WSJ:  September 12, 2003:  The Big Secret In Health Care:  Rationing Is Here

The Big Secret In Health Care:  Rationing Is Here

PHILADELPHIA -- A former machine operator and part-time minister, Angel Montanez Diaz, 69 years old, has spent 140 days in intensive care at Northeastern Hospital so far this year. Suffering from dementia, he needs a ventilator to breathe and a stomach tube to eat.

The hospital needs his bed. His stay has already cost about $280,000, nearly half of which will end up as a loss for the hospital.

Who's going to decide what happens to Mr. Montanez Diaz? In England, Canada and some other countries, a government health-care bureaucracy would supply some guidelines. In the U.S., the answer lies in the hands of people such as Lorraine Micheletti.

The nurse manager in intensive care, Ms. Micheletti makes daily battlefield decisions that influence whose lives should be prolonged and who should leave the ICU. As her hospital faces a cost crunch, she's under pressure to get patients out of the glass-walled unit quickly.

While she can't deny or withdraw care, she uses not-so-subtle means to decrease patient stays. She cajoles doctors to move their patients along. She pushes the hospital's pharmacy committee to relax guidelines that require patients on certain drugs to stay in the ICU. She prods families to let some very ill patients die with less medical intervention.

Without any official rules, she uses only her judgment from 27 years of experience. "You get a feel for it," says Ms. Micheletti, 50, who mixes straightforward talk and a ribald sense of humor to get her way. "Nine out of 10 times I'm right. Every now and then I'm proven wrong. There are always a few cases that are miracles."

The word for what Ms. Micheletti does every day at this 173-bed hospital is one of the big secrets of American health care: Rationing. Although the U.S. spends far more per person on health care than any other country, and it spends ever more each year, there aren't enough doctors, drugs and dollars to do everything for everybody. So who gets the care? And who makes these momentous, life-or-death decisions?

MORE COVERAGE   • How Medical Providers Shift Costs to Cover Health Care1   • Do you think the cost of health care has become a crisis? Are you worried that financial concerns could influence the way you might be treated by hospitals and doctors? Join the Discussion2.

There is no formal rationing system in the U.S., with its complex mix of private insurance and Medicare and Medicaid coverage, plus 41 million uninsured people who pay for their own care or get treated as charity cases. But in fact, health-care rationing occurs every day in the U.S., in thousands of big and small decisions, made mostly out of sight of patients, according to rules that often aren't consistently applied.

The people who make these decisions are harried doctors, Medicaid functionaries, hospital administrators, insurance workers and nurses. These are the gatekeepers of the American health-care system, the ones forced to say "no" to certain demands for treatment.

Many American patients enjoy more flexibility than they would in a government-controlled system and get better care. But the U.S. free-for-all creates special burdens of its own. Northeastern must give enormous decision-making power to doctors, nurses and caseworkers to weigh patient needs against what insurers will cover, a "damn-near impossible task," says Robert Perry, Northeastern's chief executive officer.

"All you should be asking them to do is take care of sick people as quickly as possible." Instead, hospital workers are forced to make rationing decisions on a case-by-case basis, he says. "Health care is all backwards in this country. The biggest decisions are all made in the worst conditions."

Four years ago, Northeastern, which serves mostly lower-income residents, was losing money and in danger of closing. To stay in business, administrators told the hospital staff that, among other things, they must get patients out faster. Since then, the average patient stay has been reduced from 4.9 days to 4.6 days. This year, the hospital's goal is to bring the number down to 4.2.

That puts a huge responsibility in the hands of Ms. Micheletti and her 26 nurses. She works closely with a private practice doctor whom the hospital pays to oversee ICU patients. "You could say I'm rationing care," she says. She firmly believes that her decisions aren't simply about money. In deciding how to dispense care in times of scarce resources, her "first question has to be, 'What quality of life does he have? Is he going to live 10 years with a good quality of life?' "

This spring, she considered the case of John Ems, a 79-year-old former refrigerator-repair specialist. In April, he was admitted to Northeastern with anemia and gastrointestinal bleeding.

After three weeks in the hospital, Mr. Ems went into cardiac respiratory failure. Nurses and doctors rushed to shock his heart back to life. They revived him, but one of his lungs collapsed. Patients in this condition can die quickly, or linger in intensive care for a long time.

The next day, Ms. Micheletti talked to the nurse who was directly caring for Mr. Ems, looked at his chart, and within minutes, she says, determined his likely fate. She saw that he had a history of emphysema and heart trouble. Considering the fact that he wasn't able to breathe without a ventilator, and that his lung had collapsed, she concluded Mr. Ems was going to die. Her goal, she says, became to prepare the family to let go of him.

She urged Mr. Ems's nurse to talk to his family about not resuscitating him or withdrawing care. "You should start having that conversation," she said.

That same day, Ms. Micheletti talked to the family herself. She motioned to Mr. Ems's son, Tom, a tall man with tattoos covering both arms, to join her outside the room where his father lay propped up on three pillows, asleep. Inside, the sick man's 14-year-old grandson continued to stroke his arm and call out softly, "Poppy, Poppy."

