Road To Hellth

Jul
24

Encouraging Common Sense in Public Policy

Science is nothing, but trained and organized common sense.
–Thomas Huxley

First a quick note. Our postings are fewer and farther between this summer due to a particularly busy schedule, but will become more frequent and regular again as we get closer to the November elections.

In the meantime, the dog days of summer seem to be producing relatively few new or interesting journeys on the Road to Hellth. Buoyed by the Supreme Court’s decision, The Affordable Care Act is continuing to allocate money in ways that appear to be directed more toward influencing the results of the election than contributing to the long-term viability of the nation’s healthcare system. A prime example is the ongoing use of “research” money to preserve Medicare Advantage benefits for millions of seniors until just after conclusion of the Congressional and Presidential elections.

Indeed, most everything in healthcare seems to be in a state of suspended animation until after the election. This only makes sense. Why should millions of companies and individuals voluntarily make elaborate and expensive plans based upon a law that may be actively overturned (or at least undermined) if Mitt Romney should be elected in just a few months. No one really knows if ACOs are going to be real or imaginary, whether all of the taxes involved will kick in, or if the dozens of promised carrots and sticks will come into play. So money continues to be spent and decisions continue to be made based upon the existing law, but they are half-hearted.

Unfortunately, this doesn’t mean that reason and common sense are spreading throughout the world of healthcare either. In case you missed it, we would like to illustrate with a seasonal example from the world of schools and camps for children.

By now, virtually everyone knows – or certainly ought to know – that too much exposure to ultraviolet light is a bad thing for skin and human health. The ACA even includes a well-intentioned but ineffective 10% tax to raise money and discourage the use of tanning salons; unfortunately tanning rates have stayed about the same, while the measure has raised far less revenue than previously expected. For many years the American Academy of Dermatology has paid for advertising campaigns that encourage the use of sunscreens and natural shade, discourage tanning and educate laypeople on the high risk of developing skin cancer as a result of unprotected exposure to the sun. One might think that schools and summer camps would have picked up on these themes long ago. But every American institution lives in world where bureaucratic requirements and legal liability concerns eventually trump every other consideration. Jesse Michener, a mother in Tacoma, Washington found this out the hard way when she sent her two daughters school field trip, only to have them return with severe sunburns. The reason? In an effort to ensure that no “drug abuse” takes place, their school has a policy that bans sunscreen use (an over-the-counter item to be sure) without a doctor’s prescription. We’ll let USA Today tell the story as Ms. Michener:

…was horrified to see two of her daughters, ages 11 and 9, return from a school field day with severe sunburns.

The girls have extremely fair skin, and none of the adults at the event offered them sunscreen — or shade, for that matter — as a rainy day turned sunny, Michener, 37, wrote in a post in her blog, Life.Photographed, that got nationwide attention. More than a week later, their skin still is peeling and red, Michener told USA TODAY Wednesday: “It’s appalling.”

Violet Michener, age 11, after her field trip.

…But sunscreen rules are common. They typically stem from state and local policies that stop kids from bringing any drug — including non-prescription drugs — to school, says Jeff Ashley, a California dermatologist who leads an advocacy group called Sun Safety for Kids.

Sunscreens are regulated as over-the-counter drugs, so many districts treat them like aspirin, just to be safe, he says.

Ashley helped get California to pass laws that say kids have a right to bring sunscreen, hats and other sun gear to school. That was nearly a decade ago, but as far as he knows, no other state has done the same.

So there’s a mish-mash of policies. Often, “sunscreen application at school seems to be an issue that each individual school district rules on,” says Jennifer Allyn of the American Academy of Dermatology. “Some treat sunscreen as they would any other fragrance-type product, and forbid their use to avoid allergic reactions. Others require a doctor’s note, and others treat sunscreen like something as basic as Chapstick.” The academy endorses sunscreen use but has no policy on how schools should handle it, she says.

But Ashley says allergy concerns are overblown: “Sunscreen allergies are no more common than allergies to soap. Are schools going to take soap out of their bathrooms?”

Another common concern: Adults will get in trouble for inappropriately touching kids if they help apply sunscreen. That was the question in Maryland last summer when the state enforced, then repealed, a rule forbidding camp staffers or even other kids from slathering lotion on campers. Now it’s OK, as long as parents say it is.

