Ethical Dilemma

Chicago 158

This week I had a patient in my office to follow up on her diabetes and high cholesterol.

She had spent almost five years without insurance and in May finally qualified for Medicare. So we went to work catching her up on all of the care she had not been able to receive for so long. Colonoscopy, bloodwork, mammogram, PAP, etc.

In the process we diagnosed her with diabetes and high cholesterol and started her on medication for these issues. She has worked hard losing weight. Her blood sugars are running in the 90’s before breakfast.

“Doc, I know you want to do blood work but I just can’t afford it today. I am so sorry!” She looked near to tears.

What a lot of patients don’t know is that I am measured on their numbers. Blood pressure, cholesterol, A1C, BMI…

Her numbers were awful last time. Those bad numbers are registered on her record. They are probably good now, but the only way to get those recorded and for me to get credit for those improvements is to do blood work. I can’t simply say, “Not indicated,” and skip doing it. I can’t make up those numbers.

Medicare part B does not cover 100% of everything. Patients are generally responsible for 20% of outpatient charges. So a fair amount of the cost of these tests is transmitted to the patient. She is not able to afford a supplement to pick up the remaining 20%.

What complicates matters is that her mammogram caught a mass. Turns out it was breast cancer. Thankfully we caught it just in time and she should do fine. She has had surgery and will start radiation this next week.

So from a money standpoint, right now what is most important? Getting her breast cancer treated or making my/her numbers look good?

KateCrimmons (She is awesome, check out her blog!) made a comment on my last post that got me thinking about this.

Sure, I could pressure her out of my own self interest and get her better numbers registered. She would do it if I made an issue of it.

But is that right?

How well I do on numbers affects my ratings with insurance companies. I get rated on the quality of my care on their websites (high ratings mean my numbers are good). And my numbers are flowed by Medicare. They are also followed by my employer. In fact, 5% of my income is tied to how I do on these quality measures and 5% is tied to my patient satisfaction scores.

Emphasizing quality IS a good idea!

I think as a whole the medical profession is doing a better job at this than we have in the past. There is nothing more infuriating to me than to have a young, otherwise healthy people with diabetes come to me saying their last doctor told them that their A1C of 7.8 was good. It is NOT good!!! When my name gets sent out to all of the physicians in my group, I want to be at the top of the list with my numbers better than everyone else’s. That means I am a better doctor, right? (Suck it all you losers! I rock!!!) It motivates doctors to follow evidence based guidelines and get those A1C’s under 7.0 in appropriate patients and prevents diabetic complications.

But there is a dark side.

When physicians start feeling the pressure financially, I believe they are going to be more inclined to make decisions for patients that are not necessarily in their best interest:

Pressuring patients to get blood work or take certain meds that may not actually be best for them. Firing the noncompliant diabetic rather than helping them to get compliant. Firing or not accepting overweight patients.

In fact this is already happening among my peers. We talk about it. I have pondered it myself, I will admit.

How do we balance quality in a way that is in the best interest of our patients?!?! Do we incentivize or penalize? How far do we take it? Is it OK to fire a patient for not losing weight or controlling their blood pressure? If we force them to seek another physician are we helping them by forcing them to think about their “bad” behavior so they will maybe work harder next time or serving them by having them maybe find a physician that can eventually reach them and get them to change their ways?

Thoughts from you?

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23 thoughts on “Ethical Dilemma

  1. No matter which way you cut this cherry there are good and bad outcomes. In my opinion the Govt. And the Medical (Overview) associations need to decide if their aim is to have healthy populations or unhealthy ones.
    It seems a fait accompli for me. If they want unhealthy people they continue to make looking after ourselves as cost prohibitive as they are doing. People cannot pay their co payment, or in some cases if they try to they have to go hungry or can’t work….. If they want a healthy population they need to stop making or allowing the insurance providers from cutting the support and increasing premiums.

    I know I want to be healthy but I also know I need help – the help I cannot afford alone. So what are my options? Try the whacko diets to lose weight, know I’m injuring myself further pushing the exercise program’s to get fit or have more tests to measure the effectiveness of the protocols? I can’t do it all. By the way, I should point out I did have full private health cover til I could no longer work, have recently scrimped enough to get it again, but the catches in availing myself of services is mind numbing. (I am talking Australia here, sorry).

    The frustration is enormous. I’ve made it a priority to understand my ‘condition’ , yet I have been sold a turkey by being palmed off to a Naturopath who ignored my advice that I had bad reactions to most B vitamins. I’m. Now out of pocket and have severe Niacin flushes and detox……

    I know this seems off topic yet it isn’t. Patients need both. We need the doctor to have a great rating fir the insurance benefits, yet we need to be listened to by penny pinching government and medical authorities who think we are too ignorant medically to know ourselves.

    My apologies fir a long reply and rant. It is a dilemma and will continue so until consensus is reached for health or smaller unhealthy populations.

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  2. I don’t think most of us understand the ratings for docs. That’s part of why I find your posts so interesting. I have learned a lot here and I don’t have an answer for you. Sometimes I don’t understand why some very basic things are so expensive. Drugs are outrageous but so are blood and other tests. My oncologist used to do a blood test in his office with a finger prick. All of a sudden it had to be a sample from a vein in the arm which is always a big deal for me with tiny vessels. The reason was the Medicare payout. Ethically I don’t know the answer but it seems like a fine line. We don’t want to lose good docs who are willing to work with financially poor patients.

