Kudos to Drs. Shulkin, Cooper, Bailey, Orient and MacDonald on the bold and intelligent steps they have taken to rejoin mainstream private practice despite the risks involved. ("Walking away from corporate medicine," October ACPASIM Observer)
These doctors send a clear message to the powers that be, especially in managed care, that physicians can stand up and be counted. I am at the twilight of my career and am glad that I have never had to work for corporate bosses. I am retiring because of the dictatorship of managed care, and I feel disheartened for young people just entering medicine. But if things go right, and if more doctors venture out on their own, medical practice without outside interference may yet return.
Byravan Viswanathan, FACP
- Previously published ethics case studies are available online.
- For additional ethics resources, visit the College's Center for Ethics and Professionalism
"When it comes to nursing home dumps, should you just go along or speak up?" (October ACPASIM Observer) missed some of the incentives physicians have to "dump" patients.
Physicians are paid little to visit the nursing home, and there are real problems collecting for repeat visits. In the hospital, on the other hand, there is no problem collecting. A colleague might even do a consult and get paid.
Even if physicians don't follow their patient into the hospital and get paid for those services, they get rid of a sick patient. The nursing home gets rid of a sick, expensive patient and Medicaid pays the home for 15 days, or maybe even 20, to hold the bed pending the patient's return. The hospital gets paid for an admission that comes with an easy and fast discharge back to a reserved bed. If the hospital and nursing home are part of the same system, HCFA actually ends up paying double.
Is it any wonder that the system functions to the detriment of chronically ill, older patients?
Louis M. Soletsky, FACP
Great Neck, N.Y.
I just finished reading your ethics case study and am furious. The "Dr. Welby" figure in this article placed his patient's best interests last, after his own financial interest and what he perceived as the nursing home's interests. Worse, the fictional medical student was "not sure" she could fault Dr. Welby. The author never addresses Dr. Welby's actions. Worse, the author completely ignores the effect his actions and words had on the medical student.
Some of your readers will know how cases like this are actually managed by competent physicians. Those same readers will also know how important it is to teach future physicians the skills to address the medical needs of the old.
A few physicians have taken the time to become board certified in geriatric medicine. Many of us dedicate ourselves to long-term-care medicine as well. Most of us are able to do this work without sacrificing our ethics, without abusing our patients and without ripping off the system.
I have taught medical students, residents and now physician assistants. I know that they won't have any trouble judging Dr. Welby.
Charles A. Derrow, FACP
As the medical director of two nursing homes and primary care provider for many nursing home patients, I assure you that my nursing home admissions to hospitals are not "dumps."
In the fictitious case of Mrs. Smith and Dr. Welby, perhaps Dr. Welby doesn't understand that under Medicare's prospective payment system, patients' IV antibiotics costs are covered by the nursing home. As a result, care for patients with IV antibiotics can be provided at nursing homes. If patients need more intensive monitoring or have unstable vital signs, then they require hospitalization (if this is consistent with the patient and the family's goals).
In this fictitious case, Dr. Welby seems to be at a loss as to what to do when there is no family member to consult. If the patient has no family and is demented, she should have a guardian, which I am sure can be provided by the state. Dr. Welby could discuss the patient's care with the state guardian, as I often do. Although defining an acceptable range of treatment options for these patients takes work, it is not impossible to do.
Dr. Welby doesn't have to change all of Medicaid and Medicare to improve nursing home care. I would suggest that he consult some of the educational programs available from the American Medical Directors Association (www.amda.com/home.htm) to find ways to better treat his patients within the current system.
Mark E. Hroncich, FACP
I am disappointed in the College's recent push for universal health care. I, like many others, trained in a government-run and financed delivery system, the Veterans Health Administration. While I practiced good medicine there, it was despite the system, not because of it. We all know what wonders HCFA has wrought for our patients and physicians. Who do you think would run a single governmental payer system?
Here is where I think we should take medical care: Employers and HCFA should offer only catastrophic health insurance that would include an annual physical exam, blood work and mammogram. It should not cover medication. Rather, the pharmaceutical industry should produce a discount medication list that would be forwarded to every participant. This would cost health plans, including Medicare, almost nothing, and benefit members significantly.
We should also reintroduce the concept of personal responsibility. Smokers who refuse to kick the habit and CAD/COPD patients who will not take their medications, for example, should pay a minimum of $2,000 a year into the system, as they get sick and require medical care more frequently.
When patients see and pay for the costs of an emergency room visit for lower-back pain, they might be more inclined to seek less expensive treatment. This would help reduce inappropriate use of high-cost health care.
Since insurers would no longer be directly involved in office visit payments, cash flow and paperwork, the overhead and attendant hassles would be greatly reduced, and physicians might once again experience some satisfaction in their work. This would also eliminate the specter of HCFA auditors coming to our offices and seizing charts for audit.
Richard E. Sacks-Wilner,
Fort Bragg, Calif.
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