Putting an arm around Tom Ems's shoulders, Ms. Micheletti asked if he had thought about the kind of medical attention his father should receive. She told him it was unlikely his father would ever come off a ventilator, which meant he would probably need to go to a nursing home, if he lived. "You have to think about what's humane," she said.

Ms. Micheletti told Tom Ems he should consider a few alternatives: Doctors could gradually withdraw medical care and make his father comfortable on a morphine drip until he died. Or they could leave everything in place but not resuscitate him if his heart stopped. A laid-off trucker who delivers pizza for a living, Tom Ems grew tearful. He told Ms. Micheletti his father, a warm, patient person, had lived with him his whole life and was the primary caretaker for the grandson at his bedside.

A few days later, John Ems's blood pressure plummeted. Nurses asked for permission to stop his blood-pressure medication and not to resuscitate him if his heart stopped beating. Tom Ems says he agreed because doctors told him his father was likely brain dead. Without the medicine, Mr. Ems's heart stopped beating. A few minutes later, he was dead.

Sometimes, rationing causes Ms. Micheletti to take on her own hospital.

Moises Montanez Diaz helping his brother, Angel, who is in intensive care.

She encountered resistance from administrators earlier this year when trying to move 26-year-old Leslie DeJesus out of the ICU to a regular hospital bed. Ms. DeJesus, a part-time security guard, was the fourth patient with the same blood disorder who remained in intensive care for days because hospital guidelines required patients to be closely monitored while receiving a calcium drip that accompanies the treatment.

In rare cases, calcium can cause heart problems. But some hospitals have changed their protocols to allow such patients to be monitored less closely believing the risk is small.

Ms. DeJesus remained in intensive care for 27 days -- much to Ms. Micheletti's chagrin. Repeatedly, she tried to persuade the patient's oncologist and her own boss to sign off on moving Ms. DeJesus to a regular hospital bed. "She's healthier than I am," Ms. Micheletti told her boss. She called the patient a "walkie-talkie," hospital shorthand for a person who is mobile and alert.

Only when Ms. DeJesus's lab tests came back clear -- and the admissions nurse had two patients waiting for her bed -- did Ms. Micheletti prevail upon the doctors to sign her out. Ms. DeJesus, unaware of the behind-the-scenes pressure to get her out, was eager to get home to her two young children. She smiled and waved to the nurses as her bed was wheeled down the hall, seven "Get Well Soon" balloons trailing behind her.

The cost of her stay was $106,000, but under the agreement the hospital negotiated with her insurance company, only about $10,000 will be reimbursed. "We took a bath on that one," says Ray Lefton, Northeastern's chief financial officer.

With prodding from Ms. Micheletti -- who is on the hospital committee that writes guidelines for using intravenous medicines -- the protocol for that treatment was changed this summer. The new guidelines, still awaiting final approval, allow patients to be monitored outside of the ICU.

The emphasis on moving patients along is a big change from the past, when cost-cutting pressures weren't so great and nurses "never thought about insurance," Ms. Micheletti says. "You just did what needed to be done. You dared not ask the question of when the patient would be released."

Born in the Philippines, Ms. Micheletti came to the U.S. in 1977 and has worked at seven different hospitals, rising from staff nurse to nurse manager -- mostly in intensive-care units. Her current post pays $76,500 a year and provides regular hours, allowing her to spend time with her husband Arnold, a computer programmer, and their two daughters, ages 6 and 11.

She derives a lot of satisfaction, she says, out of training her nurses. The hospital has little money for educational programs so she puts them on herself, luring staff to the unpaid sessions with everything from pizza lunches to picture frames and other gifts, donated by drug-company sales reps.

Since Northeastern -- one of five hospitals operated by Temple University Health System, a nonprofit group in Philadelphia -- put in place its turnaround plan three years ago, its fortunes have improved. In 2002, it posted a profit of $2.6 million, on an operating budget of $85 million. For meeting financial goals, and improving patient satisfaction, each hospital employee got a $300 bonus. Managers, including Ms. Micheletti, got a $2,000 bonus.

Despite the financial incentives, Ms. Micheletti sometimes finds herself fighting to keep a patient in the ICU.

Sam Buoncristiano, a 55-year-old junkyard owner, came to her unit in May after suffering a heart attack. He needed special tests to determine if his arteries were blocked. Northeastern doesn't perform these tests but offered to arrange for him to be transferred to another hospital. Mr. Buoncristiano wanted to go home first.

Ms. Micheletti was convinced his arteries were dangerously clogged because he continued to have chest pain. She went into his room and pressed him to stay in Northeastern's ICU. Mr. Buoncristiano said he would think it over.

Then she hovered by the door, waiting to speak to the doctor attending him. "Doctor, don't let him go home," she said, accosting the physician outside the room where Mr. Buoncristiano lay restless, his eyes moving from the overhead television to the door. "If he goes home, he's going to die," she said.

