Marc J. Yacht MD, MPH
Community Health Watch
FMA Quarterly Magazine, Fall Issue
When a doctor thinks about the future of medicine, those thoughts may travel in many directions. Each day brings new technology, new procedures, and new remedies for prevention and ways to better treat the infirm. People are living longer and healthier lives. Efforts at greater efficiency which include the electronic medical record, telemedicine, and distance learning are allowing better use of our time, are cost efficient, and offer unique benefits to patient and provider alike.
Yet as we progress and open new doors in the House of Medicine, not all is well. While our treatment modalities improve and our skills reach new heights, one cannot deny that gnawing at this progress are some fundamental ethical and moral issues that deny too many Americans, equitable health care.
While each specialty has its own vision for its progressive evolution, together, all physicians must consider whether our unique achievements are undermined by access and cost issues. For without health care equity among our population, can the House of Medicine fully celebrate progress?
The increasing punitive oversight casts another shadow on the profession. Cook books have tried to atomize medical services into peg holes and boxes. This may be described as trying to define the shape of smoke. Such characterizations may work well in mathematical models but have questionable application when caring for patients. Perhaps slicing and dicing medical management has some value in billing codes but should hospital admissions and stays be at their mercy.
Recently, I reviewed McKesson’s InterQual Level of Care 2007 (2008 is now available). I can appreciate the comprehensive nature relating to severity of illness (SI), Intensity of Care (IS) and determining the appropriateness or level of patient hospital stays. But have adherence to such criteria gone beyond the pail. Is the “tail wagging the dog,” so to speak? This exhaustive workbook drives potential hospital denials and may ultimately affect physician billings. Does adherence to such complex criteria drive a further wedge between the doctor and the hospital? What are we really saving here?
The Medicare Modernization Act of 2003 established the Medicare
Recovery Audit Contractor (RAC) program as a demonstration program to identify
improper Medicare payments. Currently
The review team, as I understand it, profits financially from denials. These were admissions previously paid. The hospital must meet a time frame for submitting charts for review and immediately reimburse for determined rejections. Although decisions can be appealed, the hospital is immediately put on the defensive in a drawn out expensive appeal process involving large numbers of professional and ancillary staff. Costs for appeal are not considered if the hospital prevails on singular chart appeals. Rigid time frames have to be respected.
Draconian oversight has its own costs and one has to wonder if there is a savings at all in casting a large shadow over every Medicare hospital admission. I would suggest there is no overall savings but an undermining impact on the provider. I would suspect that some community hospitals may not be able to survive such oversight.
Currently, I volunteer in two local free clinics. One accepts uninsured patients over 55 and the other uninsured families. In each case financial criteria must be met. Both are very busy and waiting lists for care are long. Further complicating free clinic efforts are a dearth of volunteers and needed specialty referrals. Although the clinics are helpful, I would not suggest they equal a standard of care available to the insured. (Note, the insured and underinsured also have issues but will not be addressed in this monograph.)
As we look to the future, medical professionals can anticipate breathtaking advancement in the medical arts. One can expect significant progress in treating spinal chord injuries, infectious, and degenerative diseases. T.B., Polio and Malaria may be conquered worldwide. There will be major advances in prosthetic devices and exciting successes in molecular and human genetics. One can anticipate the development of more exotic diagnostic tools along with the more efficient pooling of international research.
Yet, advancement in treatment and prevention should not fall under the penumbra of poor access. When Americans must choose between rent and medicine or treatment is delayed due to costs. If 10s of thousands of children lack basic coverage for their health needs, and equity of care escapes the reach of 50 million people. Our medical triumphs will play a back seat to an ongoing American tragedy and continued moral and ethical misfortune. We can do better as a nation.
The resolution of health care equity must stand equally with scientific achievements, if the House of Medicine can fully bask in the sunshine of progress.
MJY