what do you think of this short story?

[LizzyM]

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This is the most disturbing thing I've read in a long time. Read it and tell me what you think.

It is certainly something worth talking about in interviews if costs/insurance/etc comes up.

http://archinte.ama-assn.org/cgi/content/full/165/8/838

 

[BaylorGuy]

its restricted...any way to post it up here??

 

[0T6]

Can you get to it through your school's library site?

Archives of Internal Medicine, Volume 165(8) 25 April 2005 p 838–841

 

[Ylime]

Business as Usual
Leslie G. Cohen, MD


Arch Intern Med. 2005;165:838-841.

INTRODUCTION

I read the case on the monitor screen: "47-year-old man with colon cancer, electively admitted for partial colectomy and diverting colostomy, no positive nodes. Five days approved. Discharged after sixth. On last day, ambulatory with assistance, full liquids, no IV meds. Sixth day necessary? Denial?" I telephoned the surgeon’s office. The secretary put me on hold.

"Dr Garrison’s office. May I help you?"

"This is Dr Burnham. I’m reviewing the recent admission of a Mr Martin, one of Dr Garrison’s patients." I read the disclaimer script taped to all desks by our legal department to protect against lawsuits: "‘This is a recorded and monitored line for quality assurance purposes. Quality Solutions Limited [QSL] is a medical review company and therefore not responsible for either benefits or payments.’ I’m calling regarding the acute medical necessity of his sixth hospital day."

"But Dr Garrison has been in the OR all day."

"Please have him call back when he has a moment free."

A minute later, the phone rang: "This is Dr Garrison, I’m ready to scrub in," he said, in clipped tones. "My secretary paged me. Let me get to the point. Mr Martin, who, by the way, is a prominent lawyer, had no bowel movement, even flatus, until midnight. Are you suggesting that he should have been discharged in the middle of the night? He had a par-a-lyt-ic Il-e-us. Do I have to spell it out? Doctor, have you ever practiced medicine? In Memphis, we call you people insurance company PROS-TI-TUTES." I heard laughter in the background.

"Dr Garrison, I agree with your decision," I replied, feeling humiliated. "I’ll put through an approval recommendation. Sorry to bother you. I . . . " Click.

That abusive clown! If the reviewing nurse gave me that info beforehand, I wouldn’t have sounded like a fool. The company guidelines left me little leeway. The patient had to receive IVs or parenteral meds. No doubt, I’ll have to justify this approval to the administration.

It was the close of a bitter, troubling day. Other physicians had angrily disputed my medical necessity decisions, threatening lawsuits, insultingly questioning my credentials and years of experience—even my morality. One had even accused me of betraying the medical profession!

I stood looking at the other cubicles. The hum of business blanketed the room. Computer screens were aglow with medical data. Experienced physicians, some double-boarded, were reviewing hospitalizations, typing their notes, speaking softly into headset telephones to physicians across the country, following company policies, while making profits for insurance companies and earning bonuses.

Next to me, Paul, a retired surgeon, scanned clinical information on his screen while talking with a physician in Omaha. A soft-spoken former academic, he was a lonely widower who enjoyed what medical camaraderie there was at QSL.

"Dr Jamison, the amount of mammary tissue to be removed from each side is well below our criteria, and the patient is apparently morbidly obese. Have dietary measures been fully utilized?" Paul asked.

He listened for several minutes, said that he would have to deny the case for lack of medical necessity, and gave the appeal information. The staff surgeons mainly dealt with elective cosmetic procedures. Paul believed that plastic surgeons rarely said no to a patient, and took offense at their sending advocacy letters with Polaroid snapshots. Most of these cases were denied.

