The infinite wisdom of government has decreed that
hospitalization be reimbursed on the basis of diagnosis rather than length of
stay, and has created complex computerized formulas to guide us through the
intricate mazes of reimbursement. The program is known as Diagnosis Related
Grouping (DRG).
The obvious purpose of the scheme (or scam, depending
on which side of the DRG you happen to be situated) is to save money. The
government claims that there has been excessive hospitalization and that it all
costs too much. In order to police the system (all systems require policemen to
see that the system is properly carried out) the government has selected groups
of doctors called Professional Review Organizations to oversee hospitalization.
Towards this end PRO representatives are positioned
in each emergency room to determine whether or not a patient should be
admitted. These representatives place seeds of doubt in the minds of the
doctors but do not document their expressed feelings. Doctors are asked to
explain in writing the reason for admitting certain cases. Actually it is a
form of harassment.
PRO representatives who may block a hospital admission
do not have to assume any responsibility if anything goes wrong. It is the
favorite nouveau American ideal, derived probably from the concept of a
committee which separates authority from responsibility. PRO has the authority
to interfere with the management of the patient, but the doctor is left with the
responsibility if anything goes wrong.
This isn’t cricket, but neither is it the practice of
medicine. PRO takes the position that any tests that can be done out of the
hospital be done, and only when a diagnosis is established and a patient
requires treatment that can only be rendered in a hospital, is hospital
admission warranted.
This of course constitutes an attack on the
populations of the sick. I for one believe that hospitalization for observation
in certain cases is valid; but PRO would have me give the patient an
intravenous just to prove that something is being done.
The government claims that studies fail to prove that
this policy has caused any damage. Of course, dead men tell no tales, but
recently I heard of a spine-chilling episode which might have turned out badly
had the doctor been cowed by PRO/
The patient had digitalis toxicity, which slowed his
heart rate to about 30 beats a minute. The doctor wanted to insert a temporary
pacemaker until the digitalis washed out of his system. PRO suggested treating
him with medication instead. The doctor stuck to his credo and inserted the
temporary pacemaker to protect the patient from cardiac arrest until the
digitalis washed out of his system. But suppose that PRO had prevailed and the
patient had died. Who then would have had to bear the responsibility?
The trouble is that new doctors are educated and grow
up in the environment of DRG and other assorted regulatory agencies. They
simply do not have any memory of what it is like to be free to practice
medicine as an art and compassionate service. They acclimatize themselves to
DRG and PRO, having known no other ambience. They fall in line and soon there
will be no one left to protest.
Having a supervisor in an American emergency room
pointing right or left to determine who should be admitted and who should be
refused evokes a bitter memory, doesn’t it?