Hospital case managers get unfair rap as "utilization review police"

Regarding "Residency's end gives revealing look at dangerous gaps in coverage" (Letters, July 24/31): In discussing the difficulties in finding coverage for long-term care or home care, letter writer Christiana M. Lietzke, MD, of Memphis, Tenn., referred to the "utilization review police" who kick people out of the hospital when they still need skilled care to recover. Further in the letter, she laments about the full hospitals and patients who have to wait hours for beds. Which way would she like it?

The hospital can allow patients to decide when they are ready to go home, but you could imagine the bed shortage that would create, or they can use resources such as case managers to help physicians manage the care of their patients.

I serve as physician adviser to the case management department at our community hospital. The job of the case managers is to ensure that the patients are receiving the right care in the right setting.

While we understand that the ability to pay affects many of the decisions that are made, if a person requires skilled but not acute care, that care can and should be provided in a skilled nursing facility, not a hospital.

Most hospitals follow guidelines that are established by national organizations using evidence-based data to determine when a person is ready to transfer, be it from ICU to medical unit or from hospital to nursing home.

Payment for service is a reality of medicine, and if an insurer says they will no longer pay for care, it is incumbent upon the hospital to expedite the transfer of the patient to the next level of care. For now, most insurers are continuing to pay physicians on a per-visit basis, but several have now adopted a policy of denying payment to the physician when the hospital is denied payment. When this alignment of incentives occurs, case managers will no longer be called UR police but, rather, partners in care.

And let's not forget that case managers are also the ones called upon at 4 p.m. Friday, when physicians round and clean up the service for the weekend on-call doctor, to discharge patients who need home care, direct outpatient infusions or transfer patients to nursing homes.

Ronald L. Hirsch, MD, Elgin, Ill.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2006/09/04/edlt0904.htm.