Michener says her daughters also were forbidden to bring hats to school. That’s another common policy, Ashley says. “Schools will tell you hats can be signs of gang affiliation.” Some schools dodge that danger, he says, by selling or supplying identical sun-safety hats…

Why is common sense so uncommon among the people whom we have trusted with positions of public responsibility? Is this really the same country that managed to win World War II (although to be honest, with the help of other countries – the Soviet Union and Britain in particular) and put a man on the moon?

There is no question that, in the hands of children or abusers, some over-the-counter (OTC) medications can be positively harmful. Robitussin® (dextromethorphan) in common OTC cough syrup is often taken and abused by adolescents and drug abusers for the “out of body” feeling and hallucinations that it can produce. One study showed that 2.4 million teens — about 1 in 10 — got high on cough medicines in 2005. That makes it just about as common as cocaine abuse. Excessive ingestion of acetaminophen can cause liver damage. Laxatives and diet pills often consist of nervous system stimulants. Should parents, teachers and counselors be worried about these things? Yes, of course they should.

But as we’ve seen so many times, the problem occurs when someone in a position of power decides to draft a standard “guideline” of care without really knowing what they’re doing. The guideline rapidly becomes set in stone, and the means by which those dealing with the population in question are judged, rewarded and punished. In this case the guideline was thoughtlessly crafted to be overly broad; it doesn’t take a genius to determine that some OTC items are more subject to abuse than others, or that some of these items were themselves created and distributed to address a potentially serious healthcare problem. Sunscreen is one example, but there are others. Mosquitos and ticks can be carriers of serious illnesses such as Lyme disease and West Nile Virus. Properly formulated and administered, insect repellents are safe for use in children. Presumably the same ban on OTC products prevents their use in many schools and camps nationwide. How difficult would it be to draft a list of “allowed” OTC items rather than banning the entire class of products willy-nilly? Apparently too difficult for the people whom we are paying to look after such things.

Lest we be too critical, we should note that the provision allowing the use of standard hats as a means countering gang-related activity is a logical and thoughtful response to a pervasive social problem. At least someone somewhere is using their head.

This particular episode brings up a question that has, as far as we know, been completely ignored in healthcare reform. Why are physicians and hospitals held responsible for the quality and appropriateness of their actions and decisions, but not the bureaucrats regulating them? One could certainly argue that a policy-maker in Washington or even at a state school system has far more power over our nation’s lives and treasure than any individual physician could possibly muster. Why aren’t regulators scored, awarded and punished based upon the health and economic effects of their performance? Indeed, in some respects laws directed toward enhancing the performance of regulators and policy-makers stand a much better chance of improving public welfare than anything aimed at providers themselves.

Want to mandate the implementation of an electronic medical record system? No problem. In that case your own salary will be increased or decreased based upon the resulting change in medical productivity that results from the policy. Planning on deploying a system of pay-for-performance incentives for healthcare providers? Excellent. However be aware that if it does not result in a significant improvement in performance as measured by health-adjusted cost savings, the cost of implementing and administering the plan – including the cost of compliance – will be deducted from your department’s annual budget. Want to ban the use of sunscreen by schoolchildren rather than encourage it? Okay, just be aware that we intend to monetize the cost of any excess sunburns that may result, and apply them against the compensation of those formulating the policy.

The quality of healthcare policy and regulation would improve overnight. So would the use of common sense.

Categories : Bureaucracy Run Amok, Clinical Care, Economics, Ethics, Healthcare Policy, Overhauling Healthcare, Politics, Quality Questions, Solving Problems, Stupid Guideline Tricks, The Practice of Medicine

Dec
12

Overhauling Healthcare: Medical Rules, Regulations and the “Basic Speed Law”

by Dr. Doug Perednia

Dr. David Gelber who writes the Heard in the OR blog recently had a must-read post published on KevinMD entitled “Rigid regulation can become detrimental to patient care.” Anyone and everyone involved in or affected by America’s healthcare system should read this article. It clearly illustrates exactly the type of good intentions that are sending patient, doctors and nurses further and further down the Road to Hellth on a daily basis. We especially recommend reading the comment by “dropspinner” in the comment section. It’s impossible to count the number of times that we’ve relied on nurses to do the right thing and use the intelligence and common sense God gave them. To see their efforts, and those of their physician colleagues, reduced to being forced to brainlessly do what administrators have told them to do “because those are the rules” is a terrible indictment of our healthcare leadership.

