Healthcare Reform and the Doctor - Patient Relationship

There is much controversy over new guidelines published by U.S. Preventive Services Task Force (USPSTF) on breast cancer screening http://www.annals.org/content/151/10/716.full . The American College of Obstetricians and Gynecologists http://www.acog.org/from_home/Misc/uspstfResponse.cfm and the American Cancer Society http://bit.ly/5JWL4 disagree with the guidelines, as do many people who have been diagnosed with, or have friends or relatives who have been diagnosed with, breast cancer by early screening.



This decision is not an isolated event. In 2005 the American Heart Association modified its recommendations for stress testing in asymptomatic patients http://circ.ahajournals.org/cgi/content/full/112/5/771 based upon recommendations of the USPSTF despite recognizing that "...functional capacity, chronotropic response, HR recovery, and ventricular ectopy have been shown to predict adverse events in asymptomatic subjects, and ... exercise testing measures have been shown to improve the prediction of coronary heart disease events over and above the Framingham Risk Score." Few people actually undergo routine stress testing to screen for coronary artery disease due to the cost, since most insurers will not pay for screening stress tests. They follow the lead of Medicare, which does not pay for routine screening tests, unless specifically allowed by statute (such as mammography and colonoscopy).



Unfortunately, as healthcare "reform" progresses, tests performed outside the government's recommendations will have to be paid for by the patient at their own expense. The government will not pay for services they do not recommend, and private payors will use the government refusal to pay as justification for not paying, as well. The doctors recommending these tests will be characterized as greedy charlatans for recommending "unnecessary" services.



There are costs associated with preventive care, some of which I have previously discussed http://hartdoctor.blogspot.com/2009_06_01_archive.html . Insurers can take a long view, and pay these costs to avoid greater costs (and greater morbidity) down the road. Too often, though, they are focused on the financials of the next quarter, and avoiding the costs of preventive care increases near-term profits. After all, the insured may be moving to a different insurance company next year, and the cost will pass to someone else. As the government prepares to move into the financing of healthcare, there will be the same pressure to cut near term costs, to make the ventures appear to be more sound financially and to add less to the nation's deficit.



When a private insurer makes a decision to deny care to save money, though, we citizens have a recourse through the court system to rectify this. We can rely upon recommendations of independent organizations to set standards for care, and we can expect our insurers to pay for services that meet those standards. When the government is our insurer, though, and it also sets its own standards for care, what recourse do we have? The recently-passed House healthcare reform bill even goes as far to exempt private insurers from legal liability for decisions to deny payment for care. The physicians who may have recommended that care, of course, have no such immunity from liability, even if the patient could not afford to pay for the procedure or treatment themselves.

Don't think the government can come between you and your doctor in making decisions about your healthcare? They are already there.