Question

Health Care Management Case Study

Case Presentation

Raymond Wiley operates a small business in a rural area. There is a 10-bed hospital in his community that has a 2-bed intensive care unit (ICU). A large hospital with comprehensive services is located in a nearby city 100 miles away.

Mr. Wiley became ill with a fever and cough. Because his regular physician was out of town, he went to the local hospital, where he was diagnosed with pneumonia and admitted. Mr. Wiley received supportive care, but after 3 full days with no apparent improvement, the admitting physician transferred him to the city hospital for a referral with a pulmonologist.

The Wileys wanted to drive to the city hospital in their private vehicle, as opposed to having Mr. Wiley transported by ambulance. Their rationale was based on the fact that Mrs. Wiley could drive, Mr. Wiley was stable, and their insurance did not cover ambulance transport unless it was a medical emergency. Up to this point, Raymond had only received supportive care; his intravenous line had been capped, and he was taking oral antibiotics. Their request to drive him was refused, and he was transported by ambulance; they were charged $1300 for the transport.

When Raymond arrived at the city hospital, it took 2 days for the pulmonologist and thoracic surgeon to see him because the admitting unit got his name mixed up with another patient. A computed tomography scan was completed, which revealed he had a large mass and pleural effusion. Mr. Wiley was then seen by a thoracic surgeon, who scheduled him for a thoracotomy the next day—a Sunday. This required assembling an on-call surgical team at the higher weekend rate.

After surgery, Raymond was in the ICU. He experienced several postoperative complications precipitated by the initial delay in correct diagnosis and treatment. On postoperative day 11, an order was written to transfer Mr. Wiley out of the ICU to the medical unit, but because of a shortage of nursing staff on the medical unit, he remained in the ICU for 2 additional days before being transferred to a medical unit and discharged home later that day.

Mrs. Wiley spent 10 months of her time fighting many of the charges because her husband’s care had been delayed by the medical team, causing his complications and extensive hospitalization. The Wiley’s thought they should not be charged and held responsible for the 3 days in the rural hospital, the 2 days in the city hospital before Mr. Wiley was seen by the specialist, and the 2 additional days spent in the ICU because the hospital was short staffed. The insurance company and hospital finally agreed on how much the insurance company would pay for the $136,000 worth of services billed. The hospital ended up writing off $60,000, and the Wiley’s paid $5000 in co-payments.

Case Analysis

Mr. Wiley’s care was not cost effective because there were many delays that were costly both from a systems viewpoint and from the exacerbations to the seriousness of his illness. The hospital eventually was forced to write off nearly half of the billed charges, which will eventually result in higher charges across the system to compensate for these and other losses. Mr. Wiley’s story highlights how a lack of communication resulting in a lack of effectiveness in timely treatment continue to haunt health care, affecting the quality of patient care and outcomes as well as patient costs. Value was not attained because Mr. Wiley’s care was delayed in both the rural and the tertiary care hospitals.

Questions (Please respond to both questions in your response.)

1. Speculate as to how Mr. Wiley’s care might have been different if a pay-for-performance rather than a fee-for-service plan was in place.

2. What risks are involved with a pay-for-performance plan?

Answer 1

Mr Wiley's care might have been different if it was pay-for performance . because in pay - for performance /result -based financing the effectiveness and efficiency in health service render to patient is improved while the health care cost is reduced. In Fee -for - service: payment is directly proportional to the amount of service render. Here, physician provide quality treatment to patient because they are reimburse based on the service they provide.In this case physician go extra mile to provide quality service to patient.. 2) some of the risk involved in pay-for performance plan are: 1) lower income for smaller community that are poor: The quality of treatment physician can render to those patient in minority communities is reduced , because pay -for performance do have effect on the income of physician in those area. 2) increases variations in health care delivery: patients whose health care cost is higher than average, mostly are consider to have a higher Health care disparity from the population health mean. Physician know these patient are less likely to abide by their treatment plan and are more likely to have bad outcomes.so they are being avoided by the physician. 3) Avoiding at risk patient: At -risk patient are those with critical health conditions. Physician knows that if they attend to the people in this category more incentives provider will be used , which might not favour the physician ,so they avoid them.