A Chance to Cut is a Chance to Cure

Because of strokes she suffered while in her mother's womb, 13-year-old Callie Moore of Danielsville has a host of complex medical problems. They include spastic quadriplegic cerebral palsy, refractory seizure disorder, mental retardation, gastroesophageal reflux disease, cortical blindness, dysphagia, bone cartilage disease, scoliosis, kyphosis and restrictive lung disease.

Callie's condition mandates round-the-clock care and treatment. Under federal and state Medicaid regulations and policies, she is entitled to screening, diagnostic and treatment services and, because she is medically fragile, skilled nursing care. Medicaid is a joint federal-state matching program that pays for medical assistance for low-income families and for people who would require institutional care if they were not receiving alternative services at home.

The Moores' lawyers convinced U.S. District Judge Thomas W. Thrash Jr. that the reduction was improper. The judge concluded the state must provide for the amount of skilled nursing care that Callie's treating physician deems necessary.

Thrash's June 4, 2008, ruling has states and Medicaid plan managers up in arms. They say that Thrash's order means that states won't have the flexibility they need and the discretion the law allows to allocate Medicaid resources fairly......

....When state authorities notified Callie's mother that her nursing hours were being reduced, they cited, among other things, a policy that the cost of in-home nursing care should be less than the cost of providing that care in an institution. But the state denies in its brief that it considered cost in determining what nursing hours Callie will receive. It says its experts simply disagreed with the judgement of Callie's doctor on how many nursing hours Callie needs.

After Thrash issued multiple injunctions in Callie's favor, he denied the state's motion for summary judgment and granted the Moores' motion in part.

"Treating physicians...cannot be trusted with this sort of discretion," Senior writes. "When left to their own devices, they advocate for their patients and deem all manner of unproven, dangerous, ineffective, cosmetic, unnecessary, bizarre, and controversial treatments as 'medically necessary.'"

He continued: "Case law provides examples of treating doctors claiming medical necessity and attempting to bill Medicaid for: cosmetic procedures; sex-change operations; (unapproved) drugs; abortion on demand; 'treatments' that have never been proven to work; and round-the-clock nursing and personal assistance for patients who obviously do not need it..." (emphasis added)

Under the Obama-Biden plan, patients will be able to make health care decisions with their doctors, instead of being blocked by insurance company bureaucrats.

The “rational,” cost-cutting, “hard-choices” pitch isn’t just awful marketing–I don’t even think it’s accurate. Put it this way: I’m for universal health care in large part precisely because I think the government will be less tough-minded and cost-conscious when it comes to the inevitable rationing of care than for-profit insurance companies will be. Take Arnold Kling’s example of a young patient with cancer, where “the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200.” No “rational bureaucracy” would spend $20 million to save a life, Kling argues. I doubt any private insurance company is going to write a policy that spends $20 million to save a life. But I think the government–faced with demands from patient groups and disease lobbies and treatment providers and Oprah and run, ultimately, by politicians as terrified of being held responsible for denying treatment as they are quick to pander to the public’s sentimental bias toward life–is less likely to be “rational” than the private sector.

That is to say, the government’s more likely to pay for the treatment (assuming a doctor recommends it). So it’s government for me.

But Kaus is correct that if some high-powered and well-funded interest group gets behind a certain procedure, cost-effective or not, the government overlords of the program will likely approve it. As a result, for example, no potential treatment for breast cancer will ever be denied given the proven strength of women’s groups lobbying for breast cancer treatment (already, breast cancer research is hugely over-funded vs. other diseases given its mortality, due in large part to this powerful lobbying).

But it is not one dynamic or the other. Both will exist. There will be huge pressures to cut back somewhere, as costs skyrocket. And there will be huge pressure from certain interest groups to fund treatment for certain diseases in unlimited amounts. The result will not be, as Kaus posits, that everything will be funded more than it is today — the result will be that certain procedures and conditions with strong lobbying and political muscle will get funded more, with the difference being made up from cutting funding for conditions and procedures without a well-organized lobby.