Mark’s loud voice boomed nearby. An internist in his 40s, he was discussing the case of a cirrhotic patient who had been successfully treated for a variceal bleed a week earlier. Mark was pushing hard for discharge, with VNA follow-up, even though the patient was mildly encephalopathic. Appreciated by the administration as a "tough" reviewer, he followed the insurer’s dictates by telephoning every attending physician on every case, even clear-cut approvals, invariably asking, "Couldn’t this be accomplished on an outpatient basis?" His rate of denials was high. Mark wrote detailed case notes in graceful prose, which pleased and perturbed the administration. Implacably content, his lengthy justifications for denials prevented lawsuits but decreased his productivity.

On difficult days, which seemed frequent, I reminded myself how I got to be at QSL. Three years ago, when our long-standing group practice disbanded in a tangle of health maintenance organization and insurance company contracts and the community hospital declared bankruptcy, I felt disturbingly adrift, too young to retire and too prudent to risk beginning a solo practice. When a colleague, who had found temporary work as a medical reviewer, called I leaped at the opportunity. I figured it would be short term, allowing me time to network for another group practice. However, there were few positions open. Tiring of job hunting and not wishing to move my family and start anew, I uneasily settled in at QSL. The pay was fair, not as good as medical practice, but checks arrived on time. The benefits were reasonable, with paid holidays and vacations. The hours were regular, with no night or weekend call. There was no office overhead or malpractice coverage premium to pay, and no billing hassles with health maintenance organizations or insurers.

When newspaper and magazine articles stated that patients were being discharged "quicker and sicker," I felt responsible, by proxy. I had accepted the company norms, stifling my moral qualms. An uncomfortable feeling of inertia had set in.

Quality Solutions Limited, a national medical review company, had its corporate headquarters in a modern building situated in a manicured high-tech industrial park near Boston. The company contracted with 15 health insurance companies to perform their medical reviews. The physician staff approved or denied cases, based on company criteria of acute medical necessity, and advised the carriers on how many days they should pay for. It was well known among us that the insurers invariably followed our recommendations. The company’s mandate was to save the insurer’s money by denying what were deemed to be unnecessary hospital days or entire hospitalizations. For the past 2 years, QSL had barely broken even, leading to top administration firings and forced resignations.

 

[Ylime]

The several retired staff physicians wished to remain in the field of medicine, no matter how distantly. The few mid-career physicians, bemoaning a loss of control over their practice of medicine, had joined QSL only to realize that as employees their professional lives were under even tighter control. All of us, closely monitored for productivity, percentage of case denials, and adherence to strict company guidelines, knew from experience that our employment could be terminated abruptly. For the first time in my professional life, I felt expendable.

I still had another case to complete before our 5:00 meeting with Dr Blofeld, the new corporate medical director. One of the new breed of physicians from a combined MD/MBA program, he had trained as a psychiatrist before becoming the medical director of a Connecticut/New York health maintenance organization. Last week, Blofeld, cell phone affixed to his ear, had nodded grimly to us in the hallway.

I thumbed through the pile of medical charts and office notes on my desk. Chiropractors were requesting additional office visits for pediatric patients with allergies and chronic ear infections. A "Wellness Institute" physician was billing $500 for weekly patient visits to his office laboratory for tests that no medical textbook had indexed. A patient with terminal cancer, DNR, was receiving a morphine drip and comfort measures until her death. The referral note said: "The last 2 days could have been hospice care at home. Denial?"

"Can’t they read," I wondered? The first page in the chart stated that she lived alone.

4:45 PM. Last case: "14-year-old. Tylenol and alcohol OD. Unspecified gram total. Parent says half a bottle of pills left. Found unconscious in bathroom. Gastric lavage, activated charcoal, intubated. Acetaminophen levels high, but not toxic. Ethanol 0.285. Liver enzymes slightly up. Mucomyst begun. Awoke next day. Two days in ICU. Now day 4—on medical ward. Acetaminophen and enzymes now normal. Mucomyst DC’d. Medical necessity of days 3 and 4? Denial?" I dialed the physician’s office in Mertonville, Ohio.

