Tuesday, March 4, 2008

Appropriate Care Committees

No healthcare system, Universal or otherwise, can be efficient, cost effective, and truly serve the best interests of patients without oversight. I’m talking about consistent, uniform, organized oversight by senior physicians, nurses and clergy rather than bureaucrats and accountants who have no knowledge or experience in the practice of medicine. I’m talking about a system of Appropriate Care Committees organized at the local, state and national level created through Congressional action to put the power of the law behind it.

Organized, well-planned action to create uniform Appropriate Care Committees will shift the decision-making to those who know best. It will also be the key to addressing the issues that have gotten our healthcare system in such a mess in the first place. Issues like ICU over-use, especially in end-of-life situations, coronary artery stent over-use, shuttling nursing home patients back and forth from nursing home to hospital even though they cannot benefit from hospital care and need to be in hospice instead, would all fall under the review of Appropriate Care Committees.

I envision a committee in every hospital and nursing home in the country. This committee would be made up of senior physicians, nurses and clergy. It would have the power to cease payment for care that offers no benefit to the patient, and mediate disagreements between admitting physicians and families over options for care. The family could appeal to the committee which would review the case and make a decision based on medical evidence and the individual needs of the patient. This would be particularly beneficial in end-of-life cases where there is wide spread use of non-beneficial procedures and treatment when hospice would be the most appropriate and humane option.

Senior physicians, nurses and clergy would also staff the statewide committee. It would handle appeals from local committees, and oversee the appropriate care committee system within that state. These appointments would be salaried, therefore committee members would have no financial interest in their decisions, These salaries would be paid for by a consortium of all insurers.

A national committee, also composed of senior physicians, nurses and clergy, would oversee the entire system for the nation. National appointments would be similar to those of The Federal Reserve Bank. State and local committee nominations would follow guidelines established by the national committee in concert with individual state medical societies.

Many physicians would object to the system, thinking that it would interfere with their autonomy and could threaten their income. Many others, however, would embrace it for three reasons:
1. It would reintroduce the primacy of the patient-doctor relationship, especially for the primary care physician. It save more than enough resources so that primary care can be adequately compensated.
2. It would provide back up for the physicians who truly try to do their best for their patients, but now have to concern themselves with legal and economic issues.
3. Most physicians believe the present healthcare system needs reform because of excessive costs, lack of care for millions of our citizens, the public's dissatisfaction with the system and our less than stellar health outcomes compared to other developed nations.

There will be oversight. Make no mistake about that. The question is: do we want oversight from non-medical bureaucrats and accountants who are hundreds of miles away making crucial healthcare decisions about what’s appropriate and what’s not? It’s already happening in fits and spurts with Medicare and some insurers, and it’s a patient’s and physician’s worst nightmare.

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