Who Pays for Complex Care Coordination?

Here's a great fundamental question posed in the WSJ. We certainly have many different criteria for determining who meets "acute level of care", without which qualification, a hospital is unlikely to get reimbursed for the hospitalization. However, how does the healthcare system take care of those individuals like the patient below who will not be able to get the care they need unless they are hospitalized. But if they are hospitalized, is it fair that the hospital carries the uncompensated burden for coordinating the complicated care required?

The issues in this case are not dis-similar from the recently well-publicized case of the Florida hospital that received court permission to deport a non-US resident patient directly to his home in Guatemala. The current reimbursement system provides very little compensation for such cases, and it is unrealistic to expect that the average community hospital with scant resources, many of which are at the brink of failure themselves, can provide this kind of care.

It is unlikely that issues like this will be significantly addressed within the current healthcare reform proposals. However, moving towards a system that provides near-universal coverage would be a step forward.

An ER Doc Grapples With ‘Unnecessary’ Hospital Admissions

Published On: July 31st, 2009

It’s all well and good to talk about reducing unnecessary hospital admissions to help control health costs. But the definition of “unnecessary” gets a lot more complicated when you’re the one doing the admitting, ER doc Jesse Pines writes in a column on WSJ.com. He describes the case of a woman with a probable case of lung cancer who needed a comprehensive evaluation. She was on Medicaid, the government health insurance for the poor, which meant she’d have a hard time finding specialists to treat her as an outpatient. So Pines admitted her to the hospital, even though she wasn’t acutely ill. In the hospital, she got a biopsy, a formal diagnosis of lung cancer and a plan for outpatient treatment. She met with a psychiatrist and a social worker. Pines argues that it was the best outcome, though more expensive than it would have been for her to be treated as an outpatient. “She was not sick enough to need a hospital bed,” he writes. “But I believe admitting her was the right decision.”