By John Dorschner
At the end of March, 60 patients had been in Jackson Memorial Hospital for more than 100 days. One had been there 528 days.
Most are no longer covered by insurance. They have complex medical problems and are a crushing burden for Miami-Dade’s cash-poor public hospital. Many had insurance, but their benefits ran out or didn’t come close to paying the cost of their care. Almost all could be sent to a long-term care facility, but none wanted to take them. Five of the patients were from overseas.
They symbolize a fundamental financial problem at the Jackson Health System: patients who are hospitalized for long periods of time without insurance coverage. The average patient stays in a Jackson hospital room for 6.7 days. That’s far ahead of the 4.1 days of a typical community hospital like Kendall Regional Medical Center, owned by the HCA chain, according to state data. It’s also well above the major Broward public hospitals — Broward General at 5.6 days and Memorial Regional at 5.4 days.
As Jackson struggles to survive, with more than $330 million in losses the past two years and an expected loss of $103 million this fiscal year, length of stay is becoming a major focus for improvement.
Marcos Lapciuc, treasurer of Jackson’s governing board, calls the disparities “toxic,” saying the numbers reveal how badly the system is operating. A hospital such as Jackson, with a longer-than-average length of stay, faces two problems. Many insurers now pay for a hospital stay in a lump-sum payment, regardless of how many days a patient stays. And when those patients are uninsured — about 20 percent of Jackson’s patients are uninsured — the longer they stay, the more they cost.
Jackson executives say one explanation for the longer length-of-stay at Jackson is that the system often takes care of sicker patients, such as those receiving organ transplants. But executives acknowledge the problem goes deeper than that, and they have been working hard in recent months to improve what they call “through-put,” making sure that patients get treated promptly with the right tests and other treatments that can speed up their discharges.
Recently, new information emerged about what’s really driving up the numbers. Kevin Andrews, Jackson’s vice president of quality and patient safety, has produced a study showing the length of stay averages include outliers — patients who have been occupying beds for inordinate amounts of time because no other facility wants these patients, who generally have no money, no insurance and huge medical complications.
Andrews’ study showed that all these cases are at the main facility, Jackson Memorial, which handles transplants and those severely injured in accidents. Jackson Memorial’s length of stay averages a stunning 7.9 days. The satellite hospitals of Jackson North and Jackson South average 4.0 and 3.9 – typical community hospital levels. All these numbers are calculated by the industry standard, which excludes rehabilitation and mental health patients and normal newborns .
By adjusting for the severity of the patients’ illnesses, Andrews reported, Jackson Memorial should have an average stay of 6.2 days — 1.7 days less than the present.
Andrews’ study said that much of that discrepancy is caused by the outliers — patients who have been in the hospital more than 30 days.
A review of the week of March 28 found 113 such outliers. Many were on ventilators. Jackson has two nursing homes where they might be treated, but one is filled and the other is undergoing renovations so that it can attract more paying patients. Only 20 percent of the 113 patients were completely uninsured, but 90 percent of those with insurance had exhausted their benefits, meaning that virtually the entire group was not paying for care, Andrews says.
In the two weeks following that study, Andrews says he worked hard to get the patients placed elsewhere. He moved more than half the outliers – 60 – to other facilities. That was a major savings, since the group had averaged 58 days in the hospital. One, a Bolivian injured in an accident while visiting South Florida, was flown back home by air ambulance. Jackson paid the $47,000 transportation cost. That was cheaper than keeping him in the hospital, Andrews said.
By mid-April, the 53 outliers that remained at Jackson had been there for an average of 111 days. Nineteen are accident victims who came in through the trauma center. Five are transplant patients. Andrews’ group is still working to transport four overseas patients back to their homes in Trinidad, Lithuania, Spain and Puerto Rico.
In recent days, he was able to move out another 13 outliers.
Since length-of-stay has been a raging problem at Jackson for years, why hadn’t hospital officials worked sooner to get these costly patients transferred?
Andrews said the system was set up so that the outliers were spread among many case managers, who tended to postpone dealing with them.
“Many of these people are so difficult to place that they take an inordinate amount of time,” Andrews said. “If a patient is from another country, you’re spending hours and hours dealing with consulates.”
Because of that, case managers tended to slide the cases to the bottom of their lists and work on easier placements. Andrews solved that problem by setting up a case management team just to deal with the outliers. In less than a month, the team has managed to move out 73 of the 113 cases.
Still, tough cases remain: The patient who had been there 528 days at the end of March is still there. No other institution wants to take an accident victim with multiple problems.
Andrews says that the good news about his study is that with the outliers removed from the equation, Jackson’s average patient stays 5.8 days, when the severity-of-illness indicates the average should be 5.2. “So we’re almost where we should be,” he says.
Martha Baker, president of SEIU Local 1991, said recently that Jackson should do more to reduce lengths of stay by making sure patients receive prompt treatment, which could cut down on hospital time. “We have a lot of room to improve – potential for savings, potential for patient satisfaction, potential for decreasing labor costs. We are frustrated more hasn’t been done.”
Andrews agrees more can be done. “We’re working on it.”
One complication: As a teaching hospital, many of the patients are seen by residents — doctors in training — who often like to do an extra test or prolong a hospital stay to make sure they’ve done everything right. Their supervising physicians, University of Miami faculty, monitor their activities along with Jackson officials.
But doing that extra bit is “part of any physician’s learning,” said David Lubarsky, a UM dean for patient safety and quality. “There is a certain amount of inefficiency” in a teaching hospital and Medicare recognizes that by paying slightly higher rates to teaching hospitals.
Jackson’s problem: Only 13 percent of its patients are on Medicare, far below the 30 percent or more of Medicare patients that other hospitals have.