"Yes, this is Dr Matheson," an old man’s voice.

"Hello. I’m Dr Burnham, reviewing the current hospitalization of Jennifer Albee for QSL. This is a . . . "

"Well, I knew that eventually one of you insurance people was going to call. It’s a busy day and my office staff is out sick. Please get to the point, Doctor." Crusty. I heard a baby crying in the background.

"I can recommend approval of her ICU stay. UR says that she has been on the medical ward since and not meeting our medical necessity criteria. Dr Matheson, why is she still in the hospital?"

"Well, young man, it’s a sad story. Jennifer’s refusing to talk, eat, or take medications. May have to start an IV today. This is a small hospital in a farming community, no psychiatrists, no psychiatric ward. We’re very short on nursing staff. I know it’s not the best solution . . . , but we have the family sitting with her around the clock. I’m worried she’ll find a way to do herself in. The psychiatrist, Dr Montgomery—I’ve spoken with her every day, comes here from Toledo only twice a week. Tomorrow morning, she’ll evaluate Jennifer. Psych beds are very tight. Look, I’ve been giving them hell up in Toledo. They keep saying they first need to clear it with the insurance company."

"But, Dr Matheson, I have to . . . "

"Let me finish, son. We’re doing the best we can for the child and her family, no matter what you and your company say. She’ll probably be transferred to the psychiatric hospital tomorrow . . . , if I have my say-so. Now, you’re probably going to spout that infernal insurance gibberish, aren’t you? Well, I’m ready."

I felt like I was listening to my father. The gravelly voice, direct manner. My dad, a plainspoken, principled man, had stayed a straight course in his rural solo practice for 50 years, through all the tumult and demoralization engulfing the profession. I looked at the clock: 4:50.

"Dr Matheson, I’m sorry, but I have to recommend denial of her last 2 days for not fulfilling our medical necessity guidelines. If you appeal, our psychiatric staff will contact Dr Montgomery. Your UR people have our appeal number."

"That’s just awful. Albee works for the local fertilizer company, pays all his premiums on time, and when one of his kids gets sick, you leave him out in the cold."

"Dr Matheson, you have to underst . . . " Click.

I typed the denial into the computer. Feeling tired and confused, I walked slowly to the conference room.

"Gentlemen and lady," he began, "this will be a brief meeting. I’m sure you want to go home, and I have a plane to catch."

Blofeld was short, trim, with closely cropped dark hair and wire-rimmed spectacles. His double-breasted gray pinstripe suit, speckled-silk bow tie, and shiny tasseled loafers looked Brooks Brothers. He turned to the blackboard and wrote in large capitals: THE WAVE OF THE FUTURE IS COMING, AND THERE IS NO FIGHTING IT—A. M. LINDBERGH (1940).

 

[Ylime]

"Perhaps some of you read the New York Times Magazine feature a while back on ‘The Future of American Health Care’ written by one of my Wharton professors. He predicted that large, inefficient hospitals would become extinct, like dinosaurs. What would remain, he postulated, would be just ICUs and step-down units. There will be thousands of small, well-managed, short-stay medical and surgical subspecialty hospitals, with separate privately owned centralized labs and radiology units all connected electronically. In the near future, all doctors’ offices will be completely computerized, allowing monitoring access. The majority of physicians will be employed by either HMOs, the government, private hospital chains, or insurance companies. Private practice will nostalgically be looked upon like the Model T Ford. A bit of a shock to you old-timers, isn’t it?"

We sat stolidly, faces expressionless.

"Let me tell you what is in store for us. A sophisticated computer system will be installed so we will be able to monitor—in real time—every office visit, all lab tests, and all x-rays being done. Imagine the business that will generate for us."

Blofeld smiled. Several of us fidgeted nervously.

