quality improvement in healthcare Archives

Cardiology Care and Medical Necessity

I have been providing cardiology care for patients for years. Today was an example of how challenging providing high quality cardiology care has become. I sent a patient for emergency open heart surgery today. He should have gone last week. Why didn’t he? “Medical necessity” is why. When I saw him in the office it was clear he was having classic angina related to coronary atherosclerosis. I have 40 years of experience in diagnosing this. In days past, I would have set him up for a cardiac catheterization the next morning. But insurance did not deem it “medically necessary” since he had not yet had a stress test. To avoid him being stuck with a large unpaid bill, we set him up for a stress test. Of course, that had to have prior insurance authorization as well, taking another few days. After that, we had to wait for an opening in the stress testing schedule. All told, it would be three weeks before he could have a stress test to prove that he needed a heart catheterization.

Yesterday, he called my office to report that he was running out of nitroglycerine since he was using up to 10/day and unable to do anything without chest pain. I abandoned my patience with the insurance company and had him come to the emergency room for admission. On arrival he already had elevated heart enzymes and then required a nitroglycerine drip for pain control. At his catheterization today he had severe left main coronary disease. Fortunately, he remained stable and I was able to have a cardiology colleague set him up for emergent open heart surgery. Now it really was medically necessary!

I am aware that a tiny percentage of providers have abused the insurance system, but I am confident that we spend far more on insurance authorization than was ever spent on unnecessary claims! How have we allowed an insurance “reviewer” working off a checklist dictate what our patients need? How is it that their “approval” has more weight than my 40 years of cardiology training and experience? What happened to trust that we will do the right thing? Thankfully my patient did not literally drop dead at home. But I have to wonder how many others actually did while waiting for “medical necessity” clearance.

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Us vs. Them Mentality in Healthcare Management

The largest private sector nursing strike just began in Minnesota. On September 12^th approximately 15,000 nurses staged a three-day strike to protest staffing levels and the work environment. The prelude to this decision involved many hours of labor talks with the administration, unfair labor practice charges, and accusations of refusing to address potential solutions to understaffing or involvement by nurses in the scheduling process. According to a Washington Post interview, a nurse in Minnesota said she was sad it had to come to a strike, but that it was the only way to show the administration (who had been claiming it was the nurse’s fault) how strongly they felt and how important the issues were. While the strike is now over, no agreements have been reached. Quotes from both sides reveal how far apart they still are on an agreement.

It is not for me to arbitrate the merits of pay raises or varied staffing levels, but I can’t help but assume that somewhere along the way rather than the hospital and the providers teaming to provide community healthcare, an “us vs. them” mentality developed. I’m sure both sides of the healthcare management issues would agree that excellent health care is the goal, but our systems have morphed from “mission driven” to “profit driven” models over the last century. Tasks that used to be managed by the front-line providers are now assigned to business administrators. While the number of administrators has skyrocketed, the front line is struggling to fill positions.

In my opinion, it may be time to take a big step back and reassess the overall goals of healthcare delivery systems. If providers and administrators can agree on the health outcomes desired, it will be easier to design a healthcare management plan to accomplish it. It could mean more nurses and fewer administrators; it could look entirely different. But the message is clear: the system is currently broken and something has to give. We must abandon the us vs them mentality and look for joint solutions!

Are you interested in learning more about practical ways to improve healthcare management? “Healing the System, a Prescription for Rejuvenating the Heart in Healthcare” tackles healthcare dysfunction head-on, identifies root causes, who owns the breakdowns, and more importantly provides a prescriptive cure. The book offers straightforward, actionable processes that don’t require an act of Congress to bring about improvement. Learn more about it here.

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