This morning I got a call from a case manager at my hospital. For those unfamiliar with the hospital business, a case manager is an individual hired by a hospital to review charts and make sure the hospital is paid for its services. Insurance companies have rules, rules, rules, and rules which they call criteria, and all hospital admissions must meet these said criteria. If a patient does not not meet "criteria" neither doctor nor patient is paid. Insurance companies say the criteria are there to encourage hospitals to provide proper care, but this is a baldfaced lie. Criteria are excuses insurance companies use to deny payment and force financial responsibilty on to the patient. To prevent this from happening, case managers study up on the insurers' rules (which change constantly) and alert doctors and hospital administrators when the almighty criteria are not met.
Anyway, this case manager calls me to let me know that one of my admissions does not "meet criteria." She then explains to me that he is not getting sufficient medical treatment, according to the insurance company's admission criteria, to merit remaining in the hospital.
"He has a kidney infection; he is having abdominal pain," I protest. "I can't send him home."
"Yes, I understand that," she replied, "but the problem is that the insurance carrier feels the treatment being given could be given in an alternate setting."
"Well what exactly would qualify him for admission status?"
"He needs to be on IV fluids. An IV fluid requirement would allow him to stay on as a full admit."
"He is on IV fluids."
"Yes, but not enough. The ER put him on 70 cc per hour. He would meet admission criteria if he were on 75 cc an hour."
I had to ask her to repeat that. The difference between 70 cc and 75 cc is one teaspoon an hour, or 4 ounces a day. Put another way, the insurance company was refusing to pay for a hospital admission, regardless of what the diagnosis may have been, for the sole and entire reason that we were giving the patient 4 ounces a day less IV fluid than "criteria" required.
I boosted the rate to 80 cc. Now everything is great.
Or not so great. People sometime wonder why I am so pessimistc about the future of health care in the U.S. This is why. I understand as well as anyone the need for rules, but when rules are enforced to the letter absurdities sometimes result. Bureaucratic absurdities are acceptable in things like zoning or tax law, but in medicine, where lives are at stake, common sense should always trump rules. Except that they don't. And I can testify that these stupidities are everywhere in medicine these days, and nobody seems to care except the people these stupidities belittle.
So docs like me just bump up the IV fluid rate, feel a little more jerked around, and end up taking out their frustrations in some other way. Until eventually we get so disgusted we walk away.
Perhaps you think I am overreacting. Just your typical whiny little doctor. I do not think so. In my medical training I was taught to diagnose and treat disease. I find out what is wrong with the patient, and then I address it. I was not taught pages and pages of "criteria." I do not think that way, and neither do most doctors. If a patient looks sick we put them in the hospital. We don't worry about whether or not his temperature is high enough, if he has an elevated white cell count or not, or if he is sufficiently old or has the right O2 saturation. I don't usually think that way.
When I am forced to think that way it throws me off my game. If I have to think about whether my patient is getting 75 cc of fluids an hour or 70, I am not thinking about how sick he is, or what I think he really needs. I am thinking about what someone else -- someone who works for an insurance company, no less -- thinks he needs, and I find that more than a little distasteful.
Some advice to the reader: If you are ever getting admitted to the hospital, make sure your IV fluids are going at over 75 cc per hour. It will save you a bundle on the bill. What? You were too sick and forgot to ask? Too bad. Hope you don't mind taking out a second mortgage on your home.