Monday, February 16, 2009

A New Style of Hospital Admission Form

There are many reasons why our American health care system is so much more expensive than those in other developed countries, and yet we have inferior results. But, by far the largest single reason is the delivery of non-beneficial care which accounts for about one third of our total health care bill and contributes to a tremendous amount of unnecessary human suffering. Perhaps the most obvious example of our inappropriate care is the prolonged anguish and cost associated with the way we practice end-of-life care. Unfortunately however, the irrationality of how we practice medicine in the United States is not isolated to end of life care. Issues that must be addressed are:
•How can we create an advance directive that is both up to date and rational considering the over-all condition of the individual?
•How can we ensure that the care being given is beneficial and not serving other masters such as cash flow, avoiding legal hassles, the prestige of the hospital, etc.?
•How can we make sure that every patient and family has the right to appeal the medical team’s decision as to what is beneficial?
•How are we to avoid doing cardiopulmonary resuscitation on patients that are far too frail to benefit and who as a result suffer a disfiguring inhumane death?

The answer to these questions is my proposed hospital admission form shown below. The form provides a realistic up-to-the-moment advanced directive while providing an opportunity for the patient/family and the medical team to agree on what will be beneficial care. It also provides the patient/family and the medical team a mechanism to resolve disagreements, the appropriate care committee. This new admission form would also make cardiopulmonary resuscitation an ordered event for those patients who could benefit from it in any way, and not done routinely for the majority of patients for which it is of no value.

Monday, February 9, 2009

The Appropriate Care Committee as a Resource for the Patient

The basic concept behind appropriate care committees is to always act in the patient’s interest. Thoughtful medicine practiced with good judgment supported by the applicable medical evidence is the goal of the appropriate care committee system. Technology, procedures and medicines that do not benefit the individual not only have the potential for complications, but also create economic havoc for our nation. In large part inappropriate care is responsible for the health care crisis we now have in this country. Appropriate care committees allow us to solve this problem while maintaining the flexibility to be able to treat all patients as individuals each with unique circumstances, for instance the case of Joe Franks.

Joe Franks is a 57-year-old gentleman temporarily in a nursing home recovering from a heart attack and moderate congestive heart failure. He has type II diabetes, poorly controlled, and is 80-100 pounds overweight. His diabetes has adversely affected his vision such that recently he lost his cab driving license and is now unemployed and has only very basic health insurance. Joe’s mental status is excellent; he is an avid chess player. His doctor in the nursing home told Joe that if his obesity was controlled and he lost the extra 80-100 pounds of weight his health situation would dramatically improve. Joe told the doctor that he has tried everything, but has been unable to lose weight.

The doctor told Joe about the stomach banding procedure, a relatively simple surgery that restricts stomach size and has been quite successful in promoting weight loss in patients just like him. Joe is excited about this idea and asks the doctor to make a referral to the closest medical center offering this procedure. Immediately after nursing home discharge Joe and his wife traveled to the medical center hoping to arrange for the banding procedure.

Unfortunately the banding clinic told Joe and his wife that he was not a good candidate for the procedure and tried to send the two of them back home. However, Joe’s wife had read about the appropriate care committee system and asked for an appeal. The appropriate care committee nurse was immediately notified about his case. The appropriate care committee nurse arranged for Joe and his wife to stay the night at a nearby hotel to wait the full committee’s (two physicians and the nurse) finding early the next morning.

The committee heard from the clinic doctors who felt Joe was not a reliable patient and was unable to pay the additional fee above that of his basic insurance. The committee also interviewed Joe and his wife before rendering a decision. The committee decided that Joe was an excellent candidate for the procedure and that the clinic must offer it to him.

One year later Joe had lost 95 pounds, his Type II diabetes was cured, his eyesight and heart failure much improved. He was able to reactivate his cab driving license and was proud to again be an active contributing member of his community. He told all the overweight customers in his cab about his experience with gastric banding and how pleased he was with the clinic. After the tenth referral to the clinic because of Joe, the physicians at the clinic put on an appreciation party for Joe and his wife which included an overnight stay in a nearby luxury hotel.

How to Change a Health Care Culture of Excess

We have seen great strides in the decrease of deaths caused by heart disease in the past few decades - better control of elevated blood pressure, still far from ideal, drugs to lower cholesterol and procedures to improve ischemic (not enough blood flow) heart disease.

One of the procedures, cardiac catheritization and stenting, is provided for about a million patients each year at a cost of roughly $60 billion. The question that has recently been posed is, what patients should receive this procedure? The answer, it turns out, is that the procedure should be limited to those with very severe angina (chest pain due to ischemic heart disease), and those with increasing or unstable angina. Drugs alone are quite adequate for the majority of patients who have stable and milder angina.

As a matter of fact, a cardiologist from Miami, Dr. Michael Ozner, has recently published a book, The Great American Heart Hoax, decrying the approximately sixty billion dollar expenditure via overuse of cardiac catheritization and stenting. The science behind the concept that treating the lesions seen on an angiogram is in most cases folly is well documented and accepted by leaders in the field. In spite of this, by far the majority of patients receiving this procedure are in the non-indicated group. Of course cardiology is not the only specialty of excess. Many, if not a majority of medical areas such as end-of-life care, dialysis, orthopedics, oncology etc., combine to create a medical system of inappropriate care with a whopping $600 billion price tag.

Any solution to this problem must be timely, combining medical knowledge with excellent judgment while treating each patient as an individual. This is a task for my local appropriate care committee, salaried and made up of two physicians and a nurse.

For instance: the committee in each hospital would review 50 to 100 charts of patients who had recently undergone catheritization and stenting. Those determined to be unnecessary would require the physicians and the facility (hospital or clinic) to reimburse the third-party payers for these services. This would at the outset require the return of significant amounts of money. This process would be repeated in many areas such as the intensive care units, dialysis, oncology units, etc. The physicians and hospital administrators would quickly learn that inappropriate care is not a good idea. The culture would change overnight and we would have a different medical system.

Monies saved would be more than adequate to properly reimburse primary care and provide universal coverage. No system of saving can be perfect. However, I believe that of the $600 billion spent on inappropriate care, we could save approximately $400 billion. The process would be especially sensitive that any and all care from which a patient could benefit would be encouraged.