Selasa, 30 Juni 2009

The ‘S’ Word in Health Care

Americans greatest fear in today’s debate on health care may be the spectre of the ‘S’ word – socialized medicine.

Socialized medicine is ‘code’ for the government takeover of healthcare (already 50% ‘taken over’ by Medicare).

Socialized medicine is a poorly-defined, alarmist and pejorative label that describes Americans’ fear that individual medical decisions made between doctor and patient will be replaced with decisions made in some far-off place, like Washington DC or, possibly, Bangalore, India.

I sure don’t want this possible future scenario for my doctor to be forced to do this to treat me:

1. pick up the phone to a call center in Bangalore to get approval for my flu shot
2. wait on hold for 15 minutes
3. describe my symptoms to ‘Steve’ from Bangalore
4. wait on hold for 15 more minutes
5. then get the rejection with a recommendation to try the generic, cheaper alternative.
Rationing Health Care

The other, common usage of the ‘S’ word is in context with rationing. Rationing is another politically charged word often used to describe denial of payment based on price. Rationing is not a question of ‘if’, but ‘how’ as this article from the New York time suggests.

Similarly, and seriously, decisions about needed surgeries, diagnostic testing, preventative testing and treatment options are best made locally between the doctor and the patient.

The Moral Imperative

No worthwhile physical therapist needs to be told the moral imperative in healthcare: Do what is best for the patient. The Oath of Maimonides said to originate from a 12th century Jewish physician-philosopher is perhaps most appropriate:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.
Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

The Financial/Business Imperative

Health care delivery in America often contrasts with the moral imperative in health care. Medical businesses exist to do the following:

• make money
• provide professional autonomy
• ensure high standards of care
• allow physical therapists to practice in specialized settings

– however, the first imperative is money, without which further imperatives are irrelevant.

The American health care market, through fee-for-service, creates an incentive for physical therapists to provide higher volumes of care than is necessary.

Medicare fraud and abuse prevention efforts, in general, and the PT Cap Exceptions Process, specifically, encourage PT firms and private practices to limit necessary services to patients who need them.

The 'Black Hats'

In my town of 400,000 we have a 13-doctor practice that, in purely rational self-interest, automatically discharges patients when they hit the ‘PT cap’.

They've abdicated their moral imperative in favor of their financial/business imperative.

I use a POPTs example because, as a private practice physical therapist (PTPP), it’s fun to pick on POPTs. Based on purely rational self-interest, however, another PTPP might choose to make the same business decision and discharge patients who hit the arbitrary cap based on perceived audit risk.

Are they bad people? No. They work in a bad system.

POPT's are not evil, they’re not bad people and they’re not even bad medicine – some even do a pretty good job of post-surgical PT if anecdotal stories are to be trusted. Some of my friends work for POPTs.

But any policy that unnecessarily drives up costs and drives a financial divide between decisions made by the PT and the patient is bad health care policy. The same would be true for policies that distort with dollars decisions between physicians and patients.

How can physical therapists reconcile the two imperatives in private practice PT in America? Surely pushing decisions to far-off decision-makers is less efficient and, presumably, less effective than one-on-one decisions between doctor and patient.

Right?

The ‘S’ Word in Health Care Rating: 4.5 Diposkan Oleh: Elvina dara

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