Robert Pittenger Weighs In On The DMH Scandal
The following is a comment taken from the 2-9-06 post. I thought it important enough to repeat in a separate post (it's also on blogDecatur.) The anonymous poster signed himself as Robert Pittenger, former federal investigator who was in charge of the DMH investigation.
For some time I followed this blog while employed as an Investigator with the United States Attorney, Central District of Illinois. Having some time on my hands since retirement, I decided to see what has been said on the blog. After reading the last entry regarding Hospitalist, there may be something not yet talked about or thought of.
That being said...I'm certain that there are many GOOD reasons to use a hospitalist.
When a Medicare patient is seen by their doctor and the doctor determines they are sick enough to be admitted. There is an admitting diagnosis.
From there, the patient is treated appropriately and normally there are tests done to further diagnose the problem and then treat disease or illness causing the admission. A normal family practioner will go through that [or similar]process and once the patient is well enough to be discharged, the doctor will discharge the patient and at the time of discharge, the doctor will identify a final diagnosis.
That final diagnosis is the key element that triggers what Medicare [YOU and I] pay for that hospital stay.
Medicare is set up so that the hospital is paid what Medicare determines to be an appropiriate amount for the particular illness or disease. To do that Medicare came up with the DRG system. That is Diagnostic Related Groups. So each final diagnosis is assigned to a DRG. Each DRG pays a flat rate.
As example, here in Central Illinois [the cost varies throughout the United States] a hospital will be paid a flat rate of approximately $4,000 for what is termed a simple case of pneumonia.
That amount is suppose to cover the hospital's cost and yield a slight profit. Unfortunately for hospitals that is not always the case.
Goverment studies have shown that a patient with simple pneumonia will be in the hospital 3-5 [apx]. If the patient is discharged sooner, the hospital makes money, if they stay longer, the hospital loses money. It is expected to balance out, whether that is the case or not is another topic.
A small percentage ( about 5% )of "all" pneumonia patients are found to have complex types of pneumonia. Those are more difficult and expensive to treat and cause a longer hospital stay. Because of that, the Medicare system pays a higher rate of reimbursement to the hospital for a patient who has been discharged as having a complex pneumonia.
Goverment studies have shown that a complex pneumonia will cause a hospital stay of about 6-8 days, thus Medicare will pay the higher reimbursement, somewhere around $6,000 to $7,000 [apx].
Keep in mind that a hospital could make a larger profit by having a patient discharged after 1-2 days when they are diagnosed with simple pneumonia.
EVEN BETTER...
What if...a hospital administrator could get that primary care physician to change his final diagnosis to complex pneumonia.
Of course that does not happen too often because most physicians are honorable people. But there have been many cases where this very thing took place. NOT IN DECATUR!!
But you should understand it can be a bad thing for us taxpayers when a physician can be influenced or no longer can make independant judgement.
Most doctors that I know are honorable and would not allow a hospital's administration to pressure them to change their diagnosis, but the fact is that has happened in other cities and towns.
So while there are probably very good reasons and good arguements in support of hospitalist, there is a potential dark [ $$MONEY$$ ] side.
One thing is a fact...every Medicare patient has [cited in the social security act] the freedom to choose who provides their health care...end of story. If someone prevents that from happening, eventually we will all lose, if we have not already. Keep in mind that choice can be influenced by disparaging remarks.
Robert A. Pittenger
2/16/2006 04:07:32 PM
Mr. Pittenger, I have a couple of follow-up questions, if you don't mind:
___________________________
Any idea when we should expect a decision on this investigation?
What is the normal process for an investigation of this type?
Where/How will a decision on this investigation be announced?
Thanks for giving us a little more information than the local "media."
For some time I followed this blog while employed as an Investigator with the United States Attorney, Central District of Illinois. Having some time on my hands since retirement, I decided to see what has been said on the blog. After reading the last entry regarding Hospitalist, there may be something not yet talked about or thought of.
That being said...I'm certain that there are many GOOD reasons to use a hospitalist.
When a Medicare patient is seen by their doctor and the doctor determines they are sick enough to be admitted. There is an admitting diagnosis.
From there, the patient is treated appropriately and normally there are tests done to further diagnose the problem and then treat disease or illness causing the admission. A normal family practioner will go through that [or similar]process and once the patient is well enough to be discharged, the doctor will discharge the patient and at the time of discharge, the doctor will identify a final diagnosis.
That final diagnosis is the key element that triggers what Medicare [YOU and I] pay for that hospital stay.
Medicare is set up so that the hospital is paid what Medicare determines to be an appropiriate amount for the particular illness or disease. To do that Medicare came up with the DRG system. That is Diagnostic Related Groups. So each final diagnosis is assigned to a DRG. Each DRG pays a flat rate.
