Friday, February 18, 2011

How to Fix Advanced Directives

One of the major reasons for our excess spending is how we presently use advanced directives. They were created by The Patient Self Determination Act of 1990 in response to the Karen Ann Quinlan and Nancy Cruzan cases and were created to give patients choices as to their preferences in end-of-life situations. Although created with the best of intentions at the time, there are many unforeseen consequences. Patients cannot possibly predict their health situation years in advance. What may be appropriate for someone in their fifties may not be appropriate for the same person in their eighties. Most patients who have advanced directives do not discuss them in detail with their physician or their designated proxy. Many patients, perhaps most, are not aware of the technical issues involved with specific choices. An inappropriate choice in light of the patient’s overall condition, i.e. terminal cancer, puts the physician in the position of ordering therapies while knowing they cannot succeed rather than focusing on pain relief and comfort care. An overwhelming majority of patients never create an advanced directive, leaving the hospital and medical team no choice but to press on while knowing it will not be beneficial. Alternatively, an advance directive gives patients the sense of more control than is realistic in many situations. Families, often when emotionally distraught, are frequently put in the position of making very difficult choices in extremely complex situations. The net effect of all this is a great deal of non-beneficial even detrimental care causing increased suffering at alarmingly increased costs.

Although these issues have been discussed and written about for years, the Congress is either unaware of these problems or has chosen not to address them. This post is intended for the public to be aware of this very serious problem. It could be solved with relatively simple Congressional action, an amendment to The Patient Self Determination Act stating, “Within the bounds of evidence based beneficial care tailored to the individual.” This would in effect cause the patient and the physician to collaborate creating a rational advanced directive with each hospital admission.

Friday, February 11, 2011

The Doctor Patient Relationship

The present health care reform law euphemistically called The Patient Protection and Accountable Care Act (PPACA) is deeply flawed. It pays lip service to the fundamental problem in American medicine; the lack of time patients and physicians have to spend with each other developing a long lasting therapeutic relationship. The diminution of this core value has driven medicine to the over use of technology and a lack of coordinated care for the chronically ill.
Our nation's excessive health expenses are a large factor causing us to lose our competitive edge in manufacturing, straining the standard of living of millions of Americans. The PPACA will needlessly add to our national health care expense and will exacerbate this problem. Our increasing Medicaid expenses are causing states to scrimp on public education, just the opposite of what we need for our future.
Other advanced societies care for all their citizens costing them much less than what we spend. We can and must do better. For starters, I suggest a $2,000 federal tax credit for all adults and $1,000 for all children per year creating health savings accounts for most outpatient care and high deductible catastrophic health insurance for more expensive items. Reverse tax payments on a sliding scale for those who do not pay taxes. From this account choose your doctor; spend at least 30 minutes at each visit.
Have a system in place by which doctors help each other practice high quality efficient medicine. At each hospital admission have patients, their families and doctors decide what would be appropriate care. Do not hurt people by providing care that is of no value. Physicians and patients together can practice excellent medicine at a cost that unlike the present will not put our country into financial ruin.

Friday, February 4, 2011

Reasonable and Beneficial Care

Who is more able to help patients as to what is reasonable and beneficial medical care, physicians or Washington bureaucrats? As previously mentioned on this blog, it is now time physicians, supported by their colleagues and medical societies take responsibility for the delivery of only appropriate care. With a formal system of physician review, physicians would be able to abandon the present style of expensive defensive medicine by having the ability to confer with their peers.