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Who wants the patient with Insurance?!

August 2010

I recently had a novel experience while working in the hospital. We had admitted a patient with chest pain for the routine overnight rule-out observation stay. As with the normal protocol, we did all the usual, including keeping her NPO after midnight and preparing for a “fly-by” cardiology consult and stress test the next morning.

Rounding the next morning, I ran into our cardiologist du jour and, as a courtesy, mentioned my patient who needed a stress test to make sure he was aware of her presence. He quickly informed me that he had looked at the chart–and that he would not be seeing her that day. His reason? Her insurer (to remain nameless) was particularly difficult to deal with, and he recently had had a tough time getting reimbursed by that payer for his services.

In part, I was stunned that I was having trouble getting a consult (and procedure) on a paying patient. I was also taken aback at his disregard for the medical staff by-laws, which dictate that on-call physicians agree to see patients regardless of their payer source (and usually, that’s none). That left me in unfamiliar territory.

Now, our situation is different than in most places that I have worked in the past. Many hospitals have a population density of cardiologists that rivals downtown Beijing, and you can’t normally swing a stethoscope without hitting one.

In our small community hospital, though, we have only two groups who equally share ED call responsibilities and are very sensitive to getting their “fair share” of consults. I have had many experiences in the past having to beg, borrow and plead with specialists to get them to see an uninsured patient, but never one quite like this. In this instance, the solution was an easy one. I simply asked the other group to see the patient, which they happily did and the patient was stressed and discharged. No problem, right…?

As I started to think about this, I began to wonder if, given the current state of affairs with health care reform and the like, we won’t begin to see more and more of these types of patients. I have experienced hospitalist programs where patients with different payers are required to see certain specialists because of preferred provider relationships.

But I had not experienced one in which a patient with insurance was rejected because of her insurance. Is this a sign of things to come? With the loss of consult codes now upon us, the prospect of bundled payments and perhaps of Medicare cuts in reimbursement, we may find ourselves in these types of situations more frequently in the future. Will some docs be forced to opt out? Will there be patients with health insurance that we find harder to get consults on than indigent patients?

Medical staff leaders and hospital administrations are dealing with these issues. The “pay for call” insurgency has hit most hospitals, and it is likely to get only worse. Hospitalists have been a big beneficiary of that trend, and most facilities have recognized the need to have a contracted or employed physician group to handle these admissions.

Hospitalists, however, cannot satisfy the need for consulting specialists to remain on the panel and be willing to provide specialty care. Restructuring medical staff categories and by-laws will play a part in this, as will enticing specialists to maintain their active involvement in the day-to-day business of the hospital.