Mr. K lay on the gurney in the ED, looking comfortable, if a bit sheepish. His daughter glared at me from her chair next to him. I understood her anger. She hadn’t wanted him to come home so soon after his inguinal hernia repair. I had explained that I had little choice but to discharge him from the recovery room unless she, or he, wanted to pay a huge bill for his stay, but in truth that seemed to be a lame excuse right now.

Mr. K is 92 years old, but in great shape. He takes some medication for his prostate and an ACE inhibitor for high blood pressure, but no other prescription medications. He had a hip replaced several years ago and still uses a cane because his left leg remains weaker than the right. All in all, though, he didn’t meet any solid medical criteria for admission after I fixed his large right inguinal hernia.

I had tried to put him in an observation bed but was stymied by the process instituted in my hospital for such admissions of Medicare patients. The hospital has aggressively tried to manage such admissions because of repeated denials of payment by CMS. Now, any admission is reviewed immediately by a Case Manager (not a physician) to ensure that medical necessity is documented appropriately before the patient is placed in observation or inpatient status. Only then can the admission or observation order be entered.

“I blamed myself as well. It was my duty to do what my instinct and my experience told me was the right thing to do to protect my patient and make sure he was safe.”

Although I tried, I could not come up with a medical need for Mr. K. that satisfied the Case Manager. Unfortunately, being 92 and living alone is not considered a ‘medical need’ requiring an observation bed, much less an inpatient bed. He recovered well after a 30-minute herniorrhaphy and after two hours in the PACU was awake and alert with normal vitals, 98% saturation on room air, had ambulated independently to the bathroom and voided easily. Neither his daughter nor I felt comfortable sending him home, she because she’d have to stay with him for the next 24 hours, and me because despite the objective findings, he just looked pale, frail, and unsteady. Mr. K. himself was rather insistent that he was fine and wanted to go home, but this was the same man who had minimized his hernia until it filled his scrotum and involved most of his right colon.

So home he went. And here I was eight hours later seeing him in the ED after he had fallen while trying to go to the bathroom. He’d struck his head on the sink and had a two-inch gash above his right eyebrow that I had just finished repairing. He’d had a CT that showed no skull fracture or bleeding in his brain. He felt embarrassed, as if he’d done something wrong and his daughter blamed me for sending him home.

I wrote orders to place him in an observation bed, fibbing slightly by saying that he had a concussion with a brief loss of consciousness in order to placate the harpies from CMS.

I blamed myself as well. It was my duty to do what my instinct and my experience told me was the right thing to do to protect my patient and make sure he was safe. Instead, I had surrendered to the pressure from a bureaucrat with no real investment in my patient’s welfare to do the financially advantageous thing.

The whole process has been turned around and is completely backward. I am willing to discuss with a case manager or administrator whatever documentation is needed to ensure the hospital gets paid appropriately. Just tell me what buzzwords are needed to placate CMS and I’ll try to include them. I have even asked outright what magic words are required but to no avail. “Just document thoroughly” is about all the case manager will say, as if this were some guessing game and telling me what words to use would be cheating.

I may not have been able to “justify” keeping Mr. K. overnight after his operation, but in the end, it was my responsibility to care for him, not for the hospital’s bottom line. If, in the future, I must exaggerate, prevaricate, or outright lie to achieve that, I will. It won’t be the case manager coming to the ED in the middle of the night to deal with the consequences of not doing so.



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Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.

The Website: www.thatwhichishuman.com

The Blog: www.dancingintheor.wordpress.com