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