Health Care Thoughts: Physicians "Rationing" Health Care
by Tom aka Rusty Rustbelt
Health Care Thoughts: Physicians “Rationing” Health Care
Nine physician panels have recommended less testing of patients presenting with various conditions and diseases and less treatment for some diagnosis.
For Details: New York Times
Much of this is low hanging fruit, such as using less antibiotics for sinusitis. Some of this is old news, my physician altered his cardiac and prostate screening years ago
Other recommendations may be more controversial. In 2009 evidenced based recommendations to do less breast cancer screening were met with a firestorm of criticism. Current recommendations to do less cancer screening may meet a similar fate.
There will be another controversy, whether or not these guidelines would protect a physician using conservative treatment protocols from malpractice suits. In my experience, probably not.
Eventually payment bundling and new payment schemes may accomplish the “rationing” via a different route.
Stay tuned.
I contend that following defined standards of care should be a defense to malpractice. Almost by definition standards of care set by a national standards body should be the proper practice of medicine. So therefore not malpractice. But this does have the effect of making the physician more a follower of defined protocols rather than ones the physician decides on his own.
Whether the doctor does more or less than the standard calls for, s/he can be found negligent. But I think that’s probably the right way to look at it. Doctors aren’t following a recipe or a chemical formula. They’re dealing with sick people and that’s what makes it more of an art than a science. Considering the sheer willful disobedience of some patients esp. older ones, it’s amazing the majority of doctors manage to get through the day. But that’s the job–take it or leave it. NancyO
well
“rationing” is what the market does, as that famous econ 101 textbook tells me. so when the R’s get all huffy about the government rationing health care, it must be the “government” part that upsets them. though “rationing” is the word that excites the masses.
i think that dying is one of the hazards of living, and if your doctor lets you down, that is almost a matter of luck… unless of course said doctor has a habit of letting his patients down more than other doctors.
but then lawyering over “accidents” is another one of the hazards of living. i guess i’d leave it that way.
i am not persuaded that malpractice insurance is an intolerable burden. the insurance company’s lawyers ought to be more than a match for overreaching patients’ lawyers.
The cost of defending against a totally ridiculous lawsuit runs about $25,000, if there is even a hint of validity it costs more, not to mention the stress and time involved.
Rusty,
Read yesterday in Medscape about changing court decisions on Lost Chance suits against doctors. Seems that the standard used to be that a suit would be unsucessful if the patient had a less than 50 chance of survival. The decisions seem to be lowering that down to the 30 percent range. Seems to me that is going to make doctors do a lot more testing on patients with common symptoms. Any thoughts on this and how it will affect practice?
rusty
well, sounds like a reason to reform the legal system. because as everyone knows, if you don’t have a lot of money you don’t stand a chance in court.
i would think the insurance companies have a lot of money, and i would hope the average doctor does not face that many lawsuits, but i have to say, i don’t know the facts. do know that a whole lot of distortion of the facts is done for political reasons.
If will have to read before commenting, probably after the holiday. Thanks for the pointer.
Update: A UK study indicates antibiotic therapy might be just as effective as surgery in acute appendicitis without bursting.
Count me skeptical, as the intact appendic can become reinfected or burst later. But follow up evidence will be enlightening.
Patient: one who is acted upon.
You’re right, lyle, that is the law. In, I believe, most states (possibly all states), the standard is a “community standards” type of standard, so it may seem like it would depend on whether the new guidelines are adopted quickly and broadly in your community—sort of like a “who’s on first” joke. But following national guidelines surely would be a defense. The community-standards standard is really to protect doctors in, say, rural areas from being held to the same standards as doctors in large metro areas.
Also, many states now also have some form of prescreening-for-negligence prerequisite to filing, or at least to purify suing, the lawsuit; you need an affidavit by some other doctor, or you need to have it approved by a committee of some sort, or some such.
Rusty, could you explain what payment bundling is in this context and also what new payment schemes you’re referring to? Thanks.
These days most courts will hold that the national standards are applicable to small towns because of the easy access to information available these days.
I will write an entire post sometime, here is the Readers Digest version.
Aunt Millie breaks her hip. She is covered by Medicare, She is admitted to the hospital through the ED. The orthopedic surgeon on call sees her, and a surgery is scheduled.
Instead of paying multiple providers, the hospital will bill Medicare for the entire treatment and Medicare will cut one check, and then the hospital divides the money among the surgeon, the inpatient stay, the physicial therapist, the rehab center, the DME company and etc.