If you haven’t yet read Dr. Gelber’s post, read it now to follow the rest of the discussion.

How can we reform this type of bureaucratic and legal nonsense? (It is, after all, putting people at risk to no good end and costing us a fortune to maintain.) One step that would help is to adopt something like the “basic speed law” in lieu of all hard-and-fast rules of the type Dr. Gelber describes. (For those of you who don’t remember it from the driver’s ed course you took years ago, the basic speed law is that, regardless of the posted speed limit, you must never drive faster than is safe.) The underlying logic of the basic speed law is that the people who built the roads tell users how fast they can expect to drive to be safe under normal circumstances. However if the circumstances are aren’t cookie cutter, than the people on the scene are expected to use their best judgement based upon the particular circumstances that they’re encountering at the time.

Let’s re-state that. The basic speed law doesn’t tell you how fast to drive. Instead it gives you some technical data and limits, and then asks you to use good judgement based upon your specific circumstances. The basic speed law was created many decades ago, and has never been questioned or changed in all of that time. Why? Because the smart people who created our highway system understood and accepted that only those who are on the scene and directly involved can ultimately make the correct decision about what is “safe”.

Now how would we apply this to medicine?

We suggest that American healthcare adopt something we’re going to call the “Basic Safety Law” when it comes to crafting all rules and regulations used throughout the healthcare system. It reads as follows:

“When crafting any rule or regulation that directly or indirectly affects patient care, never make the rule more rigid than is safe. Always permit exceptions as necessary based upon the best clinical judgement of the clinician in charge.”

Here’s an example. The first situation Dr. Gelber describes is as follows:

The antibiotic I had ordered was Cefazolin, perfectly appropriate for the scheduled operation. The nurse informed me that, because there was the possibility the operation could be converted to open, she also had to receive Metronidazole in addition to the Cefazolin. I told her that the particular antibiotics she was insisting be administered were indicated if the patient was undergoing colo-rectal surgery, but all that was needed in this particular case was the Cefazolin. She replied that she was following the SCIP protocol and she would get in trouble if I didn’t order the Metronidazole. Not wanting to argue with the SCIP police, I ordered the additional antibiotic.

Under The Road to Hellth healthcare regulation Basic Safety Law (BSL) approach, the new rule will read: “If there is a possibility that the operation could be coverted to open, the patient should receive Metronidazole in addition to the Cefazolin unless the surgeon in charge of the procedure deems it to be medically appropriate not to do so.”

The consequences of this change are relatively obvious. For the purpose of safety, if the surgeon is unsure about what the appropriate antibiotic would be under the circumstances, the guidelines are there. However if the surgeon knows of a different strategy that is equally sound medically, there is room to improvise. What’s to keep surgeons from disregarding the guideline’s advice willy-nilly? Two things. The first is that, contrary to the apparent beliefs of most government and hospital administrators, the vast majority of doctors really do care about their patients and want to do well by them. Second, the existence of such a rule increases both the real and perceived consequences of making the wrong choice.

As example #2, consider this portion of Dr. Gelber’s story:

Two nights later I was on call for the Emergency Room. I received a call at about 10:30 pm from the ER physician requesting that I immediately come to the ER to attend to a Level I trauma that had just arrived. He took the time to explain that the trauma was a BB gun shot to the shoulder area and that a Chest X-Ray had already been done which was normal except for the BB which could be seen overlying the right clavicle (collarbone). He added that there was a small amount of swelling over the area the BB had penetrated, but otherwise everything was normal. My logical response was “Why do I need to come in to see a patient who obviously can be discharged home with an ice pack, antibiotics and pain med?” I was told by the nurse in charge that once a patient has been declared a “Level I” trauma I was mandated to see the patient within 30 minutes and only I, as the trauma surgeon on call, could make the decision to downgrade the trauma level. The trauma protocol clearly states that all penetrating wounds to the thorax be classified as “Level I”. The fact that this particular patient did not have a penetrating injury to his thorax was deemed irrelevant by the nurse who made the decision. The fact that the ER physician had evaluated the patient and determined that there was no significant injury was also deemed immaterial.

Here the trauma level had clearly been mistakenly assigned. In this case, the BSL would be applied as follows: “The trauma surgeon on call shall see a Level 1 trauma patient within 30 minutes unless the trauma surgeon and attending ER physician agree that the trauma level had originally been assigned in error.”

Similar logic can easily be applied to the other situations the good doctor has described.

