Monday, January 14, 2013

Who's Your Daddy Now?

I have nothing against the patient empowerment movement.  In fact, I think an informed and collaborative partnership is mutually beneficial.  But I can't help but laugh when I read some of these tweets.

Death to paternalistic medicine!
The age of paternalistic medicine is over!

True, the era of doctor knows best is long gone.  But it's a mistake to think think today's health care consumer has any more leverage than before.  It just seems that way.  The reason is that the strings are being pulled, and the levers are being switched in a slightly more diabolical way.

If you want to know the root of any modern problem, either follow the money or follow the power.  You think you have control over your health care decisions, but in reality, many are being made for you before you even step foot in the office.  You see, your options are being whittled long before the exam room door is breached.

Want to spend thirty minutes talking about end of life care?  Good luck.  The government has deemed that doctors shouldn't get paid for such conversations.  Guess who will try to avoid them at all costs?

Want a PSA test?  Well the USPSTF has deemed that they are not beneficial (which I agree with by the way), and eventually Medicare and private insurance will refuse to pay for them.  Most physicians will avoid offering such tests if they are going to be dinged on quality and cost efficiency metrics.

You just had a heart attack and your cardiologist thinks you need a defibrillator.  Not so quick.  You'll be offered a defibrillating vest first until you wait a certain number of months, unless your doctor wants to get investigated by the department of justice. 

It's not that I don't agree with some of these decisions.  Some make sense.  But don't think you have power to control your own destiny.  What once was the purview of your trained doctor has fallen to an array of nonclinical and barely clinical administrators in Medicare and private insurance.

So empowered patients of the world might just want to ask themselves a basic question.

Who's your daddy now?


Anonymous said...

Superbly and succinctly said. Excellent summation at the close. A frightening reality that bodes ill for us all. It's a realitiy that will especially shock those who felt that moving healthcare further into government control was a good thing.


youngredsox said...

I concur with your statements up until the non or barely clinical administrators. You have missed a very important part of the team the case manager. I am a case manager who has been in healthcare for almost 30 yrs now. I have worked my way up from volunteer candy striper to student in nrsg at votech to CNA to corpsman in the USN, back home to nursing school while working as a HHA. Graduated Nursing school and up until approx 10 years ago was bedside nursing. There is nothing I havent seen. My yrs of experience not only make me perfect for the job as case manager but also as advocate for my patients. Yes I've gone toe to toe many a time to fight for what I think is best for my patient! So please remember there's a case manager who was a nurse first whose best interest is always and has always been for the pt first !

Anonymous said...

There's a delay before getting a defibrillator to reduce the problem of people whose heart function will improve with medicine and lifestyle changes being bullied into getting an ICD that puts them at high lifetime risk of tricuspid regurgitation and needless shocks. BTW, if they're pressured to wear a defibrillator vest, they might want an absolute numerical estimate of how likely they are to benefit (probably less than a 1% chance - the clinical trial data are not impressive). Then they might ask themselves how likely it is that accepting an exaggerated fear of sudden death will discourage them from doing heart-strengthening aerobic activity. Putting limits on Medicare payments for ICDs isn't just to save bucks; it's to save often severe iatrogenic harm to people who aren't likely to benefit.

Likewise, the PSA test isn't being discouraged to save tax dollars, but because it saves few lives, and for every life saved, a couple dozen men wind up wearing diapers for no benefit. I do understand that doctors are excessively burdened by paperwork and regulations already, and that it's getting worse under Obamacare. But you're asking for sympathy for the time-wasting excess that's forced on doctors, while complaining about any efforts to limit the time-wasting excess that doctors sometimes virtually force on patients. (PSA testing is often done without consent and even over patient objections, and "consent" for ICDs is rarely fully informed and often follows heavy doses of biased emotional rhetoric.) If doctors don't do more to police themselves, most citizens won't object to seeing the government do it - and someone has to draw those lines, because the resources available to pay for four-plussing of the elderly are substantial but not infinite.