I had a very interesting discussion with my orthopedic physician a while back (as I age, I seem to collect more and more physicians of different specialties). He was helping me to decide a course of action to take with my balky knees that have deteriorated over the course of my lifetime, and as we discussed the specifics of my knees, we diverged and ended up discussing a wide range of topics concerning the US health care system.
He was of the opinion that the current system we have for health care is incredibly inefficient, and shared an anecdote to illustrate his point. A woman came into his office complaining of leg pain and weakness. She had been to multiple physicians in the past but had found no relief. As his assistants were taking her history, and conducting an initial assessment, they sensed that her problems were not in her legs, but were caused by back problems. They discussed this with the doctor, and he agreed that an x-ray of the back was justified.
The x-ray revealed that the patient had significant arthritis in the back, resulting in bone-on-bone contact for at least one set of vertebra. This had caused impingement on nerves going down the legs, accounting for her symptoms. The normal progression of the diagnostic process would call for a MRI exam to confirm the extent of the back issue.
But. The insurance company response to this type of diagnosis is firm and consistent. No MRI will be authorized until the patient has exhausted all other options. In this case, it means that the patient was referred to physical therapy for a 6-week course of treatment. So the insurance company was willing to spend $3,000 on a course of therapy in order to avoid a MRI expense (I have no idea what an MRI costs), with its potential diagnosis of a need for back surgery at much greater cost.
The doctor had referred the patient to therapy, and the course of therapy had not yet been completed. He said that he fully expected that the patient will have no improvement from this expensive course of treatment, and then he will be able to get the approval for the diagnostic tool he knows is necessary for this patient to finally find relief through treatment. He speculated on the reason why insurance companies would go this route – refusal to fund an expensive diagnostic tool but approve an even more expensive course of treatment. His speculation is that actuarial analysis shows that if even a few patients do receive help from physical therapy, or a few patients die during the course of therapy, or a few patients give up on the process and just keep suffering with their ailment, then the avoided surgeries more than offset the cost of the therapy.
My doctor was very generous with his time with me. We did discuss my options, and my preference for lower levels of intervention. Right now I am receiving periodic injections of cortisone. More intrusive means of treatment are available if I don’t have relief from this level of treatment, up to and including knee joint replacement. I am very grateful that my doctor has allowed me to have enough information to make an informed decision and to be an active participant in my treatment.
We discussed the problems that the current insurance-based systems impose upon doctors being able to provide options to patients. He presented a hypothetical case where a patient with a high-deductible insurance policy, but with a health savings account, would come in with symptoms that indicated a need for further investigation. The two choices would be an MRI (expensive, but comprehensive), or an ultrasound (less-expensive, but not as sensitive and potentially could miss rare issues that an MRI would pick up). The current environment would indicate that the standard of practice is to insist upon an MRI, and if the physician should ever be in the position where he / she went with an ultrasound, and that patient happened to have that obscure condition that only an MRI would detect, he / she would be liable under malpractice litigation for not following the standard of care.
But if the doctor and the patient could enter into an agreement where the patient accepted the risk of a potential for a missed diagnosis for a rare condition, in exchange for a lowered payment for the test, then overall costs for the medical industry would be reduced. That is just not possible right now, but with the huge increase in insurance deductibles, it may be coming back. No, my doctor said that at present, he has the need to reduce his liability risk to zero by over-prescribing diagnostic tests since there exists no mechanism to transfer the risk for a missed diagnosis to the patient. This is where my doctor says that the malpractice industry has raised medical rates, by insisting that all illness can be detected or treated if only the patient is tested for all potential conditions related to their symptoms, regardless of the likelihood of a rare condition. Thus a huge cost results from the excess diagnostic tests required to detect the condition that afflicts a few tenths of a percent of the population.
My doctor expressed hope that a single-payer system would emerge out of the morass of the current health-care system. He acknowledged that any such system could have its own set of problems, but he seemed to be comfortable to accept standards such as Medicare has established for treatment to be extended to the population at large. Insurance companies would still have a role in administering claims, but the ability of doctors and patients to have a say in the treatment protocol would be greatly increased.
During the uproar with the Affordable Care Act, much was made of the imposition of “death panels” who would represent government imposing life and death decisions upon poor helpless upright citizens of the US. What opponents of the Affordable Care Act have always refused to acknowledge is that the “death panels” they feared have always existed, and they belong to the faceless bureaucracy of the insurance companies, doing their darnedest to increase both the complexity and costs of the medical profession, and actually harming patients in their insistence to adhering to rigid and often obsolete standards of diagnosis and treatment.
But what do I know? I’m only a consumer of the medical industry, with very little input on treatment options and zero input on the cost of the approved treatment. I am very thankful for physicians like my orthopedist, who is treating me as a full partner in my own treatment, and who is willing to share his thoughts on the medical system.
Even A Broken Clock 