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 The plan is readied: when the time comes that battery depletion mandates surgery, the outdated device will be upgraded to the most modern clinically proven device.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 newsâ€¦
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.
Addendum: For yet another real-life example of intrusions into the doctor-patient relationship, see Dr Wes’ post from yesterday.
2 replies on “Deniedâ€¦”
Count yourself as fortunate that the Feds only wanted their money back, and did not not see fit to charge you with felony, replete with massive fines and jail time. Failing to fill out the paperwork to their satisfaction can be construed as a federal crime, you know. So the scariest part of your post is that here, the Feds were actually being nice guys.
Dr. Emanuel, the White House health czar, is overseeing the introduction of his "complete lives system" as the means of allocating –i.e., rationing — health care. Bottom Line: out of breath patients with implanted devices, in their 60s and 70s, are to be DENIED resources under "health care reform". That's the Government's best medical judgment, and that's final. See below for a concise statement of the complete lives system the Government plans to impose.
"When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated.
Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."