Wednesday, December 19, 2007

Overtreatment not the real problem

By Libby

A lot of economists write books about healthcare and the NYT quotes one point that gets close to the crux of the problem, but doesn't quite hit the mark.

Above all, it’s the natural outgrowth of our fee-for-service health care system. It turns doctors into pieceworkers, as Ms. Brownlee puts it, “paid for how much they do, not how well they care for their patients.” Doctors and hospitals typically depend on the volume of work for their income, and they are the gatekeepers who decide when work needs to be done. They also worry about being sued if they do too little, a well placed concern in today's litigious society. So they err on the side of overtreatment.

Brownlee lays the blame at the feet of the providers and over demanding patients who want the same treatments they see on the TV doctor shows but fails to factor in the root cause of the current standards of practice -- the insurance companies reimbursement policies. Unrealistic patients are certainly a driver in terms of excessive spending, insisting on expensive state of the art procedures to prolong an elderly relative's life by perhaps as little as a few weeks, and doctors will accommodate them for fear of malpractice suits. However the doctors are most often unable to render the best medical care efficiently on account of the ridiculous manner in which they're compensated for their services.

This is the way it works -- or more aptly, doesn't work. If a patient is admitted to the hospital for a certain ailment, for the sake of simplicity let's say it was for a compound bone fracture. If in the course of testing, the doctor discovers there are other conditions that need treatment, say a cardiovascular problem or even cancer, they can't treat those conditions because the patient was admitted for broken leg. Or rather, they can treat them, but they won't get paid for it.

Insurance will only compensate for services that address the problem for which the patient was initially admitted. In order to get paid for unrelated maladies, the doctor must first discharge the patient and get them readmitted for the unrelated medical condition. Needless to say, being shuffled in and out the hospital repeatedly does nothing for the patient's health and raises the administrative costs, which is where the insurance companies make all their money.

Futhermore, the paperwork is onerous. For every ten minutes a doctor spends with a patient, there's an hour's worth of papework, minimum, and one misplaced comma, one typo, one missed checkbox and the insurer will deny payment. Every insurer has different forms and different rules. Oftimes, the cost of doing the paperwork is greater than the compensation for the procedure and the hospital will eat the cost, but these costs are ultimately passed on to the consumer in higher rates and through government subsidies for unpaid services.

If there's a stronger case to be made for a single payer system which would standardize the paperwork and allow doctors to treat patients under best practices rather than private insurance rules, I don't see it. In any event, it's wrong to blame the doctors. They're just doing the best they can under the wrongheaded rules of the workplace.

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