach him quickly and he was happy to see the patient in the office. While they preferred to be admitted they agreed to follow up in the next several days. In the end it was a reasonable and appropriate plan, both for the patient and for the system.
In the back of my mind I am curious to know how they will be scoring me on my patient satisfaction score for the care they received. But that is a topic for another day.