OPINION
Letters to the Editor - Feb. 4, 2002
American
Medical News
As managed care pares hospital stays, more need for physicians to advocate
on behalf of patients
Almost daily I am amazed at the shortened length of hospital stay needed
for major surgical procedures. Although not as dramatic, medical patients
also now spend fewer days in the hospital.
Patients with community-acquired pneumonia are discharged earlier to
complete antibiotic treatment as outpatients. Patients are not being
kept in the hospital for imaging or endoscopies if these procedures could
be done as outpatients.
Social service, home care, rehab and other consults are called in early
to eliminate delays. Alternate facilities are being found for patients
being weaned from respirators and cancer patients too sick for outpatient
chemo or radiation therapy.
The decline in average length of hospital stay is in no small part due
to managed care insurers, which deny payment for unnecessary days. But
now, these same denials are threatening needed hospital days, a fact
that I discovered when I served as a physician adviser to our utilization
case managers.
Patients who came to the hospital emergency department with abdominal
or chest pain often required overnight hospital admissions until an ambiguous
acute abdomen or acute coronary syndrome was clarified. The hospital
was denied payment because a physician claims reviewer, after vetting
the record, decided that the patient could have been safely discharged
from the emergency department without admission.
Another denial was in the case of a blind woman with dementia who was
brought to the emergency department by her sister because of maggot-infested
ulcers and cellulitis of the legs. She had refused medical attention
and home care in the past. She had not been out of her apartment in 15
years. After five days she was transferred to a nursing home.
In denying payment to the hospital for this admission, the physician
reviewers stated that the patient did not have fever and her WBC was
not elevated. They added that maggots are beneficial for leg ulcers as
they help with debridement.
What is a physician to do in the present situation? He must document
the need for acute care on his daily hospital notes. When the managed
care insurer denies payment to the hospital, the physician, with his
intimate knowledge of the patient, must write the appeal letter and be
prepared to write a second-level appeal and go to external appeal when
that option is available.
Hospitals and their medical staffs must work together to utilize evidence-based
guidelines and practices to ensure economical and high quality care,
but if adhering to those guidelines causes a burden or undue hardship
to our patient, we must put the patient first and modify the guidelines.
Compassionate care trumps clinical guidelines. Physicians who review
claims for insurers should act the same way. It is hard to imagine that
someone thought maggots were helpful to the above patient.
--Irving Karten, MD New York