Denied…

When a letter comes from a hospital employee with the title Appeals Coordinator, Patient Management Services, it is not likely to be good news. And it was not.

That there is such a cubicle somewhere deep within hospital administration real estate speaks metaphorically to the current health-care delivery quagmire.

Keeping the case details turned down low, so as to keep clear of medical-legal angst, here is the scenario…

Two doctors know the patient well.  They have seen him frequently over the past years. He has a long-standing medical device–recently placed on enhanced scrutiny by the federal government–which is adequately providing survival, but is not state of the art, and is likely contributing to his complaints of chronic shortness of breath and fatigue.  He repeatedly tells both doctors that his impaired physical abilities have markedly lowered his quality of life.  His prior surgeries and co-morbid medical conditions make any further elective surgery increased in risk.  However, there is an advanced version of his present medical device available, and soon, battery depletion of the indwelling device will mandate replacement surgery.

Over the years, despite maximizing pharmacologic treatments and appropriate lifestyle modifications, the organ involved remains weak, primarily as a result of the present device. The plan is readied: when the time comes that battery depletion mandates surgery, the outdated device will be upgraded to the most modern clinically proven device.

Finally, the day came for the “upgrade,” and the chance to unleash the fury of modern technology.  He knew that the additional surgery increased the risk, but the treasure was improved organ function and an enhanced quality of life. Although, anatomic considerations made the degree of surgical difficulty high, it went without any issues, incisions healed, and he was indeed a “super-responder.”  The target organ’s function normalized and his physicality sky-rocketed.  Doctors and patient alike rejoiced.  The folow-up visit was a beautiful moment.  Grin.

The buddhists say things are impermanent, and so it is advised not to dwell too long on the very good, or the very bad, as surely “it” will pass. Like bike racing, or doctoring, or in life itself, the harder something is to overcome, the more rewarding it is to do so.

The bad news…

Then, more than a year after the successful procedure, a letter and phone call from an “appeals coordinator” says that someone, from somewhere, deep within the government, has reviewed the chart and said the upgraded device was not warranted and the hospital should pay back the difference between the more expensive device and a “regular” one.

It seems the doctor didn’t place a number to the degree of the patient’s breathlessness. Apparently, qualitatively describing a patient as breathless, fatigued and possessing a significantly limited functional capacity were not specific enough.  It seems the State–as Dr Rich would call the overseers of health-care for the 65+ cohort–thinks that some breathlessness and some amount of organ dysfunction is OK, and as such, does not warrant state of the art medical devices.  They say, not you and your doctor.

The denying reviewer has not seen the delighted patient back in the office, nor has he/she seen the imagery of the now normally functioning organ. Moreover, the reviewer didn’t even mention that the doctor and patient agreed to delay surgery until the time that battery depletion of the present device mandated surgery.  Even more ironic, is that the reviewer did not give the implanting doctor credit for installing a substantially less pricey upgrade than most of his peers would have used.

Is this an example of the covert rationing of health-care?  Is the State saying that using an FDA-approved device, which has proven effective in clinical trials, and agreed upon by an informed patient and skilled doctor is not warranted because the severity of shortness of breath and organ dysfunction was not quantified enough?

Citizens, whatever you think of doctors, be assured that in the overwhelming majority of cases, compared to the government, your doctor is far more qualified and substantially less conflicted in advising you which therapies are best.

The medical specifics of this vignette were purposefully limited, but suffice it to say, the egregiousness of the intrusion was breathtaking.  The obviousness of what was right was clear. The device worked.  The patient is better, and the cost of an even more expensive device was averted.  But yet, it was denied.

Surely the government has an important role in reforming health-care, but encroaching into the sacredness of the doctor-patient relationship is a slippery and very scary descent.

JMM

Addendum:  For yet another real-life example of intrusions into the doctor-patient relationship, see Dr Wes’ post from yesterday.