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When cost-cutting ‘rules’ cost patients


Thom Newsom, MSN, RN,* was not given to hyperbole, but in all honesty, this situation was crazy. His next-door neighbor, Mary Bremant, a 63-year-old woman, complained of acute abdominal pain. Newsom took her to the emergency department (ED) where she was medicated, referred to her family physician, and then sent home. Two days later Bremant returned to the ED, again complaining of acute abdominal pain. Although she had a history of indigestion, gastritis, and reflux, the ED physician admitted her to the hospital’s cardiac care unit (CCU). Her ECG was normal, and she was discharged to her home. The next day she visited her family physician in his office. After examining her and studying her history, he concluded that she probably had gallbladder disease, ordered a gall bladder function test, and referred her to a surgeon.

Bremant, on the advice of her family physician, went on a low-to-no-fat diet as she awaited the results of her test and her appointment with the surgeon. After reviewing the test, the surgeon said Bremant’s condition was not severe enough to warrant surgery; it indicated her gallbladder was functioning at 33% efficiency, and the guidelines placed the cut-off for surgery at 30% efficiency. He ordered some anti-anxiety drugs for her and sent her home.

Two weeks later, Newsom took Bremant back to the ED. She was admitted again and sent to the CCU. She tried to refuse a cardiac catheterization, insisting that her heart was fine, but she was told that no surgeon would operate on her unless she had the catheterization to rule out heart disease. So, she submitted to the procedure; it was negative, and she was sent home again.

Newsom, concerned about Bremant’s condition, urged her to call her family physician for another appointment. She said, “What’s the use?” As it happened, Newsom knew this physician personally and spoke to him about his concern for Bremant. The family physician agreed to see her and had his receptionist call her home to schedule an appointment. At the visit, it took him only a few minutes to identify jaundice and conclude that her problem almost surely was her gallbladder. On the basis of his exam, he called the surgeon, asked him to reconsider his decision not to operate, and made an appointment for her that day. The surgeon told her that because of the gallbladder function test, the HMO probably would not pay for the surgery. Moreover, the hospital demanded that she pay before the surgery. She refused to pay in advance, but agreed to assume financial responsibility if the insurance company would not pay.

Bremant was admitted and discharged on the same day, and has been fine ever since —no more acute pain or ED visits. And the insurance company did pay! And pay. And pay — for ED visits, cardiac catheterizations, hospitalizations, and eventually for surgery.

This patient was subjected to weeks of pain, dangerous and intrusive testing, and humiliation before finally receiving the treatment she needed — and which her family physician diagnosed on her very first visit. In all honesty, this almost seems like sabotage, with the patient used as the weapon. Three ED visits, two admissions, five office visits, an unnecessary cardiac catheterization, and, finally, the gallbladder surgery she needed from the start, constitute an enormous intrusion on the patient’s right to safe, timely, and respectful care.

Surely both patient and system could and should have been better served. Rigid adherence to the “physician practice guidelines” indicates to me that the surgeon was angry about unreasonable restrictions on professional judgment. When professionals encounter excessively rigid rules, they often respond by following the “letter of the law;” which, on its face, is unethical because the professional’s pique is given higher priority than the patient’s well-being. Yet, neither test results alone (in this case gallbladder function test) nor practice guidelines alone were ever meant to be the sole determinants of a patient’s treatment. They are guides for decision-making, not substitutes for it.

The handling of this situation also was an unnecessarily expensive burden on the hospital and the insurance company. If the problem was the HMO’s rigidity, then unnecessary expenses will undermine profitability, and almost surely lead to litigation.

*Names have been changed to protect privacy.

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today.

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