New post up on theHeart.org: Fee-for-service, AF treatment and the untangling of knots…

Earlier this year a famous group of researchers did a careful study on the relationship between surgical complications and hospital finances. Their findings should jolt you:

The average hospital makes money when patients suffer complications from procedures.

This is outrageous. It is fee-for-service at its worst.

The first thought that popped into my mind after reading this study was how healthcare policy might improve the care of patients with AF.

An AF doctor spends oodles of time undoing well-reimbursed medical care. We untangle knots. (Recall that AF patients are not a tranquil lot.) Things that entangle include:

  • Overly aggressive and reflexive use of IV-diltiazem drips;
  • Carte blanche to order diagnostic tests;
  • The entrenched practice of extrapolating data on oral anticoagulants to the IV/SubQ variety–and extending hospitals stays for AF.

Such disruptive care makes money in the fee-for-service model.

I often wonder what would happen if hospitals and doctors received a fixed amount of money to care for a patient with AF? Would this make my job easier? Would it foster wiser team-based care? Would it improve outcomes?

Believe it or not, I have answers to these questions. I hope you want to read them.

Click this link to read the entire post over at theheart.org

JMM

8 comments

  1. John – Your posts always make me stop and think. Your perspective is always different (You are the AFib “specialist” who gets referred the challenging cases). I reviewed this post by you – as well as your theheart.org post. As I’m no longer “on the front lines” – my thoughts are more on reflection of past experience plus what I read and sense from those I talk to these days.

    Clearly there is overdiagnosis and overtreatment in too much of medicine that has extended to the AFib arena. Clearly it is a paradox when reimbursement goes up for increased complications that developed from treatment that should not have been undertaken in the first place. I do think there is a place for careful initial use of IV Diltiazem (limited bolus dose and reasonable drip rate) when the initial ventricular response to AFib on presentation is rapid. That said – IV Dilt is clearly not a “maintenance drug” – and overuse is clearly associated with potential for harm.

    Bottom Line: A “plan” needs to be developed early on for patients admitted with AFib. Does the rhythm persist? – or does it resolve when an underlying/predisposing condition is treated? Is cardioversion a reasonable/appropriate option? – or is this a patient who will/should remain in AFib? Will the patient be anticoagulated? Are oral drugs indicated? Should the patient be referred (to cardiology or electrophysiology for potential “cure” )? – or is longterm management by primary care an appropriate/desired option?

    I agree – current practice gets “entrenched” too often without careful consideration of WHY various treatments should (or should not) be used – and sometimes without full consideration of what truly will be best for the patient.

    1. Thx KG. I really appreciate your input.

      This is a tough topic because I don’t want to sound too critical. All I want us to do is look inward at what we do. Sometimes it all seems so aggressive.

      1200 words makes not a book chapter. Agree, there is a role for IV diltiazem, just like there is for digoxin. But both drugs should be used with caution.

      AF is serious but it isn’t acute MI.

  2. John – In your role as “AFib specialist” to whom problematic patients get referred – you get to “pick up the pieces” of treatments gone awry. More forethought could go a long way toward improving appropriateness and efficiency of care.

  3. I’m not a doctor, only an AF patient, but I would like to offer my perspective on being on the receiving end of Afib treatment in the ER. Let me quote the statement you made that I question: “There is no evidence that acute rate control with IV-diltiazem lowers the risk of stroke, heart attack, or death.”

    From my point of view, lying on a gurney with my heart seemingly beating faster than a hummingbird’s wings, all I want is to have the beat returned to normal. If this IV drug accomplishes that, then I don’t care about the risks. Life itself is a risk I read all of your posts that I can find and admire the thought-provoking education you provide to those with this affliction.

  4. AFIB Patient Reactionto Both Articles

    Thanks Dr. John. Your posts are really great.

    …Their findings were stunning: The average US hospital makes money when surgical patients suffer complications.
    Reaction: This is why we go out of our way to drive the long way to where we are going to avoid even looking at a hospital. We don’t feel that way about doctors’ offices for the most part.

    Yet there is a value in making the diagnosis of “CHF.” It bumps up disease complexity, which then brings higher payments to the institution.
    Reaction: Please tell us this isn’t happening. We’d love to read your mind to know which institutions whose ethics you are worried about.

    We waste tremendous amounts of time and dollars treating patients with AF.
    Reaction: Waste? We’d like to know exactly WHEN it is a waste. Why can’t doctors agree on what is the best treatment given the same patient? Asymptomatic patients are a good example of an area where there is disagreement regarding pursuing aggressive treatment.

