medicine and third party payers

Monday, June 1, 2015

Instant replay is a wonderful tool to show the athletic capabilities and plays of the best players in any sport. Replay is not so wonderful when it shows the slow motion angles of the head injuries of Stephan Curry and Klay Thompson, both of the Golden State Warriors, even while the players were being escorted by team doctors from the court and into the locker room. After testing, both were cleared to return to play. But one of them, Mr. Thompson, fortuitously did not because of a bleeding ear laceration, and only later developed symptoms of concussion. The media were quick to question the decisions that allowed both men to continue to play, asking that the NBA revisit their concussion protocols.


Doctors, hired by the team, make the medical decisions on the sidelines that affect athletes’ care. It may seem that a conflict of interest may exist, where those physicians serve two masters, the player and the team management, but the doctor’s primary directive needs to serve the athlete patient. It is reasonable for the doctor to share their diagnosis, treatment plan and prognosis with the team’s management, but their assessment should not be clouded by who pays their salary. Interestingly, there is the same conflicted relationship that exists between most patients and their care providers.

Few people have an independent relationship with their doctor. Whether it is a private insurance company, HMO, Medicare or Medicaid, a third party has been injected into the equation and made a triangle out of the decision making process. Most often, there is little conflict, but medicine at the bedside is being shaped by recommend best practice suggestions, from what tests to run to what antibiotic to be prescribed. These suggestions are labeled guidelines or recommendations, but straying too often and too far from these standards are a sure way for a doctor to have the care they provide reviewed by a third party. There is good reason for medical care to be standardized and hopefully best outcomes come from best practice, but cookie cutter medicine may lose the art of the bedside evaluation.

Often the news will report that a celebrity or politician or athlete has checked him or herself into the hospital for treatment. Most in the medical profession who read those words will sigh. Patients rarely have the power to “admit” themselves. Instead, after visiting their doctor’s office or the emergency department, the patient is evaluated and only if their condition meets admission criteria, will they see an inpatient bed. Those criteria are sometimes vague and sometimes very specific, depending upon the disease or injury. And the word “admit” may be a misnomer. The patient may be placed in observation status if the doctor cannot attest that the patient reasonably will need care that will span two midnights. Presumably, the doctor has the insight to know who will always get better within 25 hours, if you are admitted at 11pm, or 47 hours if you showed up for care at 1am.

The admission criteria are often based on Medicare rules and the MCG Care Guidelines (formerly called the Millman guidelines). These guidelines are evidence- based, meaning that they are supported by research, but applying them to every potential patient situation is difficult; there is always one square peg that can’t be fit into a round hole. Private insurance companies tend to follow the government’s lead. Most of the time, the guidelines make sense and aim to admit only those patients who need acute nursing and medical care. Often, a patient may be just as well served at home in their own bed, but that decision to discharge the patient home also transfers the nursing care responsibilities to family and friends, and that is sometimes a daunting and frightening task.

The doctor is under pressure to predict the future and get the admission, observation, and discharge decision correct. Aside from pressure from the patient and family, there is oversight from hospital administration, quality assurance committees and insurance companies, including Medicare. Potential financial penalties exist for the hospital if too many patients are admitted who perhaps should have gone home, or if too many patients who are placed on observation status are then admitted, or if too many patients who are sent home and then return in a few days to the hospital in worse condition and need admission.

When there are three people who are part of the decision making process and only one holds the purse, there is bound to be conflict. Questions will arise as to whom the doctor really serves, the patient in front of them or the company that will pay the cost of care. When the dust settles, it is only the doctor’s internal ethical compass that expectedly points to what is right for their patient. And when Stephan Curry and Klay Thompson are evaluated on the sideline, the same expectation holds true, regardless of who pays the bill, and regardless of guidelines and protocols.

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