11:52am July 19, 2013

➸ The Not Quite Doctor: How much did his care cost?

clatterbane:

cranquis:

thenotquitedoctor:

…This is the problem with the system.  We, as providers who desperately want to make patients feel better, value action over restraint.  More and more we find that conservative measures for treatment are no worse, and in many cases better, as compared to costly and invasive interventions.  Back pain is but one example.

Imagine if we treated back pain the way evidence says it should be treated.  How many less surgeries would there be?  How many less complications?  How many less wasted dollars?

No one was at fault here, they were just misguided.  In medicine it is sometimes best to temper our innate desire to act.  Healthcare is extraordinarily expensive.  We hear everyday about its impact on the U.S. debt.  Regardless of what the news might say, swift action isn’t necessarily what we need.  In fact, perhaps we need just the opposite. 

“Conservative measures… no worse, and in many cases better.”

“Swift action isn’t necessarily what we need.”

Great sentiments! And absolutely, we doctors could save many US healthcare dollars by being more conservative in our workups and treatments plans.

But if you’ll excuse me for (once again) waxing political-ish, here’s what currently stands in the way of those noble goals:

So far, the only healthcare-related reform in the US has been health INSURANCE reform.Nothing has been done to reform the legal/tort system which threatens doctors with exorbitant malpractice costs if the docs don’t make the appearance of exhausting every avenue of diagnosis and therapy for any patient/presentation which has even the tiniest probability of being “worse than it lookedNothing has been done to improve the debt/reimbursement ratio for doctors, resulting in: an ever-decreasing revenue stream + less job satisfaction + less interest among undergraduates to enter the medical field + experienced-but-underpaid doctors having to either cut back on patient-loads or go out of business altogether… all of which leads to:The number of patients who need a doctor continues to climb, and the amount of time any available doctor can afford to spend with each patient continues to shrink in order to make ends meet financially (since the insurance companies reimburse the doctors based on a complicated coding/billing method which often does not truly reflect the amount of care provided in a visit. Note that the amount of reimbursement for the various billing codes is NOT being reformed as part of Obamacare — so it’s great and all that “everyone will have health insurance", but since that insurance will still under-pay the doctors for the care they provide, once again SOMEBODY isn’t going to be able to afford the doctor visit: only now it will be THE DOCTOR).Since doctors have less time to spend with patients and more patients to spend that time on, doctors also have less time to (a) stay up to date on the latest evidence which could help them be more conservative in their management, and (b) explain the rationale behind their conservative management to the patients themselves. Because if a patient with back pain doesn’t understand/appreciate the doc’s reasoning for NOT ordering an MRI right away, the patient will then be more likely to sue the doc if that pain turns out to be the extremely-unlikely-spinal-tumor-etc., and/or more likely to just jump to another doctor who WILL just order the MRI in order to get the “satisfied" patient out the door.All of which creates the current environment of rushed doctors practicing defensive medicine, not having the time to stay educated on the latest evidence for conservative treatments, rushing through their physical exams, not discussing treatment options properly with patients, and ordering probably-useless studies/consults in order to fend off the ever-looming threat of a lawsuit by that one patient in 10,000 who actually DID need those early (and costly) interventions.Um… on that cheery note, good luck with med school, folks! :)

(rubyvroom:)

REBLOGGING FOR INFOFROM WHAT I KNOW FROM MY TIME WORKING AT HOSPITALSI’VE SEEN ALL OF THIS GOING ONPARTICULARLY THE DEFENSIVE MEDICINEWHICH IN A HOSPITAL SETTING IS BASICALLY REQUIRED BY THE ADMINISTRATORSTHE ABOVE IS WHY HEALTHCARE IS SO DAMNED EXPENSIVEEVEN GOOD DOCTORS WHO CARE ABOUT THEIR PATIENTS HAVE TO DO THE ABOVE AND IT KEEPS THEM FROM GIVING THE BEST CAREALSONOT ALL DOCTORS ARE MAKING HUGE MONEYTHAT’S REALLY ONLY CERTAIN SPECIALISTSYOUR AVERAGE HOSPITAL DOCTOR IS NOT PULLING THAT MONEY AND THEY HAVE A HUMONGOUS STUDENT DEBT FROM COLLEGE + MED SCHOOL

Some good points here.

