Denied

Earlier this week, two letters arrived in my mailbox, return post U.S. Medicare office, identical in every way except for the names. They were denial letters, for two patients I admitted to the hospital about two months ago. “There is insufficient documentation,” both letters cryptically and chorally stated, “to justify an IP admission.” IP stands for inpatient, one of the many abbreviations heath care bureaucrats use that doctors and nurses never do. It seems that when you have a health care job that does not entail seeing patients, you make up your own language.

These Dear Doctor epistles respectfully informed me that I would not be paid for the two admissions. Or more accurately, the medical clinic that pays me will not be paid. One of stays was only 24 hours, and the other was 3 days. In both cases, the patients were admitted for vague symptoms that could have been something very serious, or possibly nothing. After a brief work up I was able to determine that the latter was the case and sent the patients home.

Although I have received letters like this before, as every doctor in America has, they never cease to annoy me. Some desk jockey in Dallas or Atlanta or Washington reviewed data from these admissions and, without speaking to me or the patient or anyone else involved in the patient’s care, decided the admission was not needed. In effect, Medicare is accusing me of either incompetence or fraud, even though none of them could pick the patient out of a police lineup, and probably couldn’t find my hospital on a map.

It is certainly true that from time to time we doctors admit patients that don’t need to be in the hospital. This can happen if a patient over-dramatizes symptoms, making a malady seem worse than it is, or if either doctor or patient reacts to the situation with too much anxiety. Sometimes a doctor may remember a recent case that presented with similar symptoms and went irretrievably, horribly bad. Or a patient recalls a family member who, at the apex of health, fell like a bird shot from the sky. So we overreact. Hey, we’re all human.

In my view (within the limits of common sense, of course), it is better to overreact than to underreact. Wouldn’t you want a doctor who would admit you to the hospital even if he thought it was a marginal admission, just to be safe? Certainly no one wants a doctor who would reconsider his gut reaction to a patient’s symptoms because he is afraid he will not be paid.

When I was in medical school, I was taught that a good surgeon will remove a normal appendix 20% of the time. With a complication rate of only 3%, an appendectomy is a very safe surgery — in fact, one of the safest. If a surgeon has good reason to believe a patient has appendicitis, conventional wisdom holds that he or she should go ahead and remove the appendix rather than delay and risk a ruptured appendix, which can be fatal. The operation is safe, and the cost of missing an appendicitis is high. If it were me, I’d rather my surgeon take my appendix if he thinks there is a good chance it is infected rather than hold off just to save money.

The same is true with hospital admissions. Let’s say I examine a patient with chest pain. The patient is a complainer, one of those people who fixates on every little symptom. Ask him what hurts and you get a 20 minute discussion. A patient like that probably has stress-related chest pain, but what if I am wrong? My gut says his pain is probably nothing to worry about, but sometimes chest pain can be the sign of a very serious problem. So I admit him, just to be safe. Better to admit a patient and do a negative workup than risk having to sign a death certificate a week later. A good doctor shouldn’t have to resort to this often, but an occasional miss, like the occasional removal of a normal appendix, is the risk you run to be sure you don’t make any mistakes.

This is the reality of medicine. The reality that people who evaluate “IP admissions” cannot see. Maybe one day the bureaucrat who denied me will end up in the emergency room with vague symptoms that don’t meant the criteria for “IP admission.” That will give him an opportunity to play the scared patient who now has to worry that his doctor may send him home because he is afraid the admission will be denied.

Next time you go to see a doctor about symptoms that concern you, consider that your doctor not only has to think about what treatment you need, but also what treatment your insurance company will pay for. This barrier between doctor and patient is one of the true costs of so-called “managed” care.