    I can’t think of a disease (except perhaps old age) that begs for a more nuanced, less disruptive approach to its care.
    Reaction: Old age is a disease now? Please cure me. :-) While we are on the subject, it seems that afib is more of a condition caused by a variety (or a combination) of diseases. If you only have had afib three times for a short time in 10 years, is that a disease? How about wice? Or once? Would you call muscle spasms that occur from time to time a disease? Just asking.

    AF is a serious but not immediately life-threatening disease.
    Reaction: So it will slowly kill me? So shouldn’t we try to ablate it? Some EPS think it will lessen my chances for stroke, heart failure, or dementia. Wouldn’t that be preventative medicine?

    In the interest of brevity, I’ll leave out the folly of treating asymptomatic AF patients with rhythm-control drugs.
    Reaction: (assuming ablation is also seen as a folly for asymptomatic patients) So, if we are asymptomatic, we shouldn’t have the possibility of lessening our chances for stroke, heart failure, or dementia, just like the symptomatic patient? Also, cancer (let’s say, non aggressive cancer)is asymptomatic in the early stages, but we treat it don’t we? (rhetorical question)

    This is why I believe capitated care for AF would force us to get to the heart of the matter. Such a model would surely save money.
    Reaction: “Capitation pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, WHETHER OR NOT THAT PERSON SEEKS CARE.” So what’s the incentive for an unethical doctor/institution investing time/expenses or even answering the appointment phone? (I’m concerned about those same institutions that would see “value” in complications) I have the same queasy feeling with capitated care that I get when I hear the word Obamacare. Also, will cutting edge treatments, new medicines, and devices develop much more slowly if using them involves a financial disincentive? (Just asking a rhetorical question again).

    Currently, an AF specialist in the US spends too much time managing fear and untying knots. I stop far more drugs than I prescribe.
    Reaction: Our fear comes from what we read and see that comes out of places that should be reliable sources. All the websites and studies start out with the same “cut and pasted” stats and background of afib , then go on to explain treatments and outcomes that conflict with one another. Anticoagulant advertisements are pretty scary too. Doesn’t give us a sense of confidence.

    There are many reasons why patients with AF get tangled up. One is that they are susceptible. Tranquil, well-scheduled folks rarely get AF. This intriguing phenotype, however, will not be the focus of this post.
    Reaction: Intriguing phenotype. Wow! We would sure like to see what you think of us as a group… what you have observed as a common thread. Really! It might help us regulate the fear. We probably won’t listen anyway, but we’d love to hear your thoughts. Seriously! Please post on this subject. Well-scheduled? What does that mean in this context? Are you saying we jump ahead of what we should be thinking about at this stage of our disease, I mean, condition?

  5. As a patient with infrequent SVT, I find the first line health care to be all over the map (ER docs, urgent care clinics, PCP’s, etc..). I quickly learned to expect a severe overreaction followed by confusion, and then a sad misunderstanding of what was really needed to diagnose the problem. I got used to saying – “can you please just give me an ECG, NOW, before I convert back to normal rhythm?”

    Incidentally, the answer was usually No – you need an IV and a bunch of drugs first.

    Because I knew a little bit about my own case, I’ve avoided some of the worst overtreatment, but still have paid thousands for useless ‘therapy’.

    I don’t think the motivation was a desire to bill more – it was a desire to do …something… when they really didn’t understand what they should be doing.

    In retrospect, after talking with my EP, it became clear that my story is all too familiar.

    I’ll say what I think too many are too polite to say. Many first line Docs do exactly the WRONG THING when someone presents with SVT. It wastes money, ties up resources, and can harm patients. There is a real opportunity to improve care through some additional education.

  6. I remember taking myself to an ER after crashing in a bike race in Indianapolis. I let the doctor suture a split elbow but told him I would take care of the road rash on my own. That was a very simple and clear-cut situation. It was easy for me to determine the level of care to accept.

    Most of us can’t do that with a number of ailments including AF. We have to trust the physician who treats us. Physicians and hospitals are going to have to take the stands you detail in your post themselves. Even well-informed patients are unlikely to questions which course of treatment is adequate and which isn’t.

    As long as making more money is involved, I don’t believe any changes will come soon.

    I enjoy your posts, even though I’m not a physician. They’re good, thoughtful reading.

  7. I also must ask… if I am unable to control my tachycardia which normally leads to AF and you are condemning the use of IV-diltiazem, then what do you recommend.. everyone gathering around chanting and preying to the tachycardia gods? I can suffer greatly from the above mentioned problem which after some days can lay me low while I am suffering oncoming CHF and once returned to sinus, it takes further days to get my groove back. So my friend, unless you have some new miracle up your sleeve, then the negative comments are not helpful. I am sure you are concerned but I need answers….

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