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.


TVille said...

I often wonder how to educate patients (I'm not directly involved in the delivery of care, but interact with patients on an administrative level) about barriers to care. What I mean is, people don't often inherently recognize "you can't" to mean, "In my opinion, because of my agenda, or the agendas I feel beholden to, I decide that you won't have access."

I want to believe that if health care operated in a model of true informed consent, patients AND providers would be better able to collaboratively decide what was best.

Your example perfectly illustrated WHY this is important. Your example could have just as easily illustrated another point I think you make; that just because technology is available (procedures, medications, etc...) doesn't make it the best option for anyone at a given time. Sometimes no treatment, or limited treatment is the most humane alternative.

And, as I think you have mentioned, creating this model will require a complete overhaul in how Americans perceive the role of health care.

Doctor Kenneth Fisher said...

Thank you for posting your thoughtful comment on my blog. We have a long way to go for our society to use health care appropriately. The present economic crisis, in part, a result of a disregard of reality, is also reflected in our present health care system. We need people like you to help carry our message to the rest of our nation. Kenneth A. Fisher, M.D.