Problems with Modern Healthcare

[LucyL]

There is a charming little blog called "A Country Doctor Writes" written by a Swedish immigrant physician who practices in (I believe) Maine. He is a pretty typical statist doctor, but one who really seems to care about his patients. What makes his blog special is he often dishes on the bureaucratic side of healthcare from a physicians perspective.

For instance, in his post Medicine is Easy but Metamedicine is Hard he writes:

Physicians, PAs and NPs all live in two parallel universes these days, the World of Medicine and the World of Metamedicine.
...
Imagine a well trained physician faced with a patient who has gained some weight and complains of swollen legs. The doctor notices that the patient seems just a little short of breath. But our patient also admits to eating more than he used to and he has been on his feet more than usually in hot weather. He wonders if that may have caused the swelling.

Our wise physician knows that right-sided heart failure predominantly causes edema, whereas left-sided heart failure more affects breathing. Suspecting heart failure, he orders a BNP, a relatively new, fancy screening test for heart failure.

The overlords of the Metamedicine universe, in their infinite and inscrutable wisdom, have determined that Medicare will pay for BNP testing in cases of shortness of breath, but not in cases of leg swelling. Our doctor orders the BNP in good faith for the diagnosis of “edema”, but the next day the lab notifies him the test was not run because there was no covering diagnosis.

And in his post The Ghosts in the Exam Room – Part 1 he writes:

Medicare is not only deciding what services to pay for; they are also scripting entire doctor-patient visits.
...
I have been brushing off the Annual Wellness Visit (AWV) until now, but it has become a quality indicator that our clinic has to report statistics on, so I need to change my ways.

For the past few days, I have been studying the scripts for the AWV. I have printed up the forms I will need in order to follow the script, since our EMR only has a template for the “Welcome to Medicare” visit, but not for the Annual Wellness Visit.

I have scratched my head about the covered baseline EKG when the USPHS recommends against it, the PSA screening when the evidence doesn’t support it, and several other items on the checklist.

I have duly noted that some clinics, after being audited, have had to call patients back in at no charge to complete missing items on the checklists. I have also noted, although I’m not sure I can comply with, the requirement that any actual physical exam performed during one of these visits requires the patient to sign an ABN (Advance Beneficiary Notice) that they might get a bill that isn’t covered by Medicare. I think I’ll just listen to some hearts and lungs without telling Uncle Sam about it.

And then the story of Gerald Incentive, Bribe or Kickback?...

Today I got a fax that made my jaw drop and my heart sink.

A pharmacy benefits manager, the part-insurance-and-part-mail-order-pharmacy for a few of my Medicare patients, was contacting me to point out that there was a new incentive for me to consider:

For each of the diabetic patients listed on the second page of the fax, I would be paid $100 if I prescribed an ACE inhibitor or an ARB (angiotensin receptor blocker) by the end of next month.

Only one patient was listed, an extremely well controlled diabetic single gentleman in his late 70’s, Gerald Spike. Gerald has lowish blood pressure, has fallen twice in the last year, and his MCV (the size of his red blood cells) is above the normal limit. His B-12 and folic acid levels are normal, and the next likeliest explanation for this is alcohol consumption. Gerald swears he only has one glass of wine every night with his dinner.

Gerald is not a good candidate for an ACE or an ARB. I personally am not convinced that any well controlled diabetic with normal kidney function, normal urine microalbumen and normal blood pressure should be on one of those medications, especially at Gerald’s age, but that is a different story. He could ill afford to have his blood pressure lowered even a little.

Offering a cash incentive for doing something that could harm a patient, and which in one or several ways profits the pharmacy benefits manager, be it in their quality metrics, moneys paid to them by the main insurer, or copays from patients – is unethical. Call it an incentive if you wish; bribe or kickback are more accurate words for this.

The changes going on behind the scenes are the doctors' offices are alarming, to say the least. When the doctors that practice their entire careers with this system become the teachers, no one will no how to treat the individual patient anymore.

I only hope there are a few more - younger - Ray Peats around because mainstream healthcare is going to be a very bleak industry in a few short years.

 

[SQu]

Thanks for this interesting peak behind the scenes. My heart sinks too because I doubt many doctors would be this conscientious. I've also noticed that the system is cutting out both patients (because doctors ignore what we say and treat the numbers) and doctors when it comes to decision making. I find it increasingly patronizing and insulting, not to mention disempowering and dangerous. Ray talks to people with respect and doesn't dumb down what he has to say. For that alone I'm a fan for life.