Monday, April 21, 2014
Who Shall Decide?
The press has recently included a number of articles about a
movement under way to have doctors take cost into account when making clinical
decisions. The idea is that whereas the
ethos of medicine has been that the doctor should only consider what was
clinically best for the patient, cost has reached such a level that perhaps it
should be considered as well.
There is some disagreement about that, of course, and in the
New York Times article of April 18 on the subject, Dr. Martin Samuels, chief of
neurology at Brigham and Women’s was quoted as saying “There should be forces
in society who should be concerned about the budget, about how many M.R.I.s we
do, but they shouldn’t be functioning simultaneously as doctors.”
I see merit in that point of view, but it leaves open the
question of who those “forces” should be.
The “who” most active in this area at present are insurance
companies, not my first choice as I think they will always be suspected of
being motivated more by financial considerations than by the interests of
patients.
I’m not thrilled about government doing it, either. I wouldn’t feel comfortable having decisions
about how much my health care can cost in the hands of politicians mainly
concerned about surviving the next election.
My vote would be for my local, non-profit community
hospital, controlled by trustees who are my friends and neighbors, united with
its doctors, and operating in a market designed to reward providers who provide
the best value for money spent – best value being defined as my best
interests.
Monday, April 14, 2014
Professional Independence
Professional independence has long been a strong element of
the culture of health care generally and of the medical profession in
particular. “Following doctor’s orders”
was something good patients did and nobody wanted to be accused of “interfering
in the practice of medicine.”
That now seems to be in a state of demise.
The April 8 issue of The Boston Globe carried an article
about cutbacks in painkiller prescriptions by Massachusetts Blue Cross Blue
Shield. The key sentence reads “Faced
with concerns about a rise in opiate abuse, Blue Cross implemented changes in
July 2013 that have reduced prescriptions by 20 percent for common opioids such
as Percocet and 50 percent for longer-lasting drugs such as Oxycontin….” The changes were limits on the number of
days’ supply per prescription and the number of refills eligible for payment. Prior authorization by Blue Cross was also
required in some cases.
As I read through the article my thought was that either
some bad medicine was being practiced or Blue Cross was interfering in doctor
business. If the former, somebody would
“view with alarm.” If the latter,
somebody representing the profession would complain.
Neither turned out to be the case. Instead Dr. Raymond Dunlap, president of the
Massachusetts Medical Society was reported as saying that “Blue Cross is
heading in the right direction.”
It looks as if the day is coming when the professional
independence of medicine will be a thing of the past. Doctors who wonder how that happened need
only look in the mirror.
Saturday, April 05, 2014
Planned vs Market Economy
We still can’t decide whether we want the health care
economy to be centrally planned or market driven.
The situation is illustrated in Omaha where the University
of Nebraska Hospital system has decided to discontinue an arrangement in which it
cooperated with Alegent, an affiliate of the Creighton University Medical
School, in providing Level I emergency trauma services. Previously, each had a Level I program but
rotated the days on which they operated.
Alegent announced it will continue to operate its Level I program so now
Omaha will have two programs, each open 24/7.
Although the article did not say so, Medicare, Medicaid and private
insurance companies will presumably continue to pay as before.
The reason given by Nebraska University is that while the
previous arrangement worked alright, it was not eligible as a divided program for
American College of Surgeons certification as a Level I facility. Currently the
programs have state certification only. ACS
certification is the gold standard and not having it has made staff recruitment
more difficult and generally detracted from University’s status as an academic
medical center.
There may be something to that, but the impression left by
the article is that University, being the stronger of the two, decided it could
make it on its own, get ACS certification, and get a leg up on its competition.
The volume of Level I cases in Omaha, about six per day, is
well within the capacity of a single unit.
So if operations continue as in the past, having two full blown programs
will clearly be more expensive. In other
kinds of activity, that disadvantage would be offset by market competition in
which each would strive to grow and prosper by becoming more attractive and
efficient than the other. But if only
one was to continue in operation it would be considered to be a monopoly and regulated
as such.
But it seems we are to have neither one.
And we wonder why the cost of care is so high.
