Who's Watching The Quality Puppets?

I had a very unpleasant conversation the other day with the most unbelievable Medicare contracted quality review company.

A partner of mine has taken care of an 85 year old female, on her third hospital stay (1st at our institution).

She had been here for 10 days. She has had a "million dollar workup"

Granny's losing weight. She ain't eating. And she is failing to thrive.

The diagnosis? Florid hyperthyroidism. The diagnosis is clear as a whistle.

Granny has been started on appropriate treatment which will take weeks and weeks and weeks to improve her quality of life.

She was offered a feeding tube and the family declined. She is still not eating well.

The patient was told she will be discharged.

The family rejected the medical opinion of the primary care doctor (us) and all her specialists, that it is time to leave the hospital.

At this point the medical diagnosis has been made. There is no further work up planned. She either eats her way out of illness, or she gets a feeding tube to help get calories. The feeding tube was rejected in favor of eating.

But eating in the hospital is the desire of the family.

Unfortunately, eating does not meet criteria for continued hospital stay.

We are not a cafeteria or a half way house.

We are a hospital.

The place where sick people go.

Medicare has rules where the family can reject discharge if they feel they are not ready. A "peer to peer" review is then conducted, shortly.

A supposed physician reviews the chart. An independent physician. And makes a determination on whether the patient can say or be discharged.

A mediator between the physicians and family.

If they agree with the physicians, the patient is discharged, but can stay if they pay out of pocket.

Shockingly, the physician made a determination the patient could stay.

The lady on the phone said the reason for continued hospitalization was "continued evaluation of weight loss"

This one falls under the category of, "Are you friggen kidding me?"

I have an 85 year old lady with florid hyperthyroidism, and some doc who has never seen the patient says she needs further workup for weight loss?

I scanned the chart, a 10 day hospital stay, in 10 minutes and made a determination that the patient is stable as a rock, with stable vitals and has declined a feeding tube. She does not belong in the hospital.

It was a stunning look in to the world of peer review.

"Who is monitoring the docs who monitor docs?"


I asked the secretary? or nurse? on the line to speak with the physician who made the clinical decision that the patient needs further workup for weight loss to understand what his/her recommendations are for further evaluation. I explained that we have nothing further to test. We have a diagnosis and we know what's going on. There is nothing else to do.

I was told I am not allowed to talk to the physician in the "peer to peer" review process.

That the review is done in a confidential manner.

I asked then that she contact the physician with very specific recommendations for orders to continue the workup.

You know what response I got?

The basis for the patient requiring continued inpatient stay was a documented weight differential of 7 kg in a span of two days, with matching ins and outs.

The lady on the phone stated to me, in no uncertain terms that the patient was "unstable" and that the weight loss needed to be addressed.

Any idiot would know that that kind of weight loss can only occurs with scale differentials, scale error or an amputation. It would be a physical impossibility to explain physiological weight loss of that magnitude on anything else. A physician would clearly discount irrational data or question the validity of such data. I could not believe that a physician based their recomendation based on clearly irrational data.

To call my patient "unstable" made me lose all respect for this quality puppet regime on the phone. Fore someone to categorize my patient as such, without ever seeing the patient is both inappropriate and clearly lacks the ability to do their job. They should be fired.

She refused me the courtesy of discussing the patient with the peer to peer reviewer. For all I know, it is a high school drop out.

Or an unqualified extender. Or a nurse. No offense, but if I'm getting a peer to peer review, I expect a physician for whom I can talk with the patient about on an even level of educational standing.

If in fact a physician made this determination, they should go back to training. They have lost all clinical capabilities.

I was told by this secretary/nurse on the phone it is my responsibility to go back to the family and ask them for a feeding tube. Again. I was asked why I have failed my duties as a physician to bring up comfort cares in this patient. I was asked why the patient is in her third admission in a month or two.

It was a bunch of Bullshit. If the family doesn't want a feeding tube. Then the go. They do not get the luxury of consuming hospital resources simply to see if granny's appetite picks up in the next week.

I should have a right to speak to my peer making clinical decisions if they have concerns about quality. It is a cowardly cloak of secrecy.


Instead, they have given this family a free ride to consume $1000 a day in hospital resources simply so granny can be spoon feed. No hospital therapies. A bed being used and abused so someone who needs it cannot.

After my 1 hour unreimbursed talk with the family, they have made a decision to "wait a couple days" to make a final decision about a feeding tube or not.

And you wonder why our country is going bankrupt.

You have quality care and recommendations being refused by families. You have poor quality care delivered for no other reason than it must be delivered to avoid legal consequences, and you have Medicare sponsored reviews filled with anonymous peer to peer review without an appeals process making ridiculous claims about the quality of care delivered.

If this reviewer was my physician, I would be running for the hills. They have no business caring for patients.