“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.
“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.
“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”
Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?
“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.
“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.
“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH
Andrea Sattinger writes frequently for The Hospitalist.
References
- Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
- Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.