The doctor nodded, picked up Mr. Buoncristiano's medical chart and went in the room. He came out a few minutes later and told Ms. Micheletti the patient had agreed to stay.

Mr. Buoncristiano went on to another hospital where doctors found he had a blocked artery and inserted a device called a stent to prop open the passageway. He is now back at work and credits Ms. Micheletti for "treating me real good."

While Ms. Micheletti has worked hard to decrease the average patient stay this year, one person can throw off her numbers. "You can eat up all of your profits if one or two patients" linger in the ICU, she says.

Angel Montanez Diaz was living with his wife and working at a corrugated-box company when his dementia set in during the early 1990s. He and his brother, Moises, had immigrated to the U.S. in the late 1950s, leaving behind the family sugar-cane farm in Puerto Rico. Outside of work, his brother says, Angel's passions were always religion and baseball, especially the Yankees. He led services several days a week and taught Sunday school at the First Christian Missionary Church, which serves Philadelphia's Hispanic population.

When his dementia grew severe, his wife and two adult children had trouble taking care of him. His brother offered to take over. A retired charter pilot, Moises Montanez Diaz says he was home anyway, taking care of his grown son who is wheelchair-bound.

Moises took care of Angel at his home in North Philadelphia for several years. In May 2002, Angel choked on some food and went to the emergency room at Northeastern. He developed complications. After two months in the hospital, he was sent to a rehabilitation center and later to a nursing home.

Nurse Manager Lorraine Micheletti at work in the intensive care unit at Northeastern Hospital

On Valentine's Day this year, Angel Montanez Diaz showed up at Northeastern ICU, with intestinal bleeding and pneumonia. As soon as he seemed stable, Ms. Micheletti pushed to move him back to the nursing home. Because he had been on a ventilator for months and had a chronic lung infection among other things, she decided he would never be well enough to go home. Yet he might live for many more months in intensive care, at a huge cost to the hospital.

Moises, now Angel's legal guardian, didn't want him returned to the nursing home because he thought the care was inadequate. Thinking that Angel needed more time in the ICU, Moises wasn't motivated to quickly find another nursing home. Angel is insured by a Medicare HMO.

In order to get him out, hospital officials started calling around trying to find a nursing home to accept him. It was a big problem.

"Either they won't accept him or they don't take his health insurance or they don't have a bed," says Ms. Micheletti. "He's really here because he's got no place else to go."

Nursing homes also ration care. They have little incentive to take very sick patients, because in many cases they receive a fixed reimbursement rate from insurance which doesn't cover the full cost of the care. As a result, nursing homes often try to limit the number of severely ill patients they take, to make sure they can cover costs.

The hospital eventually found a nursing home to accept Mr. Montanez Diaz -- but he was shuttled back to the hospital several times with fevers and infections. Once Northeastern sent him out to the nursing home, only to see him returned the very same day.

When he kept coming back to the ICU, Ms. Micheletti began prodding his brother to stop keeping him alive. Mr. Montanez Diaz was in chronic pain, mentally incompetent and unable to breathe or eat. "That's not Angel in there," she told his brother, Moises. "That's just a shell of him." Moises began to cry.

"What do you do with this patient?" an exasperated Ms. Micheletti said later. "We can't send him home because he needs too much care. He comes down with pneumonia very quick. His skin breaks down because it's very fragile. And yet his brother is not ready to let him die."

Moises says Angel, 10 years his senior, raised him after their parents died and he wants to repay that kindness by caring for him now. Moises comes to his bedside every day, exercising his frail, stiff arms and legs, and shaving his face. His goal isn't to restore his brother's mental capacity, which he thinks is unrealistic, but to get him off the ventilator so he can care for him at home.

At his home, Moises has kept his brother's bedroom the same as when he first went into the hospital. A worn black Bible sits on a small table by his bed. Angel's clothes still hang in the closet.

Pressure on Moises is increasing. In addition to Ms. Micheletti, two hospital doctors and a nursing home have also urged him to sign a form saying his brother should not be resuscitated. "They've become like Jack Kevorkian," he says. "They want to put my brother out of his misery."

On July 29, Moises arrived at the hospital at 10 a.m. to find his brother gone. He had been sent to another nursing home.

When he stopped by her windowless office that day, Ms. Micheletti hoped Moises would thank her and the staff for caring for his brother for so long. Instead, she says, he came up to her, smiled and said: "So you finally got rid of him." She lost her temper, she says, and responded, "Yes, we got rid of him."

Later, she said she also understood Moises's devotion to keeping his brother alive, particularly when she watched the two men interact. The sick man doesn't respond to commands from anyone, she says, but when his brother speaks to him in Spanish, "there's this look in his eyes, this flicker of recognition. He knows his brother is somewhere in there and he can still get to him."

Write to Geeta Anand at geeta.anand@wsj.com⁵

Updated September 12, 2003 10:33 a.m.