Thursday, January 08, 2009

Our Inappropriate Appropriateness Criteria

Ladies and gentleman, if there is any question that clinical judgement has been relegated to the back bowels of medical care, a new breed of healthcare-payment-denial-criteria-for-insurers has been born: so called "appropriateness" criteria for cardiac revascularization.

Actually, it started for cardiac imaging, and somehow, some way, our cardiovascular leadership who cozy up to our well-intensioned-but-clueless legislators on the Hill thought it would be a good idea to (QUICK!) develop even more complicated "appropriateness" criteria for cardiac revascularization!

I mean, what kind of word is "appropriateness?" Shouldn't it just be "appropriate" criteria?

But alas, just as we have seen the invasion of the word "wellness" into our health care lexicon by insurers, so too comes "appropriateness."

As if I can have more "appropriateness" than my other colleagues. Nah-nah-na-nah-nah.

In an absurd and utterly shameful attempt at categorizing every permutation and combination of coronary disease that comes our way and categorize it into three levels of judgments regarding care (Appopriate, Uncertain, and Inappropriate), the authors have succeeded in dispensing with what really matters in treating patients: clinical judgement.

That's right, your "score" will mean more than your judgement. Just get over it.

As if such a scoring system will keep the less-than-honest amongst our ranks from making sure their patient qualifies as "appropriate."

Please, spare me.

But what's really ironic (and telling) is that cardiologists don't need these criteria clinically. We can define if a patient needs revascualization MUCH better than any "score" or table ever could. That's because we can actually see and examine the patient. We can appreciate the myriad of confounding co-morbidities that shape clinically relevant treatment recommendations, like cyanosis, severity of heart failure, pulmonary disease or peripheral access issues.

But that's not good enough for insurers - especially Great Big Governmental Ones that are convinced (and I mean convinced) that Doctors Are The Evil Ones when it comes to cost overruns. Doctors are out to scalp the system, relentlessly. We never have the patients' best interest at heart. It's always about our wallets, right?

Give me a break.

Week after week we sit in cath conferences with our surgical collegues and discuss in great detail not necessarily if an individual needs revascularization, but which form would be more appropriate: bypass or stenting. Do these so called "appropriateness" criteria for revascularization help us with that decision? Not at all!

Really, how "appropriate" is that?

But maybe, just maybe, my keeping these criteria "appropriately" vague and limited to "only" 4000 potential permutions, the authors tacitly achnowledge the limitations of their efforts. Unfortunately, by creating these inappropriate "appropriateness" criteria, they have helped the insurers grant more reasons for denial of payment than they have helped their collegues manage patients. They have virutally guarenteed that in the end, as the ongoing battle between those that deliver care and those that pay for it continue to lock horns, the patient will bear the brunt of the battle and remain the most confused about their obligated portion of their health care bill.

And to me, that's what's really inappropriate.



Anonymous said...

This reminds me of the ridiculous "medically necessary" locution. I recall once putting on a prior authorization form that not only did I think the test I ordered for the patient was medically necessary, but that every test I've ever ordered, lab I've ever drawn, and prescription I've ever written has been medically necessary.

Is there some "just for the hell of it" criteria for doctors ordering tests that I don't know about?

Anonymous said...

"Appropriateness" was brought to you by the number 96, the letters B and S, and the creators of "pre-existing", where delay and denial are the favorite indoor sports.