"Next week, I’ll be negotiating contracts with several large carriers in the Sunbelt and Northwest and opening branch offices in Phoenix and Seattle. As you well know, health care is a very big business that will soon rank near energy and the military in the economy. QSL will soon be a leader in the industry. Well, that about sums it up. Let me remind you that every day of acute care denied is at least $1500 saved. I want you to review cases as if it were your own money being parceled out. Any questions? Please stand and identify yourself."

Allison, ordinarily soft-spoken and shy, raised her hand.

"I’m Allison Joseph, a psychiatrist. . . . It concerns me. . . . who pays for hospital days that are denied. The patients?"

Blofeld stared stonily, "It is contractually our job only to advise, to recommend. The insurers are responsible, not us. Don’t let it bother you." Another tight smile.

Al, a stocky, balding man sat beside me. "What a bunch of crap," he grumbled.

I whispered, "Al, . . . cool it."

"Any other questions?"

"I’m Al Grunewald, a gastroenterologist," he said, standing up. "There is something bothering me. This company’s clinical guidelines are way too strict and arbitrary and in many instances are incompatible with good medical care and make us liable for lawsuits. That should bother you, doesn’t it? I don’t want to get dragged into court. And, . . . doctors shouldn’t have to push sick people out onto the street, we . . . "

Blofeld’s cell phone rang: Beethoven’s Fifth.

"Doctor, it’s Grunewald, isn’t it? I’m sorry, I don’t have time to continue our discussion. I have to leave. Keep up the good work."

Blofeld nodded and briskly left the room.

We sat stunned. Al walked to the door, locked it, and turned, facing us. "You know, the other night my wife and I were watching an old movie on TV. The one with William Holden and Faye Dunaway, where the TV anchorman flips out and screams, ‘I’m mad as hell ’n’ I’m not going to take this anymore,’ and all the people in New York City open their windows and start screaming the same thing. Well, . . . that’s how I feel right now. What ’n the hell does that automaton know of medicine? I’ve had it. I’m out of here. I don’t care if the room is bugged. I’m going to tell that arrogant twit to his face."

We turned our heads, nervously scanning the room.

"Look what’s happened to medicine. Maybe it’s been a business all along. But now, . . . guys like Blofeld run the whole show. Insurance men, not doctors. Don’t get their hands dirty practicing. Number crunchers. I used to love being a doctor. Remember those days? Now it’s just a living. Thank God, I’ve still got my practice to go back to. Sure, after I’ve been up all night doing emergency gastroscopies on GI bleeders, I’ll still have to endure insulting calls the next morning, a voice, some doctor or nurse sitting in a cubicle a thousand miles away, second-guessing me whether the gastroscopy was necessary. Me, with 25 years of experience, just like I was a wet-behind-the-ears medical student!" Alshook his head angrily. "I’m not going to be the voice following Blofeld’s orders. There, I’ve had my say. Any of you guys coming with me?" Silence. "Sure, sure, I understand. See you around." He shook his head and walked out, slamming the door.

Silence.

"I think Al’s got it all wrong," Mark offered. "If there weren’t some form of medical review, a hell of a lot of substandard, really shoddy care would go unchecked. You all know that." We nodded in agreement. "Unproven cockamamy therapies, epidemics of tummy tucks and nose jobs. Sy, you know about all the wombs removed for the patient’s convenience and the gynecologist’s income." Sy nodded. "And doctors who don’t even know the name of their hospitalized patients, the unnecessary admissions that stay there forever, and the . . . "

Paul interrupted, looking at his watch. "Let’s go home. Look, I’ve seen a lot of these fire-breathing medical hotshots come and go. They burn themselves out or move on to bigger jobs. I’m going to sit tight, play ball, and wait him out. That’s how I see it."

We walked, heads down, to the parking lot, quietly chatting about the weather, vacations, and home repair imbroglios. No one mentioned QSL’s bright future, Blofeld, or Al.

 

[dramatispersonae13]

i hope this article is fiction..

 

[WedgeDawg]

13 year old thread that probably did not need a bump
Locking