Why don’t we have a “basic safety law” approach already? There are two reasons. The first, as Dr. Gelber has already described, is that many of the people making this rules don’t know what the heck they’re talking about. They’re not medically trained, and it is frankly irresponsible to place them in the position of making rules for doctors and nurses to follow. Second, the administrators and (well, bureaucrats) making these rules are too lazy to think in terms of “what if”. It is far, far easier to make inappropriately rigid rules and let others deal with the consequences. They can get away with not-quite-murder-but-closer-than-one-would-like, because there are no standards of quality for administrative work in healthcare. Think about it. It should be inexcusable that any patient should be placed in danger or that excessive resources should be used because a “medical” administrator can’t be bothered to build flexibility into their written (or unwritten) policies.

No one is minding the minders.

This is no way to run a healthcare system. EVERY rule and regulation that affects medical care needs to be specifically designed so that it can be overridden by the appropriate medical personnel. Furthermore, every rule and regulation should be subjected to review and comment at regular intervals. This would give those affected a guaranteed means of asking that it be revised or discarded based upon both experience in the field and the latest medical and scientific evidence.

Our lives and those of our families and children are too precious to trust to shoddy, rigid rules and regulations.

Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Hospitals and Health Systems, Overhauling Healthcare, Politics, Solving Problems, Stupid Guideline Tricks, The Practice of Medicine

Apr
7

Wasting Your Money Is As American As…Um, Medicare

by Dr. Doug Perednia

(Click on image to enlarge)

Having spent the last few posts discussing relatively lofty topics such as Medicare’s plans for ACOs and how human psychology influences the effectiveness of incentive programs, it’s time to write about something practical. Something down-and-dirty. Something that illustrates why America’s healthcare system is so complex and messed up. How about looking at a stupid bureaucratic rule that drives knowledgeable healthcare providers nuts and wastes your Medicare tax dollars?

Oh, man. So many choices, so little time.

Ah, here’s one. Apparently the folks at Medicare do not trust your endocrinologist to know anything about diabetes, and they don’t actually know anything about it themselves. So they’ve invented a rule that wastes money on pointless labs and often forces doctors to “game the system” so that their patients can receive appropriate care. Will that do? Sure it will.

So let’s talk about diabetes, one of the most important and expensive chronic medical conditions on Earth. We know that diabetes is important to the federal government and the citizens of the United States because Secretary of Health and Human Services Kathleen Sebelius said so back in November of 2009:

“WASHINGTON – People with diabetes still carry some of the United State’s highest healthcare expenses, according to a report released by Health and Human Services Secretary Kathleen Sebelius.

‘Americans with diabetes are suffering in our current healthcare system,’ she said. ‘Health insurance reform will help ensure these Americans can get the prescription drugs and supplies they need and bring down premiums so all Americans can have high-quality, affordable health insurance.’

Affordable treatment remains inaccessible to many Americans suffering from chronic diseases. The report, ‘Preventing and Treating Diabetes: Health Insurance Reform and Diabetes in America,’ outlines the ways in which health insurance reform will lower costs and improve access to quality healthcare services for Americans with diabetes.”

For those of you who may not be medically inclined or diabetologists, we should first explain a little about diabetes. This is a disease in which there is too much sugar (aka, glucose) hanging around in the blood on a regular basis. Normally blood sugar is regulated by having a special kind of pancreas cell called islet cells secrete the hormone insulin. Insulin causes most other cells in the body to grab glucose from the blood stream and deposit it internally, thus lowering the level of sugar in the blood. Having too much sugar in your blood over a prolonged period of time is unequivocally a bad thing. Over time it damages the small blood vessels that supply oxygen and nutrients to virtually every important organ in your body, including the heart, kidneys, brain, eyes, skin and nerves. This leads to serious and expensive complications like blindness, kidney failure, heart attacks, strokes, infections, skin sores, amputations and so on. As a result, maintaining good control of blood sugar is something that every diabetic, physician and Medicare administrator should aspire to.

Another diabetes fact that is helpful to know for the purposes of this discussion is that there are two different types of diabetes, (creatively named “Type 1” and Type 2”).