As example, here in Central Illinois [the cost varies throughout the United States] a hospital will be paid a flat rate of approximately $4,000 for what is termed a simple case of pneumonia.
That amount is suppose to cover the hospital's cost and yield a slight profit. Unfortunately for hospitals that is not always the case.
Goverment studies have shown that a patient with simple pneumonia will be in the hospital 3-5 [apx]. If the patient is discharged sooner, the hospital makes money, if they stay longer, the hospital loses money. It is expected to balance out, whether that is the case or not is another topic.
A small percentage ( about 5% )of "all" pneumonia patients are found to have complex types of pneumonia. Those are more difficult and expensive to treat and cause a longer hospital stay. Because of that, the Medicare system pays a higher rate of reimbursement to the hospital for a patient who has been discharged as having a complex pneumonia.
Goverment studies have shown that a complex pneumonia will cause a hospital stay of about 6-8 days, thus Medicare will pay the higher reimbursement, somewhere around $6,000 to $7,000 [apx].
Keep in mind that a hospital could make a larger profit by having a patient discharged after 1-2 days when they are diagnosed with simple pneumonia.
EVEN BETTER...
What if...a hospital administrator could get that primary care physician to change his final diagnosis to complex pneumonia.
Of course that does not happen too often because most physicians are honorable people. But there have been many cases where this very thing took place. NOT IN DECATUR!!
But you should understand it can be a bad thing for us taxpayers when a physician can be influenced or no longer can make independant judgement.
Most doctors that I know are honorable and would not allow a hospital's administration to pressure them to change their diagnosis, but the fact is that has happened in other cities and towns.
So while there are probably very good reasons and good arguements in support of hospitalist, there is a potential dark [ $$MONEY$$ ] side.
One thing is a fact...every Medicare patient has [cited in the social security act] the freedom to choose who provides their health care...end of story. If someone prevents that from happening, eventually we will all lose, if we have not already. Keep in mind that choice can be influenced by disparaging remarks.
Robert A. Pittenger
2/16/2006 04:07:32 PM
Mr. Pittenger, I have a couple of follow-up questions, if you don't mind:
___________________________
Any idea when we should expect a decision on this investigation?
What is the normal process for an investigation of this type?
Where/How will a decision on this investigation be announced?
Thanks for giving us a little more information than the local "media."
posted by Watcher2300 at 2/19/2006 02:20:00 PM
3 Comments:
After having time to reflect on Mr. Pittenger's comments, I have the following thoughts:
Does DMH administration *ACTUALLY* believe their "hospitalists" can discharge patients sooner so as to make the hospital money (less cost for the DRG collected)?
Have DMH "hospitalists" "upcoded" their DRG's to a more financially rewarding number at the behest of DMH administration?
If DMH is a "non-profit" entity, why all the focus on making more and more money?
As in the above post:
"Any idea when we should expect a decision on this investigation?
What is the normal process for an investigation of this type?
Where/How will a decision on this investigation be announced?
The other observation I have is this:
WHY HASN'T ANY REPORTER FROM THE DMH HERALD AND REVIEW, WAND, WSOY, OR ANY OTHER LOCAL MEDIA ASKED THE FBI OR LOCAL INVESTIGATOR THESE TYPES OF QUESTIONS?
Could it be that DMH has bought their silence?
I double dog dare ANY local reporter to interview Mr. Pittenger.
Most, if not all investigations at the federal level take longer than at the local level.
The two systems have different processes. 15 years ago, if a Decatur Police officer received a complaint, he/she would investigate and act accordingly using "probable cause" to base their decision on what action to take. As opposed to a federal agent who will take weeks, months, or years, to discuss their findings with prosecutors, then collectively they decided to charge or not to charge the offender. It takes a special person to be able to make those split second decisions, I'll take the "good street cop" any day. But realistically, both systems work quite well.
When talking about a health care related matter, the issues, rules, regulations, and laws, are so complex that causes even more due diligence on the part of the investigators and prosecutors, thus lenghtens any investigation. And those are never (to my knowledge) done at the local level.
I cannot answer your question about any specific investigation, but normally a health care matter will take years to prepare for court, or settle.
On the federal level if there is no action taken, be it an indictment or a civil law suit, the general public will never hear about it, because it never existed.
On the other hand, indictments and civil law suits are normally announced in some manner, be it a news conference or in a press release. Those issues are normally made public by the lead attorney and/or the United States Attorney of the appropriate Federal District. And, there are always exceptions.
I hope that addressed your questions.
Robert A. Pittenger
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