I would include the financial incentive to run a bunch of diagnostic tests, for insurance reimbursement, also mentioned in the link below. (It’s amazing how few tests you suddenly need when you become uninsured, or under a managed care system like the NHS. Some happy medium is totally possible there. :/)

Also, I am not sure that some of the malpractice tort reform approaches getting pushed won’t just make things worse for a lot of people. Not least , those who have been legitimately seriously harmed, and really do not need caps placed on the compensation they can receive which, in some cases, may not even cover the costs of further medical treatment required because of their injuries. (Another symptom of problems with the system. If medical care did not cost so much, people wouldn’t even need as much compensation to cover their expenses. Which also applies to other injuries, yeah,)

Doing a better job of sorting out bogus claims would be better. Though, how many bogus malpractice suits are there really? As we have seen recently in the UK, there can also be problems with admitting mistakes and holding the few bad apples responsible for poor and outright dangerous care accountable, to the point of whistleblowers getting in serious trouble. I am personally more concerned about that set of problems. Which can also get very expensive, beyond harming patients and other staff.

It turns out that people who have been harmed are actually not that prone to suing. From Medical Malpractice and Tort Reform: Yes, Deal Better With the Issues but Don’t Get Sidelined From More Costly, Needed Health Care Reforms:

The truth is medical malpractice costs — both direct costs of insurance premiums and indirect costs of defensive medicine — are not among the primary drivers of health care costs. Percent direct costs in 2009 to providers of medical malpractice liability insurance, costs including insurance premiums, settlements, awards and administrative costs, totaled $35 billion, according to the Congressional Budget Office. If those costs were lowered by 10 percent, it would reduce national health expenditures by 0.2 percent. Even if reforms resulted in less use of health care services driven by fear of lawsuits, savings to the system would be about 0.5 percent, or $11 billion in 2009…

A study that received considerable attention in 1999 was the Institute of Medicine’s report “To Err is Human.” The report noted that as many as 98,000 people a year die because of mistakes made in hospitals. The report, based on earlier studies, also found that for every 100 people hospitalized, one patient suffers a serious, preventable injury. Yet only 1.5 percent of those injured patients filed a malpractice lawsuit. The actual number of malpractice claims paid remained fairly steady between 1991 and 2003, according an analysis by the nonpartisan Kaiser Family Foundation: 13,687 in 1991 to 15,287. By 2011, the number of paid claims nationwide went down to 9,497, with 849 of them filed in California. The total number of claims paid is just one-tenth the number of hospital deaths that can be attributed to mistakes, so it’s hard to argue that patients are overly litigious.

It is difficult and expensive to file a malpractice suit. I have personally experienced blatant actionable medical malpractice which was actually likely to be taken seriously—and knew I could not afford to pursue it, either financially or with my health in the state it was in after almost getting killed. I have known several other people in similar situations, who also ended up racking up huge additional medical costs because of the initial bad treatment.

Busted health care system is seriously busted. But, reducing accountability and the remedies available to people who do get hurt ain’t going to fix it. :(

Agreed totally.

Also, I could be dead for now if it weren’t for exhaustive tests that they weren’t sure would find anything. At first I had a doctor who flat out refused to believe that my lung infection was anything
more than uncontrolled asthma. Even when it didn’t respond to asthma treatment. Even after my lung collapsed. And then he refused to look into why I still felt sick after.

New pulmonologist ran every test in the book including ones that she never expected to show anything. High res CT scan showed bronchiectasis. Which is very rare in my country especially if you don’t have cystic fibrosis or a compromised immune system. And without treatment it can to into a downward spiral ending in death.

And that’s just one example. Ice got plenty more. Because I have a lot of weird conditions, many of them genetic, and not testing for and treating them would be really really bad. Very early insert gallbladder failure, anyone?

Especially because I have developmental disabilities and a psych history, which means some doctors need hard proof of a problem before they will even believe me.

Which is why my pulmonologist did a cat scan this spring, just to prove to doctors that I really had aspiration pneumonia, because they still insisted on calling it “sensations of aspiration”. As if anyone can mistake waking up unable to breathe, then spending hours coughing bile out of your burning lungs, could be anyone else.

So I need the tests. So does my mother, who went all the way to the Mayo Clinic, which saved her life. And we have the same conditions.

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