In Type 1 diabetes the islet cells in the pancreas have died off, leaving the body unable to make the insulin it needs to maintain healthy blood sugar levels. Once you’re a Type 1 diabetic, you’re always going to be a Type 1 diabetic until researchers figure out a way to implant or re-grow pancreatic islet cells. As a result, Type 1 diabetics are insulin-dependent; they must inject man-made insulin in order to regulate their diabetes. In Type 2 diabetes the pancreas is still able to make insulin, but the other cells in the body tend to be resistant to it. That is, it takes much higher levels of insulin than normal in order to get them to take up enough insulin to lower blood sugar to a safe level. Type 2 diabetics may or may not require injections of insulin in order to keep their blood sugar under control. Some Type 2 patients can be controlled with medications that increase insulin uptake by otherwise resistant cells, or simply flog the islet cells into making more insulin. However every patient is different, and both Type 1 and Type 2 diabetics can be very complex and difficult to control. That’s why many of them need to see endocrinologists; specialists who devote their entire lives to trying to figure out how to manage this and other hormone-related diseases properly.

How does one tell Type 1 and Type 2 diabetics apart? One can usually, but not always, tell by the patient’s history and physical condition. Young, thin people who suddenly become diabetic are almost always Type 1s, whereas older obese people are usually Type 2s. If it’s really important to know which one you’re dealing with, you can check a couple of specific lab tests. The first is to look for antibodies to the pancreatic islet cells (called “beta cells”) that make insulin. These will be present in most Type 1 diabetics, but absent in Type 2s. Unfortunately, at $429 a beta cell antibody panel isn’t cheap. A second distinguishing test is called a C-peptide level. C-peptide is a protein fragment that is made and released with insulin, and serves as a specific marker of insulin production. As a result, most Type 1 diabetics will have low or absent levels of C-peptide, while most Type 2s will have normal or elevated levels, especially in the presence of high blood sugar levels.

We should also make one other very important point. The vast majority of the risks and complications of both types of diabetes are almost exactly the same. Both Type 1 and Type 2 diabetics can be have trouble with blood sugars that are too high, or too low. Both can require injections of insulin to control adequately. And both types of patients can develop blindness, heart attacks and all other manner of expensive, life-threatening complications.

Armed with this information, we can now get back to our story.

Mr. Overton is a 65 year-old Type 1 diabetic who recently had to switch to Medicare because, as the courts have ruled, older Americans are not allowed to collect social security unless they also drop their private insurance and sign up for Medicare. He had been on an insulin pump for many years. An insulin pump is a $4,000-$5,000 device that can be programmed to deliver both a steady continuous dose of insulin as well as larger amounts to be delivered as needed at specific times. Insulin pumps are particularly useful in managing blood sugars in Type 1 and Type 2 diabetics, like Mr. Overton, whose diabetes is difficult to control. Just prior to signing up for Medicare his insulin pump broke. Therefore one of the first orders of business after the insurance changeover was to get it replaced.

Most private health insurers will pay for insulin pumps based upon the need to manage the patient’s clinical condition, regardless of whether the patient is Type 1 or Type 2. For example, you might have a Type 2 patient who does hard physical labor. While he is working his muscles readily take up glucose and his blood sugar levels are pretty good, but when he stops for the day his blood sugars will suddenly run very high. This type of patient is not a great candidate for long-acting insulin, but a pump can be used to rapidly change his insulin dosage based upon both the time of day and his level of physical activity. Other good candidates for pumps include patients who get very low blood sugars in the middle of the night (a phenomenon known as “nocturnal hypoglycemia”), patients who suffer from the “dawn phenomenon” (in which their blood sugars skyrocket in the early morning), women whose diabetes becomes difficult to control due to pregnancy, those with wide fluctuations in their blood sugars throughout the day, and patients with multiple emergency room visits for severe hypoglycemia. All that an endocrinologist needs to do in order to get a pump approved in cases like these is document that these sorts of problems are occurring despite their best efforts to manage them without a pump.

But despite Ms. Sebelius’ obvious concern about the quality of care that Americans with diabetes receive, the federal government has a very different perspective on how to distribute insulin pumps. As Mr. Overton found out, when it comes to Medicare, even the most deserving patient isn’t going to get an insulin pump without first spending at least $80 on unnecessary tests.

Medicare’s written policy on paying for insulin pumps can be found on page 123 of the Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 280.14. Like most private insurers, Medicare will only provide a pump if it is clinically indicated by virtue of diabetes that is otherwise difficult to control, and/or if the patient had an insulin pump prior to their enrollment in Medicare. But for reasons of its own, CMS added another requirement: it will only pay for a pump if the patient has a positive beta cell autoantibody test, or BOTH a low fasting C-peptide level and a concurrently obtained fasting blood glucose level that is less than or equal to 225mg/dL.

