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Oncology Times:
doi: 10.1097/01.COT.0000360976.81754.1f
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Simone's OncOpinion: ‘Harbingers of Change in Health Care (7/10/09 issue)

Kutell, Michael A. MD

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Miami Beach, FL

Regarding the column about health care costs (McAllen, etc.): I recently retired from my solo Hematology practice. The office was in the Hospital Office Building and there is a complete outpatient x-ray facility run by the hospital. I was struck by the “young doctors don't think…” opinion and will add just one example to the one Dr. Simone gave about gallbladder management.

A 70-year-old man with known (prostate) bone metastases and sudden onset of thigh pain called me, and as I was in my office, I had him come in. (Note: this is efficient, non-ER care.) His exam was unchanged except that he was in great pain. Previously the thigh had not been a problem. But, he was taking opiates for other known metastatic bone involvement. I arranged a stat plain x-ray in the outpatient area and spoke to the radiologist to ask him to expedite and call me. Before the patient left I gave him morphine 10 mgs IM.

Since he was partially tolerant, after about five to 10 minutes and good pain relief without an adverse reaction, we took him to the x-ray. The radiologist called to say that after the x-rays— which were normal—the patient became diaphoretic. I had them send the fellow to the ER, and I spoke to the EP and said to give the patient Narcan 1 mg IV and that I would be down quickly.

It took me about five minutes to stabilize the office and I went down. My patient was not there, so I asked what happened to him. I was told that they sent him to the (ER) CAT scan. I panicked. I asked if he received the Narcan and was told he had. I asked if he was OK and was told he was “fine.”

So then why was he in CAT scan? They told me that he had what they termed “change in mental status” and that ALL patients with this diagnosis get a CAT of the head. Of course, the additional thousands of dollars revealed nothing, and he went home. So even when told what to do, the instructions were not followed.

That is just one example of many similar stories I could tell about ER and hospitalist physicians. Many primary care physicians seem to consider that their purpose is to refer patients out.

I don't believe that the problem is all venal, penurious, or even harried practitioners, but rather a lack of knowledge—could it be that there is now just too much to teach and absorb during four years?—and very poor modeling or mentoring by older, but still young, faculty. I hope Dr. Simone and other academic physicians can find a solution.

MICHAEL A. KUTELL, MD

Miami Beach, FL

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Reply from Dr. Simone:

You make excellent points that greed is not the only, and maybe not the worst, system failure. The example of the older gentleman getting a head CT that was unnecessary shows, at best, a lack of judgment that cost somebody a thousand dollars. This is a case of not recognizing the difference between a guideline and an imperative. Presumably, making the distinction is one reason we have doctors.

However, don't expect academic physicians like me to change things; we don't have the power. This is one instance where government is the only reasonable agent with the muscle to make the difficult changes in health care that we would all like to see.

I am by no means condoning the medical practice patterns of McAllen, TX, as shown in the well-documented and in-depth study by Atul Gawande in The New Yorker. This was what I term “pocket-book medicine.” Yet, in a complex system, such as health care, operation and function is maintained by a system of checks and balances. I was surprised that both Dr. Gawande and Dr. Simone in his OT column ended with a hope and prayer that “the fox” will do a more sincere and better job at “guarding the chicken coop.”

I was disappointed that both authors gave the hospitals' administrators a pass and the benefit of the doubt, that they are unaware of what really transpires in their institutions. This was the same defense used by Enron's, Worldcom's, and Tyco's Chairmen, Presidents, CEOs and CFOs. They were all found guilty and are spending time behind bars. I refuse to absolve the senior hospital administration, hospital board members (number-crunching experts), and medical directors of all the hospitals involved.

Similarly, I would question the regional administrators of Medicare, Medicaid, and insurance companies. Instead of forwarding the billing data, from more than a decade ago (1996), to an expert half-way across the country, should these payers not have confronted the medical establishment (doctors and hospitals) in the city/ county, within two years of internal analysis of their data?

Questionable practice patterns in New York state lead to an automatic referral to the state medical or licensing board. All that's needed is a letter alerting the authorities to possible misconduct. With clear attempts at bribery, the referral should have been made to the FBI; but the hospital, nursing home administrators, and others chose “to go with the flow.”

The insurance companies could provide their data to organizations that accredit hospitals, such as JCAHO. Over these years, this authority probably did not show due-diligence and ask the hard questions that Dr. Gawande inquired about. The hospitals benefited from the health care environment. In many places, hospitals contribute to the environment by actively recruiting more specialists (working in hospitals), which, as the study suggests, is the root cause of excess medical care.

Other bodies that may have failed are the national specialty organizations that accredit hospitals' specialty departments. Were any specialty-departments at the hospitals accredited? Accreditation is a valuable marketing tool in a competitive environment, which also certifies good practice patterns.

Both Dr. Gawande and Dr. Simone encourage good doctors to provide leadership in their communities—a.k.a. “anchor tenant theory.” Good doctors, while willing and capable of providing leadership, first have to be handed data from a knowledgeable and preferably non-competitive source, like insurance data, that was provided to Dr. Gawande. Just a hunch will not encourage an honest discussion of the problem(s) and a scientific search for solutions, if necessary with the use of outside consultants.

I am always amused by hospital board members who are delighted to see their hospital make money, sometimes hand-over-fist, but then complain about the escalating costs of health insurance for businesses and its impact in their town. I guess like the rest of us, they would like to “have their cake and eat it too” and find it difficult to “walk the talk.” McAllen's health care is a seminal study, but may reflect a system failure beyond that city, a fact that many would like to overlook.

GILBERT A. LAWRENCE, MD

Radiation Oncology

Faxton Hospital

Utica, NY

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Reply from Dr. Simone:

You raise many points that I agree with, particularly that hospital administrators “get a pass” when it comes to controlling costs. But the real culprits are the trustees of hospitals that award bonuses to hospital executives based on financial performance, just as they would for executives that sell auto parts. There is no reward for demonstrably improving the quality of care or the patient experience or efficiency.

I would point out that they will respond to financial pressures to do the right thing. The length of hospital stay dropped dramatically when it was demonstrated that long stays were unnecessary and Medicare stopped paying for the longer stay. In our capitalist society, money talks.

© 2009 Lippincott Williams & Wilkins, Inc.

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