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.

Medical Defendants and Defensive Medicine

My name is Steve, and I am a recovering defendant.



It has been a little over 15 years since I was last sued in a medical liability case, but the experience is still with me today.



Attorneys seem to be able to take these things fairly lightly. Sure, they work hard, and argue their clients' cases passionately. But at the end of the day, win or lose, they go home and start working on the next case. Maybe it is different when they are the ones being sued. Where you stand on an issue often depends on where you sit.



Physicians I have met who have been sued, though, have trouble not taking these things personally. They put a great deal of themselves into their patient care, and a lawsuit alleging that they have been negligent in that care or that they have not met the "standard of care" for their patients is often felt as a personal, as well as a professional, failure, even if they feel the care they rendered was appropriate at the time. And even if there was no wrongdoing, there is still a prolonged period of self doubt and agony leading up to the trial. Then there are the depositions and the trial itself, when the physician's life is examined under a microscope looking for flaws.



An "expert" witness for the plaintiffs at my trial testified that the standard of care required that any patient with chest pain unexplained by an abnormal EKG must have a CT of their chest. My malpractice provider even informed its other insured clients that this would now have to be considered the standard of care in our area. Although I was found not guilty by unanimous verdict in my trial, I would estimate I have ordered 4 or 5 chest CT's a month ever since then to avoid ever being put in such a situation again.


The costs in money and radiation exposure of this one change in practice is large. When multiplied by many other physicians who do not wish to undergo the personal agony and humiliation of leaving themselves and their families open to the possibility of a lawsuit, the cost is enormous. Estimates of the annual costs of "defensive medicine" are in the $100 to $200 billion range. These are likely underestimates of the costs, since the documented "indication" for a procedure is never stated as such. 83% of physicians reported they practice "defensive medicine" in a survey by the Massachusetts Medical Society last year (http://www.massmed.org/AM/Template.cfm?Section=Advocacy_and_Policy&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=23559). They reported that 18 to 28 percent of tests, procedures, referrals and consultations, and 13 percent of hospitalizations were ordered for defensive reasons.



I have survived the death of two parents and a spouse. When these deaths occurred, I never had the inclination to find someone to blame...someone to sue. In our grief and pain the death of a loved one seems "wrong," but every death is not "wrongful." We are mortals, and none of us will get out of this alive. Ultimately, our expected mortality rate is 100%, even with appropriate medical care.



Our current medical tort system does more than damage our budgets. It damages the trust our patients have for their doctors, and the trust our doctors have for their patients.



Until we are ready to recognize these economic and personal costs, and enact meaningful tort reform, we will not be able to enact meaningful healthcare reform.