Wednesday, May 11, 2011

Unintended consequences of national health care: incentives

I met with a new vitality and longevity doctor last Friday. We had a great time swapping stories and perspectives.

"I'm all for evidence-based medicine," he said. "The only problem is, whose evidence? And how much is required?"

I will give just two examples from my own experience:
  • Thyroxine: Kaiser Permanente (at least the doctors I've been dealing with) takes the perspective that a TSH (Thyroid Stimulating Hormone) test is "good enough" to tell whether and how much you need thyroxine supplements. Problem is--and I've seen it in my own body, not to mention read enough stories of others: Your TSH may come back in the "normal" range but the actual thyroxine hormones--T4 or T3 (not to mention Reverse T3)--may be completely wacked out. Or, as many (primarily women) have discovered, their T3 levels may, according to the standards of the laboratory, be within the low "normal" range, but they are feeling sluggish and exhibiting all the signs of significantly low thyroxine. "But the test shows you are normal," says their conventional doctor. "Yeah, but my body says I am low."

    Guess who's going to "win" this particular battle?

    The only way the woman is going to win is to find a doctor who is willing to consider the broader range of diagnostic symptoms than the TSH test and the supposedly "normal" range.
  • Testosterone: Yipes!

    According to the latest LabCorp standards, "normal" serum levels go all the way from 193ng/dL on the low end up to 740ng/dL on the high. Strangely, up until sometimes late last year, their "normal" range went from 280ng/dL to 800. And while that was LabCorp's standard, my longevity and vitality doctor was recommending a range of 700 to 900 as optimal.

    Well, I can tell you from experience that, at least for this guy, at 441, I was definitely below optimal. From the mid-500s up to 900, I was doing very well. When I hit 194 last year (supposedly "normal," right????), I was in major trouble. I had no physical response at all. Without getting graphic, let's say it was as if all the nerves had been cut to a certain portion of my anatomy that, when healthy, would have plenty of neurological receptors.

    But there was nothing.

    Kinda scary when you think you might have a few years, yet, to live! Or, at least, you'd like to imagine you might have a few more years left.

    But "evidence-based medicine" would have told me that my labs were "normal," even if they did come back at the bottom edge of normalcy.
So my doctor and I were discussing things like that.

He brought up the upcoming/expected healthcare program from our federal government.

"The bill is 2,000 pages long," he said. "We are told we can expect that there will be approximately 100 pages of regulations for every page in the bill. In other words, 200,000 pages of regulations.

"Guess what the penalties are if a doctor breaks one of the regulations?"

"I have no idea," I said.

"A $100,000 fine for the first offense," he said, "and it goes up from there."
According to Andrew Breitbart's BigGovernment blog,
The National Coordinator for Health Information Technology “will determine treatment at the time and place of care”. They are charged with deciding the course of treatment for the diagnosis given by the doctor.

Now it becomes obvious why there has been a big push towards the implementation of universal electronic medical record use. It becomes a tool to completely control the physician and the patient. Those physicians and hospitals that choose to practice individualized patient care in consultation with their patients will be punished because they are not “meaningful users of the system over time.”

Beginning January 1, 2013 penalties for doing the right thing for a patient will cost the doctor $100,000 for the first offense and jail for the second offense. This will have a chilling effect and may be the straw that completely breaks the foundation of good medicine – the doctor patient relationship.
And then he said almost exactly the same thing my last pre-Kaiser general practitioner said to me: "I'm going to quit practicing medicine. It's not worth the risk."

My last pre-Kaiser GP, who may be about 60 years old at this point (he would have been in his low 50s back when I dealt with him) said he had made only $75,000 a year in the last three years of his practice; he felt he received no honor anymore as a doctor; all of his decisions were second-guessed and overridden by the insurance companies ("A high school graduate reads down a list and tells me, 'Yes, you can do that,' or, 'No. You may not provide that kind of service to your patient.'). My brother-in-law, who owns a carpet store can win trips to Hawaii, but if I so much as accept a pen from a pharmaceutical salesperson, I am charged with ethics problems. . . ."

He quit.

The doctor with whom I was speaking last Friday made another comment that struck me with respect to my old GP's comment about honor: "We are no longer called 'doctor,' anymore. We are called the same thing as nurse practitioners, chiropractors, and hospital orderlies: We are all 'healthcare providers' or 'healthcare workers.'"

"Why would anyone go through all the pain and agony of a full medical education to wind up hundreds of thousands of dollars in debt . . . and earning $75,000 a year?" asked my old GP.

"Why would anyone want to go through the pain and agony of a full medical education only to become a 'healthcare worker' on the same level as a nurse?" asked my vitality and longevity doctor.

One last comment he made:

"I did my residency in what was, arguably, the very best hospital in the country at the time. But I am paid no more by the government than the person who was trained at ___________" (and he mentioned a fine, but certainly not nationally-recognized facility). "What's the point?"

I'm sure there will still be those who desire to do the best or be the best, no matter what. But one does have to begin questioning the impact of incentives.

blog comments powered by Disqus