Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, August 27, 2007

An Inexact Science

Medicine is frequently and correctly described as an inexact science. What this really means isn't just that we aren't always right, but that it is expected -- and fully appropriate -- that "errors" will occur a certain percentage of the time.

This post was originally inspired by a line by Susan Palwick about handouts to the homeless, attributed to her father:
If you aren't getting scammed occasionally, you aren't being generous enough.
That struck me as an accurate restatement of my views about being duped by drug-seeking patients. I would rather be fooled on occasion than run the risk of leaving a genuine sufferer in pain. This stance in no way relieves me of the obligation to exercise caution not to fall for every drug scammer. I use my knowledge and experience to make the best decisions I can based on the information I have, knowing I will not always be right. The art of medicine lies in balancing the risks against the consequences of a given course of action in the event that I am wrong.

This issue comes up quite often in surgery. It's often said that if you don't have a certain percentage of "normal" appendices going to pathology, you are taking dangerous risks by not taking enough people to the OR, presumably increasing the risk of appendiceal rupture. Sid Schwab could tell you better than I what actual numerical level of "false alarms" would be considered -- respectively -- excessive, too conservative and "just right." The fact remains than a "zero" error rate is neither achievable nor desirable.

Similar risk-benefit analyses happen with c-sections, only here the "risk" side of the equation includes the always subjective, always nebulous "risk of litigation." Set that variable high enough and it's a wonder anyone is allowed to deliver vaginally anymore. Although the consensus might be that the present US rate of 29% is too high, surely if it were "too low" there would be some babies being put at unnecessary risk from labor. How are we to calculate what the "just right" rate is?

I bring up this subject now in the context of the recent Medicare rule changes about no longer paying for "preventable complications." Dr. RW does a magnificent job of explaining why these rules have been given this ridiculous doublespeak name. But if the underlying assumption is that complications should have been prevented, caring for them should not have been necessary, and Medicare should only pay for "necessary care." Think for a minute about the logical extension of the policy -- oh so reasonable on its surface -- of not paying for "unnecessary care."

How long before Medicare refuses to pay for an appendectomy if the pathology is negative? If the appendix was normal, then it didn't need to come out, right? What about a negative breast biopsy, or any kind of exploratory surgery that doesn't yield positive pathological findings? Couldn't a cardiac catheterization that showed clean coronaries be considered "unnecessary"?

What about imaging? Billions of dollars spent annually on diagnostic imaging means tremendous opportunities for reigning in costs by refusing to pay for studies that are normal. No brain tumor or other abnormality found on that MRI? Then why should we pay for it?

It's the ultimate Catch-22 and a med-mal lawyer's wet dream; the ultimate damned-if-you-do and damned-if-you-don't for physicians: retroactive denials based on negative results that you needed the test to determine in the first place. I submit that the slope from these new Medicare regulations to this nightmare farce of medical care is as steep as it is slippery.


At Mon Aug 27, 06:25:00 PM, Blogger Susan Palwick said...

Very thought-provoking post! I'm honored to have inspired it! (And yes, my dad really did say that!)

At Mon Aug 27, 07:30:00 PM, Blogger rlbates said...

I wish I'd written this post. Nice work.

At Mon Aug 27, 08:09:00 PM, Blogger Sid Schwab said...

Good subject, well addressed. I don't know when payors will start refusing to pay for normal appendectomy, but it's certainly often referred to as "unnecessary surgery" when it happens. So I'd guess it's in the forseeable future. It's an excellent example of the imperfection of our "science." No test is infallable; we get misled in both directions by any of them. One of the commenters on my post on the subject of these new medicare rules referred to them as all stick and no carrot. I think that's a good characterization.

I don't have a basis for declaring what a reasonable amount of normal appendectomies is; in training, we were told 15 - 20%, or we'd be missing too many. In practice, it was very much less than that -- in mine, less than 2%. And I don't think I ever sent anyone home without surgery who came back ruptured. I admitted and observed a little more than some peers... I suppose it ought to be true in all fields that we would expect to progress toward fewer and fewer "negative" results of all forms of interventions. But as you say, given that both we and our patients are humans, it'll never be nil.

At Mon Aug 27, 08:50:00 PM, Anonymous Anonymous said...

The CMS "rule" shows that bureaucrats run the show, and that doctor input is nil.

We are now expected to be perfect, in retrospect, in 100% of cases. Even though the human body is nowhere near perfect and nowhere near predictable.

I have a case right now where the CT scan of 8/23 showed a normal appendix with enlarged mesenteric lymph nodes. Mesenteric adenitis, right? Was that a "negative" test and therefore not reimbursible?

Pt. came back 8/25 with return of RLQ pain. Ultrasound showed and appendix at the upper limit of normal, still with the mesenteric lymph nodes. Still a "negative" test and still not reimbursible?

8/26 pt. still tender in the RLQ, normal white count. My surgeon did a diagnostic laparoscopy. Appendix not normal and therefore removed. No other visible cause for pain (no Meckel's, no inflamed bowel to suggest Crohn's). Path pending. Still not reimbursible?

Per Medicare's warped sense, I would have to appeal all this to my carrier, argue for hours over the phone or write letters on behalf of the patient and the hospital, just to get MY portion of the reimbursement (two hospital visits) covered. I'd lose 10 times that in lost patient contact time!

And where Medicare goes, private insurance will follow especially when it saves them money. Sicko, the movie, should have shown how the biggest insurer in the country, Medicare, abuses patients.

At Tue Aug 28, 12:55:00 AM, Anonymous Anonymous said...

It gets so discouraging sometimes, I don't know why any of us do this anymore. If I had a working crystal ball or my own personal x-ray vision, I wouldn't need to order these tests, but unfortunately I don't, so I need to rely on diagnostic tests. It's so f-ing ridiculous--if we already knew who had the disease, we wouldn't need tests...period.

What about when the equipment that leads to the "complication" is necessary?? What about someone in shock or renal failure who needs a foley so you can tell if they're making any urine/perfusing their kidneys? What is they get a UTI? You don't get paid for that? Would it have been better to float a swan to monitor their hemodynamics, with all its potential complications?? Everything in medicine has risks/benefits/potential complications. Who decides what is the hospital and doctor's fault and what isn't?

What's so insane is that this has nothing to do with providing quality care and everything to do with not paying hospitals and physicians for the work they're doing.


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