Labels: health care reform, Hope and Change

1. Has full, unrestricted admitting privileges (no "consult" or "courtesy"privileges).
2. Takes call, according to bylaws, without compensation from the hospital.
3. Does not receive a payment from the hospital on a fee-for-service or other basis for providing uncompensated care
4. Does not have a contract to provide services to any hospital, with the exception of such things as EKG, echo and PFT interpretation. I am uncertain as how to approach unpaid "medical directorships".

I will admit that the above requirements are stringent, but they probably were the norm for most non hospital-based physicians in the not too distant past. I will also admit that I do not meet my own definition of "independence". My thoughts as to the "why":

1. The rise of hospitalists and the economic realities of outpatient versus hospital burdens for primary care providers has caused many to forgo hospital privileges
2. Hospitals are having to pay physicians to take call and provide guarantees for Medicare/caid rates for unfunded patients
3. Hospitals are increasingly employing specialist physicians, as the procedures they perform can generate income for the hospital.
4. Given the lifestyle concerns of recent (and not so recent) residency graduates, the appeal of a salaried hospital position is strong.

It is also difficult to get physicians to participate in the ongoing workings of the medical staff. yes the quarterly meetings are popular because a free dinner is thrown in. But it is a Herculean effort to get physicians to agree to be on committees, much less show up for them, for many the same reasons that local medical societies struggle to survive.

Proponents of a strong medical staff have our old, dear, friend the Joint Commission to thank since they require hospitals to utilize their medical staffs for credentialing and peer review.

But if the members are dependent on the hospital for all or a goodly portion of their income, just how independent are they?

Labels: Future of Surgery, Hospital overlords

Labels: Bulldogs, college football, to hell with Tech, UGA

Make no mistake, specialist organizations are ready to throw primary care under the bus, with the opening salvo of implying that generalist doctors can be easily replaced by mid-level providers telegraphing their intentions.

Let's hope that the ACP is aggressive in countering these tactics. It's becoming clear that a conciliatory approach with specialist organizations may not be feasible, and more contentious, potentially confrontational, methods may be needed to be heard above the din.

The American College of Surgeons, joined by other surgical specialty societies, has created Operation Patient Access (OPA), a campaign to "bring into focus the urgent issues facing access to quality surgical care in the United States ... and to call attention to urgently needed policy changes to address gaps in the availability of quality surgical patient." According to the OPA website (which is pretty nicely done, by the way), 400 surgeons - sporting "Will a surgeon be a there when you need one?" buttons - descended on Capitol Hill last week to urge lawmakers to "consider a wide range of solutions, such as providing more funding for graduate surgical education, reducing liability costs, expanding the National Health Service Corps, and implementing alternative payment methods for health care. If we fail to act now, these shortages will undermine attempts to expand access to health care and will further endanger the lives of all our citizens."

If this sounds familiar, it is because the surgeons' diagnosis and policy prescriptions are virtually identical to the case that ACP has been making on the primary care physician shortage.

Which is a problem, because it blurs the urgent need to rebuild the primary care physician workforce in the United States by suggesting that the crisis in surgery is of greater concern. The tools to increase the numbers and proportions of primary care physicians in the United States - payment reform, scholarships and loan forgiveness in exchange for service obligations, and graduate medical education funding - will be ineffective if the limited funding for such programs are broadly diverted to increase the numbers of surgeons, including some surgical specialties where there is scant evidence of a shortage. The OPA website speaks broadly of shortage of surgeons, when the evidence that I've seen - including the evidence on the OPA website - suggests that the shortage is principally in general surgery and a few of the surgical subspecialties and in certain parts of the country, particularly rural areas.

Labels: Future of Surgery, Physician/physician relations

Labels: Tales from the Trauma Service

Labels: medical television