Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, March 22, 1992 TAG: 9203230193
SECTION: VIRGINIA PAGE: A-1 EDITION: METRO
SOURCE: By CHARLES HITE MEDICAL WRITER
DATELINE: LENGTH: Long
It was about 4 o'clock on a Friday afternoon and Cynthia Counts dozed in room 358 at Lewis-Gale Hospital. A woman's voice woke her.
"Mrs. Counts? Mrs. Counts?"
The woman, dressed in street clothes, identified herself as a nurse from Blue Cross and Blue Shield of Virginia.
Counts pushed a button to raise her bed to a sitting position to hear what the woman had to say.
The insurance company had decided Counts' condition no longer required her to be in the hospital. If Counts stayed beyond midnight, the woman said, she would be responsible for paying hospital charges.
Counts, recovering from an appendectomy incision that didn't heal properly, listened in disbelief as the woman read her a one-page letter.
"I said, `You mean after midnight tonight Blue Cross won't pay anything?' She said, `Right.' I asked her if she would like to see the hole in my side. She said no and walked out," Counts said.
Cynthia Counts had just encountered "managed care," a system of rules and regulations imposed by insurers and businesses to help hold down increases in health care costs.
Nearly everyone with health insurance has some type of managed health care. It takes the form of pre-screening for hospital admission; restricting choice of physicians; mandatory second opinions; or, as Counts experienced, limits on the length of time in the hospital.
The restrictions, regulations and paperwork not only have left patients like Counts disgusted, they also have deeply irritated physicians.
Doctors commonly refer to managed care as "the hassle factor." Many say it puts too much emphasis on saving money and sometimes threatens the quality of patient care.
"It used to be that the patient and doctor decided what would happen in the course of treatment," said Dr. Reif Kessler, the surgeon who removed Cynthia Counts' appendix last month. "Now there is another force - the insurance companies and Medicare."
Counts' experience is "a very typical example" of the hassle factor, Kessler said.
Counts was readmitted to the hospital after she developed an infection and abscess at the site of her appendectomy incision. She was getting antibiotics and having the wound packed with special dressings. She was on her second day in the hospital and Kessler planned to let her leave the next morning. But the insurance company said a third day was unnecessary for a patient in Counts' condition.
"It was a hassle," Kessler said of that decision. He was left to deal with a distraught patient and an irate husband. "The insurance company was long gone. It was my task to smooth things out."
Kessler would have preferred to watch Counts one more night. He knew, however, that she probably would be all right if she went home that evening. If he had thought leaving the hospital would have threatened Counts' life, Kessler said he would have insisted she stay and appeal the decision.
Counts knew she could stay and appeal, but said she felt she couldn't afford the financial risk if she lost.
"They say it's entirely up to you and your physician," Counts said. "Not really. It's also up to your pocketbook. I know very few people who could afford out-of-pocket hospital expenses."
Dr. Daniel Camden, a Lewis-Gale internist, talked to hospital President Karl Miller early last year about his frustration over the increasing time he was spending on the paperwork demands of government agencies and private insurers. Miller was so taken with Camden's concerns that the hospital produced a 30-minute videotape on the subject last summer. Its title: "Code Blue - Red Tape: Bureaucracy's Intrusion Upon Healing."
The tape has been shown to numerous civic groups in the Roanoke Valley and sent to Virginia's congressional delegation and to state legislators.
"In every aspect of care of my patients there is some agency looking over my shoulder under the pretense of providing quality patient care when in my mind it's causing interference in patient care," Camden said.
The time required in "satisfying bureaucratic red tape could be much better spent in direct, one-on-one interaction with the patient," Camden added. "We have been forced to practice cookbook [medicine] rather than the art of medicine."
Most physicians understand insurers' and businesses' need for some system of controlling health-care costs, said Dr. Joseph Nelson, a gastroenterologist at Lewis-Gale.
"If I had a business, there is no question I would set up standards about the length of a hospital stay," Nelson said. The problem with the system, Nelson added, is very little flexibility: It has almost no room to accommodate the cases that occasionally fall outside normal patterns.
Frequently, Nelson said, the insurance representatives reviewing a patient's care seem to have a very limited understanding of information in a patient's chart. Yet they may be making a decision on whether a patient should be admitted to or needs to leave the hospital.
