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.

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