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  3. I don’t have an answer, either, but I believe that arguments like the one that you just presented here, if it was taken up by a large number of physicians and fed to the press, etc., perhaps the rating system of the insurance companies could be canned. Being ethical is the ONLY thing in my mind, and this system that you have described, by its very nature, would seem to be in opposition to that. You’re livelihood should never be compromised for steadfastly doing the right thing. Peace to you . . .

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  4. Thank you for the education !
    And I want to share a story in support of the need for those numbers:

    I went to a NP for 3 year, and on the third year, after constant complaints of mid afternoon fatigue and hair loss, I was placed on Synthroid 25 mg. I kept my quarterly visits, had lab work ordered yearly, and weight gain and fatigue were continued complaints at each visit. I also complained of a funny feeling in my chest. It resulted in office EKG’s – ( I couldn’t make the palpitation happen on cue!)
    I was told to stop walking 4 times a week and start running in order to lose weight and have more enenrgy.
    In frustration, I pulled my records, picked a new md, and he said ” lets do some different tests” Here’s the outcome.
    A thyroid antibody test was 20 times higher than it should have been – biopsy of the big fat nodule on my gland was thankfully normal.
    A 24 holter monitor showed 6 episodes of one minute runs of PVC’s.

    It’s all the lab tests that keep my Hashimoto’s in line and all the diagnostic testing that led me to the hospital for a successful ablation.

    I don’t have a smart phone, nice jewelry, or a Coach bag, things I see carried by people in the free clinic I volunteer at, but…

    I’m living because the numbers were important

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  5. From a patient point of view only here ok! Maybe you could ask around and see if your facility has a social worker that may be able to help you help your patient. If she qualifies for Medicare and is low income she may also qualify for state help (Medicaid ) known in the billing department as Medi-Medi. I know it may seem like you are butting into her personal affairs but let’s face facts here you are her dr, you know more personal stuff about her then some of her friends. If your facility doesn’t have a social worker then suggest she contact the state on her own to find out. As a patient I would rather my dr care enough to suggest something like this then say well if you don’t go get the blood work you’ll have to find a new dr.

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    • She does not qualify for Medicaid, sadly. There is a local grocery store that runs AIC tests and full cholesterol panels for a pittance as a service to the community once a month. She is going to get it done there. But in the end I don’t mind taking a hit on my numbers. I just worry about her absorbing the uncovered portion of the radiation treatment. She doesn’t qualify for our system’s charity program, either, now that she has some form of insurance. Frustrating!

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  6. Wow… it is also starting here in Australia and I am starting to see where all the changes that’s happening is leading to. We call them KPI’s here (Key Performance Indicators). It is also a numbers game and a lot of it is not within our control. I have had patients who have been sloughed to me because they were making numbers look bad. When they change the bed card (transfer to another surgeon’s care), the patient restart from Day 1 which will not increase the other surgeon’s average length of stay. It really discourages us from taking on complex cases and encourages us to discharge patients before they are ready! But it does get the lazy surgeons off their butts and make decisions about their patients, instead of leaving them lingering indefinitely in hospital! Good and the Bad….

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    • It is interesting how we can find ways around it, right? They powers that be took away my ability to say a flu vaccine was not indicated, though. They figured out everyone’s game on that one. Bastards.

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  7. It is a difficult dilemma. There have been times when I couldn’t afford parking, let alone the medical tests, so I well understand this patient’s plight. But it sounds like you made the best of it.

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  8. I don’t have any answers. I surely wish I did. I had insurance which was lost after a second heart attack. what peeves me is my doc ordering an exercise stress test AFTER my first heart attack..which induced the second..in his office..and because he failed to get prior approval for the stress test the insurance also failed to pay for the emergency stent operation that saved my life. AND they lowered his rating…which got me fired from my doc of 15 years so he could get his numbers back up again. Now uninsured (high risk insurance is far more than we make a month per premium) and using a free clinic where they can not test more than once a year due to lack of funding. So how do I know if my meds are damaging my liver..or even working properly to reduce my BP? I check my eyes daily for signs of yellowing, check the color and smell of my urine (oh boy that is fun!) and go to the grocery store for the free BP monitor daily. I feel badly for the doctors who are empathetic and struggling with the dilemma.

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  9. I would rather pay my insurance premium directly to a trusted doctor than to insurance that will continue to raise premiums, lessen what they cover, and leave me holding the bag in the off chance I do need medical treatment. I hate that they get to determine what is medically necessary and what isn’t. Did any of those asshats go to medical school? It is sad that we live in a society that claims to place a high value on human life, but it is merely a talking point for the public. I have great insurance, but I still have high out of pocket expenses. I am still paying off a medical bill that is over a year old. Tell me how that is in any way logical when you have insurance, have only seen that doctor that one time. I am in good health, with areas that need improvement. Of course how can one improve their numbers when they have to work two jobs now to avoid being sued. I am of the mind that I will never go back to see a doctor again. The only way I’ll end up at the hospital or a doctor’s office is if they drag my unconscious ass there, because if there is any fight left in me someone else will be in need of medical attention. I blame the insurance industry for the bulk of it. Okay…I’m done now.

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