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Executive
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Texas
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Hospital
Care Strictly Limited
Increasingly unwilling
to pay for hospital care, HMOs, utilization review agents, and finally
independent reviewers struggled to define the minimum amount of inpatient
care absolutely necessary to the wellbeing of the patient. Fifty-two cases
involved denials of some portion of a person's hospital stay, while in
eight cases the hospital stay was denied altogether. Independent reviewers
overturned about half (54 percent) of hospital stay denials.
IROs only overturned two of the eight cases where the HMO believed that
the patient should have never been treated as an inpatient at all, and
generally supported managed care efforts to promote outpatient options
for all kinds of care.
IROs agreed with the HMOs' denials if it appeared that the patient had
undergone testing that could have been completed and assessed as an outpatient.
For example, in one case a woman was admitted into the hospital for chronic
diarrhea. The procedures she underwent, such as colonscopy and an abdominal
X-ray, could have been completed without hospitalization, the TMF reviewer
said. Her condition and her normal X-rays, normal lab results and normal
physical did not justify inpatient care.(1)
In another case, a TMF reviewer maintained that because a patient admitted
into the hospital with abdominal pain had a normal white blood count and
his lab work produced "unremarkable" results, he should have
been observed as an outpatient.(2)
Patients who received physical therapy or oral medication were directed
to outpatient treatment. In one case, an Envoy reviewer, decided that
a patient suffering from low back pain did not receive any treatment as
an inpatient that she could not have received as an outpatient.(3)
A TMF agent reached the same decision in a case where a man suffering
from severe low back pain and weight loss received oral medication. The
CTscans and other tests he underwent did not warrant inpatient stay.(4)
Patients could stay in the hospital if their conditions required medical
observation and IV management. In one case a woman suffering from severe
pain had unsuccessfully tried outpatient therapy, and was on IV medication
difficult to administer as an outpatient, the Envoy reviewer wrote.(5)
In the other case a TMF reviewer found that a patient admitted with acute
pancreatis could only be appropriately cared for as an inpatient. "It
is the standard of care to admit patients with this diagnosis," the
reviewer wrote, adding that the patient needed to be monitored because
of diet modifications, lab tests and the necessity of IV fluids.(6)
Hospitals were once a one-stop shop for the tests, treatments and services
needed to diagnose and manage illness. There are efficiencies for the
patient as well as the doctor when tests and treatments are all integrated
in one location. But increasingly, patients must navigate the medical
system to make appointments and get results on their own because hosptial
care may be a luxury we can no longer afford.
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Footnotes:
1. Texas Medical Foundation, IRO Decision Letter, Fortis,
3/3/2001.
2. Texas Medical Foundation, IRO Decision Letter, Insurance Management
Services, 9/14/2001.
3. Envoy, IRO Decision Letter, Healthsmart Preferred Care, 7/27/2001.
4. Texas Medical Foundation, IRO Decision Letter, Prudential, 3/22/2001.
5. Envoy, IRO Decision Letter, Accountable Health Plan, 9/13/2001.
6. Texas Medical Foundation, IRO Decision Letter, Central Reserve Life,
4/24/2001.
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