"They may be reading from a sheet of paper with certain criteria," Nelson said.
He added, "You get the sense that somebody in a foreign office - who in some cases doesn't have a pre-medical education - is presuming a certain amount of intelligence about the patient. I think most of us find this disturbing. It interferes with our ability to get on with an already busy day. You don't have time to sit down and make a court case over why somebody needs to be admitted."
On the videotape, Nelson vividly recounts an admittedly extreme example of the hassle factor. It happened early on a Saturday when Nelson was on call at the hospital several years ago.
A woman in her early 60s came in with chest pains and shortness of breath. An electrocardiogram showed no clear signs of a heart attack and her chest X-ray and laboratory tests looked good.
Test results alone, Nelson said, gave no conclusive sign that anything was wrong with the woman. "But when you walked in that room, with the lady clutching her chest, you knew something was wrong."
Nelson admitted her to the CCU - a critical care unit for heart patients.
"Sometime Monday morning my nurse interrupted me from seeing patients and I came out and there was a lady from the insurance company who was on the phone," Nelson recalled. "And she wanted to know specifically why this lady was still in the CCU. She had been there three days. We didn't have a diagnosis and she - as far as they were concerned - had spent enough time there."
The conversation went on several minutes. Nelson said the insurance representative kept pressing him to justify the woman's admission.
"It came to the point that I actually felt I was being harassed over the phone by someone telling me how to practice medicine."
As he was getting ready to end the conversation, Nelson heard an announcement over the public address system. "Code blue. Code blue. CCU. Dr. Nelson."
The emergency was about the woman with chest pains. She had a heart attack and died.
About an hour later, Nelson returned to his office. The insurance company was on the phone again.
"It was a physician," Nelson said. "He identified himself and seemed very short with me. He made a point to say I had hung up on his insurance technician and that he thought I was rude in doing so. He went on to say, `Now we have a problem with Mrs. So and So. We have a problem with her admission.' "
Nelson hesitated a moment before replying.
"And I said, `You have no further problem. You no longer have a problem. She has just died.' And there was a pause on the other end and he said, `Well, I'm sorry.' And he hung up."
Despite this experience, Nelson acknowledged the need for review and guidelines in paying for hospital care. They make physicians more aware of the need to be efficient and cost-conscious in caring for patients, he said.
"It's not all bad," Dr. Kessler, the surgeon who operated on Cynthia Counts, said of the insurance companies' rules and regulations. "We all have had to come to live with this."
What worries Kessler and Nelson is that the pressure to be more efficient in medicine sometimes causes the patient to be overlooked. Doctors may have cut the time in the hospital for a certain procedure from 10 to six days, Kessler said. "But when you get it down to six days, they want to make it five."
Counts and her husband, Michael, feel shaken and betrayed by the incident. Michael Counts, a volunteer rescue squad member, learned to change his wife's dressings and stayed at home with her a couple of days after she left the hospital.
Cynthia Counts said she was afraid to be left alone, even though she knew a home health nurse would check in with her daily. She was by herself at home when her infected incision burst.
"There's a feeling you can't even trust your doctors," Cynthia Counts said. "They are being forced into decisions that are not in their patients' best interests. And that's scary."
There has to be some type of allowance for special cases, especially those like the woman who died of a heart attack in the CCU, Nelson said.
Without some flexibility for a physician's judgment, Nelson said, the patients will bear the brunt of the burden.
"The doctors get the hassle," he said, "but the patients suffer."
MANAGED HEALTH CARE\ STATE TASK FORCE RECOMMENDATIONS\ \ SINGLE FORM: Minimize the "hassle factor" in health care by replacing many hundreds of insurance claims forms now in use with a single form.\ \ LESS REVIEW: Limit case review to random samples or those falling outside certain performance guidelines instead of spending huge amounts of time and money reviewing every case.\ \ OPEN CRITERIA: Require insurance companies to disclose the criteria they use in deciding whether to pay benefits.\ \ INDEPENDENT APPEALS: Establish an appeals process of health-insurance decisions that is "timely, objective, understandable and assures quality care." This process should include parties not directly involved in the dispute. Decisions should be binding.\ \ MEDICAL LIABILITY: Review the responsibility of insurance companies and health- review organizations. These organizations now have little or no liability when medical-treatment decisions in which they are involved result in bad outcomes.
by CNB