A hospitalist and insurance medical director walk into a bar…
And they have a conversation about a patient using totally different vocabularies and both leave peeved.
I wish this punchline was funnier, but it reflects the reality of many conversations between physicians in these roles in a fee-for-service world. How do two doctors, who received similar educations and treated the same kinds of patients, wind up frustrated and angry about the same topic?
The answer is: Inpatient status versus observation status (queue the ominous music).
I hate this topic. It seems so dumb, yet the hours spent arguing, documenting, educating, re-educating on the difference between these patient statuses number in the thousands — and that is just for my hospital system.
Why does it matter? Money. (It usually boils down to this, right?) An observation status results in significantly less reimbursement than inpatient status, even though the care is the same. The bed is the same, the nurse and doctor are the same — even the food is the same! Quality is not generally part of the discussion. Observation is technically an outpatient status, even though a patient’s derriere (and the rest of them) is physically located in a hospital, thus the payment in the eyes of an insurer should be lower. Not to mention patients often bear some of the cost of medication, imaging, and other services while in observation status.
This came to head a few weeks back… again. A hospitalist physician diagnosed a patient while she was on observation status with a significant medical issue. He placed an order to admit her as an inpatient, busted his hump ordering stat imaging, consults, and ultimately had to transfer the patient to a higher level of care. Hours and hours of his day were spent on it. He was shocked then, to get a call from our case managers that the hospital day was denied by an insurer. We only had her as an inpatient for a few hours and were the stabilizing facility. We appealed it and requested a peer-to-peer phone call. The call did not go well and the interaction was escalated on both sides. I eventually had a conversation with a VP physician of the insurer and we hammered it out.
For those of you not familiar with the peer-to-peer process, this is it in a nutshell. If you are, feel free to skip this paragraph, you may experience nausea and flashbacks of unpleasant phone calls. After a case is denied, the hospital or doctor can request a discussion with a physician employed by the insurer, the medical director. They connect by phone, sometimes days or weeks after the care has been rendered. The medical director explains why the insurance company feels that they don’t have to pay. This is based 100 percent on the documentation that exists in the EHR. The hospitalist explains why the patient needed whatever was denied.
In some cases, this explanation helps supplement the medical records and the denial is reversed. In many others, it leads to angry conversations with the medical director citing things like objective criteria, such as Interqual and MCG guidelines. These guidelines live in multivolume books or web pages which detail what care should be done as an inpatient vs an outpatient basis. Meanwhile, the hospitalist is focused on other things like how sick the patient is, lack of family support, day of the week, or call schedules to explain why the patient needs to be where they are.
Are you exhausted after reading that? I’m exhausted after explaining it. Imagine doing it!
It doesn’t have to be this way. In a system that values outcomes, all of this goes away. Imagine the patient getting the care they need without the nonsense of determining an arbitrary status. The hours and cost associated with the above can be rerouted into improving the system of care. Doctors in the hospital can take care of patients. Medical Directors at insurers can work to make sure their members are getting the care they need. Care managers can help patients transition safely to different settings.
When we get to this place as a country (and I think we will), maybe the scenario at the bar ends with arms and glasses raised singing “shot through the heart” at 2 am. It’s still not the most hilarious punchline, but if you have ever seen me doing karaoke, you know how funny this can be!!
This piece was written by Jonathan Kaufmann, VP & CMIO at Bayhealth. To view the original post on LinkedIn, please click here.