Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, consider and discuss the costs of acute bacterial skin and skin structure infections patient hospital admissions, extended lengths of stay, and IV antibiotic protocol and reimbursements.
Peter L. Salgo, MD: Buried in your comment, and I was listening, was this whole thing of “Well, they’re going to get admitted.” Who’s going to get admitted? Who gets into the hospital with this problem?
Yoav Golan, MD: Several studies recently did surveys among emergency department doctors and asked the physician, “For the patient that you admitted, what was the reason for admission, and what were the secondary reasons?” What they found was that in about 80% of the cases, the most common reason by far to admit someone was the need for IV antibiotics. In about 40% of the admissions, the need for IV antibiotic was the only reason to admit someone. They needed to get something, with the perception that it’s just given in the hospital, and therefore you need to admit them. In fact, many of those patients did not have comorbidities, and of those who had comorbidities, most of them did not have any exacerbation of their comorbidities. There was no concern that their infection was out of control, and just with monitoring, they need to be admitted.
Peter L. Salgo, MD: This was simply pragmatic—which is that IV antibiotics are what you need. You can’t get that in XYZ home office. Is that a fair reason to admit somebody?
Bruce M. Jones, PharmD, BCPS: I don’t think so, because many times these are limited-comorbidity patients. They’re not that sick in terms of what we would associate, a lot of times, with being sick. As he mentioned, IV antibiotics are the main reason why these patients are being admitted.
Peter L. Salgo, MD: But you said it yourself—these are not sick folks for the most part; they just need a therapy that mechanically is tricky in some settings to give outside the hospital.
Bruce M. Jones, PharmD, BCPS: Logistics are the issue.
Peter L. Salgo, MD: Let’s pull this back to money. Not sick, just needed an IV, just need some antibiotics…That should be cheap, but now you’re occupying some very expensive real estate.
Yoav Golan, MD: I think that you touch the heart of the point. We talk about the incidence—we talk about the increasing skin infections—and it causes some major, major issues, first of all for patients. Infections that could be treated at home now require admission to the hospital. Most people don’t like that. It’s an issue for hospitals, interestingly, because patients with skin infections tend to stay in the hospital longer than what the hospital is going to get reimbursed for. Skin infections are not the best way to fill your beds if you can do it otherwise. Of course, it’s a major issue for the community because we end up paying for that. We are now in a crisis situation, and the biggest question is, how do we do it better? To be fair, until recently, we didn’t really have any options. Someone comes into the emergency department stating, “I took this, I took that.…I took Bactrim (trimethoprim and sulfamethoxazole), I took Keflex (cephalexin).…It didn’t work. Now it’s 2 or 3 days—I have a fever,” and the ED doctor is looking at the cellulitis. The next step is IV vancomycin, and the only way to give vancomycin is to admit the patient, so there were no other treatment options.
Peter L. Salgo, MD: Let’s explore some of these issues that you brought up, because a lot of them are—whenever you discuss money—bureaucratic to some degree, because there’s somebody out there evaluating your treatment plan, your program, and your reimbursement. The first thing is, they’re going to be in the hospital longer than what the reimbursement folks are going to pay for, yet there are protocols for IV antibiotic therapy. How come the reimbursement protocols aren’t in sync?
Bruce M. Jones, PharmD, BCPS: Patients, when they come in—to your original point—was length of stay; they’re staying for at least 5 days. Many times, when we’ve looked at our numbers, they stay even 6, 7, 8 days, and it’s just being able to get these patients out. Many times, you can’t; it’s the DRG (diagnosis-related group) that loses money. On average, every patient that we admit, you lose money. A lot of times, it’s case management being able to set these patients up.
Peter L. Salgo, MD: So, here’s a DRG, right? The DRG says—and I’m going to make up a number— “Here’s 20 cents; go treat this patient.” You know you can’t do it for 20 cents if you’re going to follow all the protocols in the infectious disease literature. It’s going to cost you $20. Where’s the disconnect here? Is it just some bureaucrat who says, “No, I’m not going to pay you for it,” or does it make sense to find something that you can use that will get them out of the hospital more quickly?
Bruce M. Jones, PharmD, BCPS: I think it’s both sides. It’s finding a way to either not admit those patients, or target them and get them out for an earlier discharge.
Peter L. Salgo, MD: If somebody has to stay for medical reasons, and the hospital keeps them and if there’s a DRG, they’re going to lose money. If there’s no DRG, there’s still a penalty. What kind of penalty does the hospital look at?
Yoav Golan, MD: Well, I’m not a reimbursement specialist—I should say that—but I think that when you look at the DRG, there are some patients who stay for a short period of time, and there are some patients who stay for a longer period of time. With skin infections, they tend to stay longer than the DRG would. There’s really no reason for payers to incentivize hospitals to keep the patients longer. We are in a DRG era, and that’s how we get paid. So, I think that at the end of the day, we’re stuck with that.
Bruce M. Jones, PharmD, BCPS: Yes, and I think a big concern for us is readmission. You worry about these patients.
Peter L. Salgo, MD: Yes, we’re going to get to that.
Bruce M. Jones, PharmD, BCPS: If they’re coming back within 30 days, your hospital is going to eat that cost. That is where a lot of the concern comes in.
