IV dilaudid? Or observation status?

I’M NOT SURE if I am frustrated, disillusioned or just furious. Let me explain.

I am a hospitalist in a decent-sized county hospital in Washington state. I split my FTE between direct patient care at the bedside and physician advisor.

In my latter role, I am responsible for reviewing the incoming denials for patients’ “appropriate level of care” and deciding if it’s worth proceeding with a peer-to-peer discussion. That’s what payers offer hospitals, a chance to prove to the insurance plan that a patient clearly deserves to be admitted as an inpatient rather than be placed under observation status.

Honoring a patient’s wishes

In this function, I have daily peer-to-peer conversations with so-called medical directors from different insurance plans. (I sometimes have the impression that some of my phone partners have not worked clinically in a long time.)

Some peer-to-peers are monologues, as the person on the other end has already made up their mind about what our conversation’s outcome will be.

Some conversations are true discussions, while some are even personal and refreshing. But others are monologues, as the person on the other end has already made up their mind about what the outcome of our conversation will be, despite any arguments I make or supporting documentation I provide. They keep trying to fit a complex patient into a framework determined by certain criteria, which can be discouraging. But at least I know in such instances that I have a good case, one that our denial management department can fight from the back end.

Recently, however, I thought I’d lose it. Here’s the case: My colleague admitted an 88 y/o lady with multiple comorbidities who presented with progressive back pain.

Further workup revealed a 3.9 cm thoracic mass that eroded the T9 and T10 vertebral bodies. MRI showed significant spinal cord impingement. She underwent an IR-guided biopsy as the team was clearly worried about any underlying malignancy, especially in the light of an abnormal SPEP. Pain control was challenging because she made clear to her team that she wanted to avoid IV narcotics due to previous negative side effects.

And that is exactly why her insurance company is refusing to pay for her inpatient stay. “She did not need any IV dilaudid? Well, because she is just on oral pain medications, she qualifies for only observation level of care.”

Checklist medicine

WTF? Please excuse my explicit language. But some studies indicate that swearing can improve pain tolerance (and more: See “Is Cursing A Sign of Intelligence?” from the Cleveland Clinic) and that’s what I need right now.

Why is our health care system so screwed up? Physicians at the bedside are the experts in patient care. They have clinical insight, they can see and evaluate patients, and they are simply trying to do the right thing: provide compassionate care, listen, coordinate consultants, and discuss treatment plans and pain regimens.

If your patient doesn’t want IV pain meds, so be it! Isn’t there an ongoing opioid crisis in the U.S., and aren’t physicians being discouraged to use narcotics? But if you take your patient’s concern seriously and don’t give that geriatric patient narcotics, their inpatient stay gets denied. This does not make sense.

I will not talk about the details of utilization review or the CMS criteria for inpatient vs. observation. I won’t dare discuss the two-midnight rule that even Medicare Advantage plans must follow since January 2024.

I will also not talk about how ongoing denials not only contribute to physician burnout but also result in a costly denial process that eats up health care dollars that could be better used elsewhere. Nor will I talk about the stress on patients when they receive their hospital bill for observation care with significantly higher out-of-pocket costs than if they’d been admitted. I will also not mention how this practice benefits only insurers’ revenue while harming the sustainability of hospitals and clinics that are fighting to stay open.

But I will talk about the ignorance of some insurance companies that use a checklist (MCG Health, Interqual or some homegrown version) to determine if a patient may be treated as an inpatient or not. I will mention how insurance plans need to trust clinicians’ ability to treat patients in an evidence-based manner. And I will talk about the face that insurance plans need to adjust criteria to individual patients instead of mandating a “one-size-fits-all” policy.

Patient-centered care

If I can’t overturn a denial during a peer-to-peer and I feel strongly that a patient meets inpatient criteria, I will forward the case to our denial management department. They will continue to fight this claim, and I hope they eventually win.

In the meantime, here’s my message to insurance companies: Please try to focus less on your profit and consider becoming more humane, patient-centered and fair. This will not only help your members but will also help bedside physicians avoid ongoing frustration and moral injury—and the liberal use of profanity.

Angelika Koch-Leibmann, MD, attended medical school in Germany and finished her internal medicine residency at Seattle’s University of Washington. She has been a hospitalist with EvergreenHealth in Kirkland, Wash., for the past 16 years, decreasing her FTE in 2020 from 1.0 to 0.7 when she became the medical director for care management. In that role, Dr. Koch-Leibmann is responsible for peer-to-peer reviews.