Friday, March 11, 2005

Money and medicine

I consulted on a patient in the hospital and my physician's assistant(PA) called to tell me the neurologist on the case had ordered an electroenecephalogram(EEG- measures brain waves, good for determining if a patient has a seizure/epilepsy problem). There wasn't any doubt in my mind that the patient did NOT even have a question of seizures. My PA asked why the EEG was ordered. The only answer I could give her was that it was a procedure, and the neurologist can bill not only for doing it, but for reading it, and procedures are a good source of revenue(better than just doing consults or office visits).

I referred a patient for a procedure that was recently approved by the FDA(food and drug administration). It has been in use in Europe for a long time, and is a significant improvement on what was available previously. The insurance company declined to pay for it, saying there was insufficient evidence for effectiveness. This despite FDA approval, and many scientific studies from other countries. Are they really trying to protect people from unproven procedures? Of course not. They dont want to pay for another procedure. They said they would revisit the issue in 3-5 years.

Doctors get paid for doing more procedures and having more office visits. Insurance companies make more by limiting what they will pay for. No one has the patient's interest solely at heart, except for those who specifically and narrowmindedly put aside any financial motive and focus exclusively on what is good for the patient. I try my best to be one of those, and in all honesty I think I am successful in keeping away any thoughts about reimbursment when I am deciding about patient care. There are many doctors who do. Unfortunately, there is a significant number who let greed infuence their decision making.

GREED. That is the problem with our society in general and the practice of medicine in particular. Greedy doctors, greedy health insurance companies who want to look good for wall street and pay their CEO's millions and millions of dollars, greedy malpractice insurance companies who want to recoup what they lost on natural and other disasters and also pay their CEO's millions of dollars and look good for wall street, greedy patients who want excellent care but dont want to pay a lot for it, greedy lawyers who are willing to file lawsuits they know are not justified but have a chance of winning large sums of money.

There are no specific checks on any of this greed activity. It is hard for a patient to know if the doctor is making a recommendation based on what is good for the patient or what is remunerative for the phsycian. It may be hard to tell even by someone looking at it from the outside. Sometimes it is little things like an extra EEG. Sometimes it might be surgery. But as long as something looks reasonable, there is no check on what is reccomended, and because medicine is frequently subjective, there usually is some justification for the test, or procedure, even if it wasn't totally neccessary.

There is little recourse if your insurance wont pay for a procedure. Well, you can argue with them, and you and your doctor can paper them with letters, phone calls, etc. You can call your congressman, call your human resources person and try to threaten them with transferring your company insurance coverage, but it takes a lot of effort and time to get anything done, with no guarantee of success. Ultimately, sometimes it takes a law suit to get coverage.

There is also little recourse for physicians who get charged exorbident rates for malpractice insurance. There is a market, but very few companies offer insurance, and the rates are always pretty similar. Going without coverage is against the law in most states, and also not allowed by a lot of hospitals. The option is to move to a state with lower rates, limit your practice, or stop practicing.

Any lawyer can file a malpractice lawsuit as long as he can find a doctor to certify that there is a cause for the case. Unfortuantely, there are a lot of doctors needing money, or wanting more, who, for a fee, are willing to say almost anything with a bad outcome is malpractice. Even if the suit is thrown out, it is very difficult for the doctor to go back and sue the lawyer for filing a frivolous lawsuit. Most of those get thrown out. So, there is very little repercussion for filing lawsuits. There is no penalty for losing, and the client pays your expenses anyway.

In order for there to be a fair system of health care, all these problems need to be addressed. taking care of one or two, and neglecting the others will just skew the system, not fix it.

carefully putting away my soap box for use at another time.

Shabbat Shalom

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