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02-11-2009 10:48 AM |
I read the link and the replies with interest. While I am sure to get flamed there are some tough but valid questions raised by this article.
Having medical records at your fingertips is extraordinarily helpful and really a necessity in today's practice of medicine. I could not take care of my hospitalized patients adaquately without even the basic systems we have in place.
The "tracking" is an issue that warrants some exploration and discussion. Physicians and hospital's treatments are tracked now, make no mistake about it. Penalties(financial) are being used now when the goverment doesn't think providers/hospitals are towing the line as prescribed by the incredible, undecipherable morass of beauracratic regulations that the majority of us can't even fully comprehend. This is not new, perhaps the screws are being tightened a bit but this is certainly not groundbreaking.
The "guidance" concerning doctor's decisions has been in place in both private and government payers rules for a long time. This is in the form of refused reimbursement, denied procedures, etc. Obviously with the private companies it is profit driven. Physician's autonomy has been slowly and steadily stripped away for the last two decades.
The goal is to reduce costs and guide physicans decisions? The question is who is doing the guiding. It was and is beaurcrats..in every political environment that has preceeded the present one, so all may share the shame equally. The inherent problem is overpayed, undereducated people that have little or no working knowledge of or medical system. You would be beyond amazed if you were exposed to an inkling of the ridiculous hoops that have to be jumped through every day with every patient and for every problem. I sat in a meeting last night that spent nearly an hour discussing one tiny piece of admissions criteria for hospitals to get reimbursed, containing two pages of information and left with no better appreciation for the situation that I started with, a sentiment echoed by my colleagues. So these people have been are are to continue to be our guides?
As far as praising Europeans for being more accepting of hopless diagnosis..probably true and worth some exploration. Approximately 30% of all Medicare dollars on spent "in the last year of life". That's 30% of about 454 BILLION dollars for 2008. More than you can imagine is spent keeping terminally ill people in their 80s and beyond on life support for weeks or even months on end, knowing beyond a shadow of a doubt that the outcome will not not be changed. Are you aware that if you are over 70 and arrest in the hospital and receive immediate resuscitation to "bring you back" that your chances of ever leaving the hospital are alive are 1%(if unwitnessed arrest) or about 10% (if the arrest was witnessed)? This would be in spite of full blown "life support" for days or weeks on end. The numbers for functional survival at one year out are equally as dismal. These numbers worsen with age. Are you aware how many tens of thousands of patients with severe advanced dementia coupled severe heart and lung disease, diabetes and other progressive illnesses there are that exist on feeding tubes and around the clock care, with multiple hospitalizations per year? Are you aware of the amount of critical carethat is provided to drug abusers and noncompliant patients that have 10 or even 15 hospitalizations per year directly because of their own choices and behaviors? The tough questions, which are more societal in nature than political is where and when is it appropriate to limit some of this, when is it appropriate to limit interventions and diagnostic labs and procedures when we know we are not positively affecting the outcome, who makes those choices, and who pays for it?
Is a "new" beauracracy the answer? I seriously doubt it. Look at what a couple of decades of much the same have gotten us. I think any oversight without practical input from people that actually work and function in the system is doomed to the same failure we see now. I also suspect that unless we are ready to examine some of the futile ways that we use our resources things will continue to decline. Is some oversight necessary? I think most physicians in the trenches would say yes, but not in the old standard way of doing things. Is the thought of care being rationed out and decided by some formula comparing costs and benefits scary..certainly is in some ways, for the above stated reasons.
The real kicker here will be that as long as the legal system is essentially a personal injury lottery, doctors will continue to order and do things that are really not reasonable in an attempt to protect themselves no matter what the government or private payers say. When the penalties of not following guidelines exceed the malpractice suit risks, a lot of us will leave as our colleagues are now doing.
In summary, very little of what is proposed is new, and has been happening to a great degree, in ever growing frequency with EVERY administration in recent memory. The basic problems and questions inherent to our system (only a few of which are above) are not being addressed, nor have they been in the past. This is not a Clinton, Bush or Obama problem and presenting it as so is simply more rhetoric and waste. We have some hard decisions to make about what we can do, what are the right things to do, and how we can implement those things. What we have been doing is a dismal failure, and without a major paradigm shift in both patients and providers (and the legal/lottery system) we will continue to watch our system race to catastrophic failure.
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