This caps the total cost to Medicare. This requires a complex contracting system with all of the providers (unless the hospital is so integrated all of the services are provided by its own employees).
This will likely be the first step in innovative payment methods which are still somewhat on the drawing board, likely with pay-for-quality and pay-for-prevention components.
Malpractice lawyers still use the spray approach (file ten suits, knowing one or two will pay off) and this racks up large defense costs, wasted time and stress,
Watching television in Michigan is really irritating, all of the hysterical “your Zoloft is killing you so you get cash” commercials.
Hi Jack!
Good to see you here and bring your legal expertise to bear.
rusty
on the other hand, your Zoloft IS killing you, so…
but i would think there would be some kind of legal malpractice provision for lawyers who file frivolous suits. not sure i think that would turn out to be a good idea. it’s already too easy for the courts to deny justice based on “legal technicality.”
“ … or at least to purify suing”??? Yiiikes. Leave it to spellcheck to change “or at least to pursue the lawsuit” to “or at least to purify suing”. And leave it to me to mindlessly click the changes spellcheck suggested.
Oy.
So … here’s how that sentence should have read: “Also, many states now also have some form of prescreening-for-negligence prerequisite to filing, or at least to pursue the lawsuit; you need an affidavit by some other doctor, or you need to have it approved by a committee of some sort, or some such.”
Hi, Jack. Hey, what run said! (PS: See my comment below correcting my “purify suing” spellcheck typo. Yikes.)
coberly:
No attorney is going to invest a large amount of money suing some doctor unless the case is pretty ironclad. While 1-877 I Sue Big (actiual phone number -google it) might be on a bill board, these cases are contingent on winning inorder to get money. Michigan has legalized advertising for attorneys which makes it appear they are running amuck when in fact it is still pretty much the same.
Courts pretty much do whatever they wish to do without regard for the truth or a lie. It is still all about the win, the conviction, and who gets the notch on the gun. If you go to trial, the probability of winning is slim. And if the judge is wrong? 5-10 years down the road he may be overturned as the courts are in no hurry once you are convicted.
The health insurers already ration in their provisions about what they will and will not cover. It’s curious that some prefer private to governmental rationing. Of course, it’s only rationing in the sense of they won’t pay for it. If you want to, you can
run
sounds about like the way i see “the law.” lawyers are paid to win cases. some of em shop for cases and that may or may not be bad. and if there are some shotgunning as rusty says, i would expect they would be in danger of hearing from the licensing board or something.
but i don’t know that there is any “fair” way to decide in advance who is the bad guy. certainly denying plaintiffs the right to bring a case could be pretty bad. i suspect most judges think they are “just”… and forget that they are only human.
one thing people forget about the famous Solomon Baby Trial is that he did NOT divide the baby.
I do suspect that this scheme will mean that there will be outpatient only and hospitalists in the future. I wonder if this becomes a trend how residencies would change. Would an outpatient residency be spent mostly in the outpatient setting? Would the outpatient residency need to be as long, as basically anything that passed some level would go to the hospitalists?
There will still be a need for inpatient, Aunt Millie cannot be treated outpatient. The hospitalists will care for her before and after the surgery and try for an early discharge to the rehab center.
Much of the lower level care (my cataract surgery for example) is already outpatient.
Interesting article. Of course physicians rationalize all the time about lawsuits and the tests that they do “for the lawyers”. The problem is, it’s not a valid rationalization. Providers, at least most of us, including myself care about our patients. We are scared of missing something not because of lawyers, but because of our own insecurities and fears. It’s easy to rationalize, but the simple fact is, none of us wants to miss anything. For example, I was recently speaking with a younger attending physician, and we were discussing testing. I remarked that the longer I have progressed in my career, the fewer tests I order. I have become more conservative. She remarked that she hoped that she could get there someday, but for now, she wouldn’t be able to sleep at night for fear of missing something or hurting someone. I remarked that perhaps she needed to re-evaluate why she was ordering the test…was it for the patient or for herself. And if it was the latter, then perhaps the test wasn’t needed.
Agreed, I was just wondering what the training impact on the outpatient only folks might be. In one sense recall that 50 years ago after a year of internship a general practice physician hung out his shingle, but today its 4-5 years of residency. Or perhaps does the outpatient role move to more of the nurse praticioner model?
coberly:
Romillist, I take it?