Sunday, July 11, 2004

So, since I’m blogging today, I thought I’d describe one more apparent impropriety at the University of California. This one doesn’t involve the University of California directly, but is about the Long Beach VA Medical Center, which is partly staffed by UC Irvine. The content of this post comes in 2 parts:

As an intern, I rotated through the Long Beach VA Medical Center Emergency Room. After a while, it became obvious that the VAMC ER was admitting a lot of people who didn’t need to be admitted; people who weren’t really sick. I asked about that (made a stink is more like it), and eventually was summoned to the office of the director of Emergency Medicine at the Long Beach VA. She basically told me to shut up and do my job, but she also told me that the department of emergency medicine there was contracted (apparently in an unwritten contract) to admit at least 30% of their patients to inpatient units. It was implied that this was whether 30% of the ER patients were really all that sick or not.

OK, that’s possible fraud right there. But still, it was possible that 30% of the ER visits were legitimate admits. However, while working in the ER, and later while working in inpatient VA units, I noticed that some of the admits were not even close to being legitimate. I am not referring to old men with bronchitis who could have been treated as outpatients, but who were admitted for observation, or similar judgment calls. I am, instead, referring to the practice I observed of simply making up a serious diagnosis for ER patients, then using that diagnosis as an admitting diagnosis for inpatient admission.

For example, I had a patient, admitted by Dr. Queeda Draine of the VA, who was admitted for digoxin overdose. Digoxin is a medicine given to people for certain heart diseases; in overdose, it can cause arrhythmias and death. Admitting someone to the inpatient units for dig overdose is perfectly reasonable. However, this patient had no signs of digoxin overdose. His EKG was normal. He had no cardiac history which would have required digoxin therapy. He was not on digoxin. He claimed that he had never taken digoxin in his life. His serum dig level, which was available to me as the patient was being wheeled out of the ER to the ward, and which therefore should have been available to the ER attending Dr. Draine, was zero. To me the conclusion was inescapable: the admitting diagnosis of digoxin toxicity had been simply made up. Before admitting this patient, I called Dr. Draine to ask how the patient could have digoxin toxicity with a dig level of zero; Dr. Draine hung up on me.
Under orders from my attending, I admitted this patient for observation. The patient, as healthy in the morning as he had been on admission, was discharged at morning rounds, after I opined in morning report that this admission constituted pretty obvious fraud. I don't think it was the "fraud" part that caused the patient to be discharged; I think it was the "pretty obvious" part.

The patient never really knew why he'd been admitted; according to him, he spent the night in the hospital because 'that doctor in the ER thought I should.' As for why he had come to the ER in the first place, it is my recollection that he had come with complaints of "being tired." Being tired is a problem, but is generally not justification for an emergency admission.
Nevertheless, I have no doubt that the hospital billed for my services in admitting this patient for an apparently made-up diagnosis, and for observing him overnight for a disease which he did not have. In fact, based on the events referenced in the post immediately above this one, I have no doubt that the hospital overbilled for that work.

I observed a lot more examples like part 2, and was left with my own conclusions about inpatient admissions at that facility. I invite you to draw your own conclusions.

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