Peter L. Salgo, MD: If I’m going to put on my cost accountant hat for a minute. OK, I’m going to lose money if I keep them longer than what the DRG will pay for or what the length of stay protocol is from this insurer. But if I send them home too early, they’re going to bounce back, and I’m going to eat that money.
Bruce M. Jones, PharmD, BCPS: Absolutely.
Peter L. Salgo, MD: So maybe it’s cheaper to keep them and eat a small amount rather than bring them back and eat a big chunk.
Bruce M. Jones, PharmD, BCPS: Absolutely. In this day and age, compliance, adherence—such big issues. Sometimes with being able to see them in the hospital every day and know they’re getting their IV antibiotic, it’s easier to think, “Maybe I can prevent that 30-day readmission.”
Yoav Golan, MD: I agree with that. First of all, as a clinician, I think that the cost comes second to patient’s benefit.
Peter L. Salgo, MD: You, sir, are a dying breed.
Yoav Golan, MD: Well, I think that if you do it right for the patients, the cost will follow as well. First, you have to do what’s right for the patient, and in this case, I think it’s aligned with also reducing your cost. This is a great opportunity with those 2 things, and then when you talk about cost—I just want to mention 1 thing—cost for one person is different than cost for the other person. You can talk about length of stay, but then the pharmacy director sees the cost of the antibiotics; someone else who’s the payer is looking at the overall cost of the admission. We as a society pay for our premiums, so everyone’s cost is different. As we discuss cost—and I have this suspicion that we are going to discuss it further later—I think we have to take it out of the silo mentality, and actually look at what is worth investing in and what is not.
I know you are an ICU doctor, and when you see a patient who’s a little diaphoretic and maybe unstable—or maybe you are in the ICU but an internist sees a patient and says, “I’m really concerned about this patient; I’m not sure what’s going on, maybe he’s bleeding”—God knows, we’ll send him to the ICU. Every day in the ICU is $2000, $3000. Why would he do that? It’s so expensive to send. Why do we have ICUs? The question is not what is the cost but what do we get for the cost, and how do we come up with that rationale, just as a segue?
Peter L. Salgo, MD: You mention again—there’s a lot buried in the stuff you say that’s fascinating, which is that it’s time to get rid of silos. I’ve always made this argument, and I’ve always gotten strange answers. If I’m going to save money at the pharmacy level—maybe the cost is a little more on the bed occupancy level but, at the end of the day, the net is a savings to the institution—I get “Yeah, but that’s not my money. My money is in the drugs. I’m losing money here.” How do you get people to talk to one another?
Bruce M. Jones, PharmD, BCPS: Actually, that’s a fight I deal with every day, because I have a manager. Depending on what antibiotic we use, you get into more expensive ones—they may treat a patient better, they may get them out faster. Trying to make administrators understand that that was the best antibiotic in that case to use is always hard.
Peter L. Salgo, MD: I think they understand it, but there’s something about budgets. My budget is not your budget, and the whole hospital budget doesn’t really impinge my decision to kick you out because I’m going to lose money on your next dose of vancomycin.
Bruce M. Jones, PharmD, BCPS: Absolutely. There’s an inpatient budget for drugs, and antibiotics get lumped into it. When they see it tick higher, that’s what they see. It’s not the outcome side of it, it’s not the right therapy—sometimes that’s the magical big number.
Peter L. Salgo, MD: Do you have any insight into how this evolved? It doesn’t make clinical sense, right? If I can get somebody with a moderate stay, with a cheaper antibiotic, or even outpatient with a more expensive antibiotic that never comes in, isn’t that better?
Yoav Golan, MD: Well, I think that when you start to fragment your institution and look at different parts as cost centers, all of a sudden, they have to justify their existence. In some parts of the country, people are recruited to the job in order to contain cost. When you do that, you really narrow the perspective, and you need to have a broader perspective. If you do what you need to do to benefit patients, this will follow with shorter length of stay, and it will follow with prevention of unnecessary admissions. At the end of the day, it will also follow with the pharmacy budget, but you have to take the approach in which you are looking at that in a systematic way. You monitor that, you document that, and you actually can show that, and then the system will accept that.
Bruce M. Jones, PharmD, BCPS: With antimicrobial stewardship, what we always like to associate that with is cost savings. It’s always the term that’s tied with it. Especially early, you usually see a return on that, and it tends to plateau. They start coming to you: “Why aren’t you saving us more money?” I think sometimes it’s just tying those 2 words together.
Yoav Golan, MD: That’s a problem, but again, I think you really start with putting together a system in which people buy in; people understand it. You ask, how do I benefit my patients in a way that’s cost responsible, that I can justify the cost? It starts with putting together a team that really cares about patient and patient care, and I think that it is important. That’s why I brought the example of the ICU—because no one doubts that if someone needs ICU care, they should be in the ICU. That’s why we have ICUs. If you think about a more costly antibiotic that can save a life, it’s just the same, principle wise, as an ICU bed, only that it’s much cheaper, even if it’s the most expensive antibiotic.
Bruce M. Jones, PharmD, BCPS: You have to collect numbers. People in the C-suite, that’s what they’re used to; they’re used to being given numbers. I think if you can show them that what you’re doing is benefiting patients—maybe it’s saving money, but more than anything you have to be able to show them. Usually they’re kind of interested and excited, and they just didn’t know what was going on.