"Discharge patients sooner, or we'll discharge you"

Doctors in New Jersey faced that threat when their hospital tried to implement a controversial new policy. It didn't take long for them to strike back.

By Mark Crane
Senior Editor

A New Jersey hospital presented this scary ultimatum to its medical staff: Reduce your patients' length of stay, or you could lose your privileges. About three dozen physicians were identified as "outliers," because their patients exceeded length-of-stay expectations. They were told that their hospital privileges would be revoked unless they quickly came up with a plan to cut inpatient days.

Hospital officials told the physicians at JFK Medical Center in Edison in early March that they had 30 days to submit a written proposal on reducing lengths of stay. If it was accepted, they'd be reappointed for three months—instead of the normal two years—while the hospital assessed the plan. "Failure to prepare such a plan within the allotted time period will be met with a recommendation of nonreappointment," the hospital noted.

"This is the first time in the state, and possibly the country, that a hospital has linked privileges solely to length of stay," says Steven I. Kern, a Bridgewater, NJ, attorney hired by the physicians. "Length of stay is a legitimate issue, but hospital officials came down with this heavy-handed approach based only on a statistical analysis. They didn't pull a single chart to question a physician's judgment. The policy violates the hospital's own bylaws by deciding recredentialing without any due process."

The average length of stay is 6 days at JFK, a 441-bed facility owned by Solaris Health Systems. The statewide average is 5.1 days. The hospital sent letters to physicians in groups whose overall performance exceeded the DRG-based "expected" length of stay by 30 percent.

One of those physicians was Robert A. Panebianco, a cardiologist in Edison. "We all want to make the hospital more efficient. But instead of asking for cooperation, the hospital thought it would try coercion first," he says. "There was no attempt to determine why a patient stayed in the hospital longer than average. Did he have multiple problems? Was it dangerous to release him? None of that mattered."

Physicians had little idea what kind of plan to submit. "Should I say that I won't admit patients who are really sick, like patients from the nearby veterans home who may have dementia or can't swallow?" Panebianco asks. "Length of stay isn't totally within a physician's control. Is the patient cooperative? Does he refuse testing? Are there delays in getting tests and lab results because of other hospital departments?"

To protect himself, Panebianco is among the doctors who now highlight hospital deficiencies in their patients' charts. "When I order a test and it takes the hospital three days to get it done, I write that as large as I can on the record," he says.

"What's so galling is that the hospital said doctors must come up with a corrective plan before there was any proof that we'd engaged in something wrong," Panebianco adds. "I challenge the hospital to pull any of my charts and tell me whether there's a quality-of-care issue. But they didn't review the charts. We were automatically guilty based on a consultant's software program, and the message was clear: Push patients out of the hospital as fast as you can."

The physicians threatened a lawsuit, held several angry meetings, and granted interviews to the largely sympathetic news media. Even liberal activist groups not normally associated with defending physicians, like the New Jersey Public Interest Research Group, came to their aid in protesting the hospital's "blatant economic credentialing."

"It all became a public relations nightmare for the hospital," says Steve Kern. "The media portrayed this like the drive-through deliveries and mastectomies that received so much publicity several years ago."

Hospital officials argued that the doctors were overreacting. In a full page "Letter to the Community" in a local newspaper, they wrote, "No patients at JFK Medical Center are discharged from the hospital sooner than determined by their physician. Headlines and sound bites from the media have distorted the issues."

The ad said the hospital was simply providing information to doctors in an effort to aid them in delivering appropriate care. "No actions have been taken against any of these physicians, other than required participation" in coming up with a plan to reduce length of stay.

Less than three weeks after the plan was announced, the hospital backed down, say Kern and the doctors. "We've been told that doctors will be reappointed for the usual two years," says Kern. "But nothing is in writing."

The hospital isn't saying much. Several calls and a letter seeking comment weren't answered.

"The only reason physicians won this fight was because of the media attention," says Panebianco. "Without it, we would have been railroaded. Quality of care isn't going to improve until the medical staff and the administration can trust each other again. Obviously, that may take a while."

 

Mark Crane. "Discharge patients sooner, or we'll discharge you". Medical Economics 2001;13:100.