The first question that doctors, patients and taxpayers ought be asking themselves is “why”? By adding the lab test requirement, Medicare’s official policy is to only pay for insulin pumps for patients with Type 1 diabetes. But as we’ve seen, when it comes to both managing the disease and developing potentially expensive or fatal complications, there is no real difference between hard-to-control Type 1 and Type 2 diabetics. They both have problems that can be helped by insulin pumps, and they can both cost Medicare a fortune if their diabetes is not well controlled. So why does Medicare insist upon discriminating against patients with Type 2 disease?

The second more technical question that one might ask of an agency headed by a quality guru like Dr. Donald Berwick is, “why doesn’t your C-peptide testing requirement make any clinical sense?” I’ve asked several distinguished endocrinologists about this myself, and they have no idea. You see, for the vast majority of diabetics, the higher the blood sugar level goes the more insulin they will be trying to produce. So if you want to verify that someone’s C-peptide level really is low, it really shouldn’t matter if their blood glucose level is greater than 225. In fact, with higher blood sugar levels you can be pretty darned certain that they really can’t produce adequate levels of insulin. But the way Medicare’s requirement is written, if a patient’s blood sugar level is 226 mg/dL at the time the C-peptide level is drawn, they magically no longer qualify for an insulin pump. Who the heck thought that up?

The result is predictable, and happened in Mr. Overton’s case. His endocrinologist ordered the fasting C-peptide test and blood glucose. The results came back with a low C-peptide and a fasting glucose of 247 mg/dL. Total cost: $80 spent for nothing. Since he obviously needs the insulin pump, his physician re-ordered the tests but had him inject some regular insulin shortly before drawing his blood. The result: C-peptide still low, but the blood sugar was now less than 225. Same patient, same disease, the pump is approved, but Medicare has now spent $160 of your tax dollars for no reason at all.

How can we possibly trust the government to “reform healthcare” if this is how they approach the management of one of the most common and expensive chronic diseases in the world? And if we were to adopt a government-run “single-payer” system, what’s to keep our single-payer from wasting money like this on every diabetic instead of just those over the age of 65? How is it that Medicare and Medicaid have the temerity to reward and punish physicians based upon “best practices” and “guidelines of care”, when their own insurance coverage criteria are irrational, medically defective and economically wasteful?

If you know the answers, please share them. We’re stumped.

Categories : Bureaucracy Run Amok, Quality Questions, Stupid Guideline Tricks, Waste Fraud and Abuse

Jan
24

Violate A “Guideline”, Go to Jail?

by Dr. Doug Perednia

The digital ink was barely dry on our last post about the sometimes questionable and largely non-evidence-based nature of clinical guidelines, when the Justice Department decided to weigh in on the topic. As if to underscore Dr. Rich’s assertion that “guidelines are no longer guidelines”, the Federal government has raised the prospect of fining your doctor and/or sending her to prison for the crime of not strictly following guidelines of care. As reported by MedPage Today:

“Federal prosecutors are looking into physicians’ prescribing practices relating to implantable cardioverter defibrillators (ICDs), the Heart Rhythm Society has told its members.

In a mailing sent to HRS members, the group said it had been contacted by the Department of Justice to assist in a probe of ICD prescribing.

“[HRS] has agreed to assist in an advisory role to lend expertise concerning proper guidelines for clinical decision making,” according to a copy of the notice posted by two members on the Internet.

The notice indicated that the society was prohibited from commenting further on its role in the investigation. Justice Department officials could not be reached for comment.

It was therefore unclear whether the probe is related directly to a report in the Journal of the American Medical Association earlier this month indicating that ICDs are often prescribed for patients who don’t qualify for the devices under published guidelines…

The HRS notice appears to raise the possibility that the Justice Department may be considering prosecution of individual clinicians, in addition to its already disclosed investigation into alleged payola schemes by ICD manufacturers.”

If the Justice Department investigation is, in fact, going to target clinicians based upon their adherence to guidelines, the American healthcare system is headed down a very slippery slope. Government regulators and prosecutors will, of course, contend that they’re simply looking for “waste, fraud and abuse”, and that looking for non-adherence to guidelines is a reasonable screening tool when looking for criminals. But let’s not kid around. Any such policy is going to have a chilling effect on treating patients as individuals rather than statistically average widgets. You may need a test or procedure as a part of good medical care, but your doctor is going to be too scared to order it if her record of “guideline compliance” is at stake.

