Don Liss, regional patient management medical director at Aetna U.S. Healthcare, was recently quoted in the Philadelphia Business Journal as saying that increased reliance on broadly accepted clinical guidelines spurred the surge in denials. For example, there is a considerable amount of credible medical literature from respected university centers that says it is possible in most cases to definitely rule out a heart attack within about six hours, without a hospital admission. This is actually occurring today in many California hospitals. In the Philadelphia region, hospitals have not established these types of programs. As so often happens in health care, clinical and financial concerns merge in this issue.
Some hospitals are more efficient than others.
Buckley points out that HMO executives do not come to his hospital to see firsthand how and why patients are placed in acute care. Liss reportedly indicated that Buckley may soon get his wish. Their function is to help identify ways to improve efficiencies and arrange nursing home or outpatient testing. This is something that the consultant William DeMarco likes to hear. Then they should go to the managed care company and say 'This is what we're willing to do'.