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Monday, August 27, 2012

Why Your Doctor May Not Offer You Best Care

Your doctor may not offer you best care available.  This is because she is not the only entity controlling the quality of care to which you have access.  Two additional players affect quality and access: the hospital and the insurer.

"My patient comes first" may be the mantra of pure fiduciary obligation espoused by your doctor but given the economic realities of health care with finite budgets and resistance of payers to increasing cost, that mantra may be more bark than bite.

Let's look at how the hospital and insurers affect the quality and type of care you receive.

Hospitals make decisions regarding personnel, equipment, and management culture at that facility.  Any of these areas affect the quality of care you may receive.  For example, due to salary cost concerns a hospital may preferentially hire new nursing graduates with little experience or managers with limited managerial skill sets.  Furthermore, there may be an outdated MRI or other diagnostic equipment which is good but not best.  Some equipment may simply be too expensive to have all together, thus, you do not even have access to some types of care.

Insurers determine which physicians/hospitals are "in-network".  Going "out of network" is an option but comes with a hefty medical bill. Thus, due to this financial burden, you may chose to stay in-network even if an out of network facility offers better quality.  Similarly insurers also control which medications are preferred to treat your conditions (known as formulary medications).  Non-formulary medications may come with a high co-payment or require full out of pocket payment.

I used the term fiduciary above without defining it.  In health care, a fiduciary is an entity obligated to recommending or making decisions in the best interest of the patient.  For example, if you were out camping and were bitten mercilessly by mosquitoes and now you have headache, fever and confusion, I may recommend a lumbar puncture due to a high suspicion for West Nile Virus encephalitis.  You may, however, refuse this procedure.  Nonetheless, I have acted as your fiduciary by advising what I believe to be in your best health interest. 

Now, what if you had agreed to the lumbar puncture but the facility is out of stock of spinal needles due to poor materials management?  Do they have a fiduciary obligation to assure your access to such care?

Now, what if you agreed to the lumbar puncture and the facility has the needles in stock but your insurer states they prefer a physician who is in-network perform the procedure rather than myself.  I have a lower complication rate doing lumbar punctures than does the in-network physician.  Does the insurer have a fiduciary obligation to you for best quality care?

Your doctor, the hospital and the insurer are all co-fiduciaries.  It would take a perfect storm of consensus regarding health care access, cost and quality of all possible medical conditions for a patient to be guaranteed best care at all times.

By the way, there is yet another player affecting quality of care, yourself.  What is your obligation to participation in your own health?

Interestingly, the first edition (1847) of the American Medical Association's Code of Medical Ethics defined obligations of the physician to the patient as well as the obligations of the patient to their own care.  This was the only edition of the Code of Medical Ethics within which patients' accountability for their own health appeared.  Some feel it should be added again.  What do you think?

By Rajesh Harrykissoon, MD, CPE