A recent New York Times article reported on a trend in the U.S. of decreasing admissions to some nursing homes and skilled nursing facilities¹. According to the report this is due to the changing healthcare environment, leading to a decrease in admissions to these facilities.

I find this trend disquieting and a portent of future problems with our healthcare in the United States. In the movie Jurassic Park, the character Ian Malcolm, played by Jeff Goldblum, is a scientist who studies chaos theory. During one part of the movie Ian Malcolm warns the prehistoric zoo creators that their ostensibly well-constructed and “safe” attraction will likely break out of control. Malcolm explains that in chaos there “is the Butterfly Effect. A butterfly can flap its wings in Peking, and in Central Park, you get rain instead of sunshine”². Now, luckily we’re not talking about uncontrolled killer dinosaurs, but the point is that there are often unanticipated consequences to our actions.

The same, of course, is true for medicine. Let’s take an example reported in the New York Times article that due to provisions of the Affordable Care Act, hospitals are penalized for readmissions. Because of these penalties, hospitals have created a work-around in which patients are increasingly admitted for observations as opposed to full admissions. This avoids the readmission penalty because the patient was never admitted. However, because these patients are not fully admitted they no longer qualify for skilled nursing facility admissions after their hospital stay. A further down-the-line consequence is the closure of an increasingly large number of facilities due to decreased admissions there.

The biggest loser in this situation is the patient who is now being manipulated during his admission to the hospital and also losing the potential longer-term quality care at a subsequent facility.

This is a really sad situation because we are all well aware of the good work our skilled nursing facilities do. I recall a poorly controlled diabetic patient who had undergone several surgeries by me for lower extremity complications. Regardless of what we did, the patient suffered infections and dehiscence after every surgery. It got to the point where I wondered what I was doing wrong. That is, until I performed a Charcot reconstruction with the use of an external fixator. The circumstances are a bit complicated to go into here, so I hope you’ll accept on face value that the surgery was necessary. The patient was admitted to the hospital after my surgery, and due to a series of events, they ended up in a skilled nursing facility for almost twelve weeks. This length of time is almost unheard of, and I still don’t know to this day how they stayed there that long.

The interesting part was that the nursing facility did such a good job controlling the patient’s blood sugar that they were able to heal perfectly and did not have any complications.

We know there’s an important role to be played by our skilled nursing colleagues, and it is a shame that they are hurt by an upstream issue for which they have no control.

Just like water running down a hill, pulled by gravity, or a dinosaur breaking out of its previously impregnable cage, everything we do is likely to have some unintended consequence. Of course, the very nature of these being unintended is that we are unable to predict the results of our actions. Similarly, our policy makers need to keep this fact in mind when they create sweeping policies that hurt the medical profession more than it helps patients. Ah, if only foresight was 20/20!

Best wishes.