Who practices medicine?

by Deane on May 14, 2011

The title question is deadly serious and critical to your health. Supposedly, doctors are the only people who “practice medicine.” Supposedly, they are the only ones responsible for medical outcomes. Both suppositions are reasonable but wrong. Insurance carriers – both private and government– are increasingly guilty of practicing medicine without a license as well as cost shifting.

I am a doctor with a newborn patient who has a rare, previously fatal congenital heart condition. Only one surgeon in the U.S. has had great success with this problem, having operated on over 400 such babies in the past ten years. Other surgeons, who claim they “can do it,” have operated on maybe 10-25 children, using an old and less successful procedure. I want my patient to go to the one who has the proven successful track record.

The baby is covered by Medicaid via Molina. Molina has contracts for heart surgery with two centers, but not the successful one. When I tried to send the baby there, authorization (and therefore payment) was refused. I scientifically compared outcomes’ evidence from the two contract Centers to the successful one. The difference was dramatic. I showed this comparison to Molina. Their decision stood: I could not send the baby to the experienced surgeon.

Who is practicing medicine – bad medicine – on my baby patient?

Searching around for some solution, the parents found a private insurer who might cover the baby, and who might allow me to send the baby where her chances are best. Of course, the parents have to wait three weeks before they can change insurance, so the baby stays in the ICU chewing up thousands of unnecessary dollars waiting until we are allowed to get her the care she needs. And Molina is happy, because they just transferred a large cost from their budget to someone else’s.

Who is cost shifting? Who is increasing costs?

Put aside my anger and frustration. Ignore the fact that this baby might die needlessly if operated by the wrong hands. Let’s not point the flaming blaming finger and think we have fixed anything. The problem we need to address – the root cause – is the system, not simply an insurance company practicing [bad] medicine.

As long as the system pays for performance instead of long-term positive results; as long as system generates profit by delaying, denying or diverting care; and as long as health care providers are held responsible but do not have the authority to do what is right, patients will suffer and costs will continue to rise uncontrollably. (When you think about this baby, keep in mind how much bureaucratic and administrative expense was and is being generated.)

The healthcare system we now have is not a system, and certainly is not focused on our health. The current self-styled “system” supports the bureaucracy to the detriment of We the People. Want proof? The way the system is structured with cost cutting as the primary goal, the “best” – read cheapest – outcome for my patient is death! Such a system cannot be reformed. To make matters worse, PPAHCA is exacerbation, not reform: it expands the bureaucracy even further.

The U.S. needs a totally different healthcare system where only doctors practice medicine.

For more on this subject, read “Uproot U.S. Healthcare.”
System MD

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