Think about it. For the first time your doctor may have a real choice to make if your medical condition doesn’t happen to fit neatly into some academic cookbook. Adhere to the guideline and commit malpractice, or violate the guidelines and risk jail time.

Using guidelines in this way is unscientific, unethical and just plain wrong.

Categories : Abuse of Power, Stupid Guideline Tricks, Waste Fraud and Abuse

Jul
7

Stupid Guideline Tricks: Am I Fat Enough, Yet?

by Dr. Doug Perednia

Thinking is hard work. This is why so few people bother. At least voluntarily. So whenever it seems like the threat of brainwork looms in modern American medicine, we can thank our lucky stars for the geniuses behind healthcare “reform” and guidelines of care.

This comes up as a result of a conversation that I had with a patient the other day. A pleasant, obese gentleman. He had been struggling with his weight and Type II diabetes for some time, and there were now some early indications of some potentially serious long-term complications. He mentioned to me that he was working hard to prepare for gastric bypass surgery. I asked him how he was doing that.

“Why, by eating!” he replied. Huh? By eating?

“Oh yes”, he explained. “You see, I’m getting these complications from my weight and diabetes and all of my doctors think that I’m an excellent candidate for weight loss surgery. Based on my previous weights, if I can just get lose about 40 or 50 pounds, I should have much better blood sugars and need far less insulin. God, that stuff is expensive when you’re using hundreds of units per day!”

That sounded perfectly reasonable. This gentleman is a walking advertisement for the virtues of slimming down. And for gastric bypass, in fact. So why is he holding that venti whole milk mocha with 508 calories and 27 grams of fat?

“Oh, this?” He looked a bit sheepish. “Well the problem is that the surgeons won’t operate on me yet because I don’t quite fit the guidelines they have to follow for doing the operation. Insurance won’t cover the surgery until I reach a BMI [body mass index] of 40, and I’m a couple of pounds short. So I have to gain the weight and have them document that I’ve reached the magic number. Then I’ll actually lose the weight again when they put me on the special post-surgery diet to make sure that I can tolerate it. If all of that works out okay, then they’ll schedule the surgery.”

Now I realize that I’m revealing some age here, but in the old days we would have looked at the patient, considered his history, physical condition, social situation and medical compliance, and decided whether the surgery was indicated and likely to be beneficial based upon all of those things. He doesn’t quite meet the BMI criteria established by some study? Well so what? He’s a good candidate. Let’s do it. And we would. And lo, the patient would usually get better because we wanted to pick good candidates and have them succeed. That was our job. We were the medical experts and we were being paid to think. Besides, if someone else knew way more about medicine and our patients than we did, why weren’t they the ones taking care of them instead of us?

But of course then we’d have to use our heads. Thank God those days are over. Now if the patient’s vital statistics don’t match whatever the insurer’s guideline computer tells the high school graduate who happens to be denying authorizations that day, then you’d best go away and come back when they do. No use fretting about it. You’ll never make it through the insurer’s phone trees or get a reply to your voice mails asking to speak to a medical director anyway.

I wished our patient luck, and later brought up the case with the doctor who was taking care of his diabetes. He was visibly exasperated about the whole ordeal.

“We’ve been working very hard on his diabetic control.”, she said. “He’s been pretty good about his diet, but has one of those bodies that really uses energy efficiently. It just hangs on to every ounce of weight. We had his hemoglobin A1c down to 7% (Ed. note: normal is 4% to 6%), but since he’s had to start gaining weight it’s back up to 7.9%. I’ll be glad when this whole ordeal is over and we can go back to treating his disease rather than the damned guidelines.”

Silly doctor. Why would you want to do that? You’ll have to think. Besides, wake up and smell the mocha. You’re being paid to follow the guidelines.

Hellth, anyone?

Categories : Stupid Guideline Tricks

Archive for Stupid Guideline Tricks

Encouraging Common Sense in Public Policy

Overhauling Healthcare: Medical Rules, Regulations and the “Basic Speed Law”

Wasting Your Money Is As American As…Um, Medicare

Violate A “Guideline”, Go to Jail?

Stupid Guideline Tricks: Am I Fat Enough, Yet?

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