Monday, March 30, 2009

Guidelines: Our New Health Care Derivatives Market?

I didn’t attend the American College of Cardiology meeting in Orlando, FL this year, mainly because I am concerned about my ability to pay for my son’s college. I do not quality for financial assistance for his tuition so I cannot afford the luxury of attending every cardiovascular meeting each year right now.

I’m sure many Americans feel the same way, particularly those who have seen their retirement savings evaporate in current economic mess we’re in. People are angry, frustrated, and dumbfounded that our political and financial leadership failed to realize the consequence of their actions when they permitted banks to lend more than they had assets to cover. I mean, who knew, right?

But back in the not-so-distant “glory days” of banking, it was all about “OPM:” other people’s money. You know: using other people’s money to buy a house. Using other people’s money to leverage a shopping center. Using other people’s money to buy some risky asset and sell it to another person so you could all reap some profit. OPM was the financial way to get ahead at almost no downside risk to you. What was not to like? If things went bad, well, it was other people’s money!

And now, in retrospect, we see it for what it was: a time of overindulgence; a time of greed…

… all on the backs of OPM.

Health care is kind of like that, unfortunately. We use OPM all the time when we pay for expensive treatments and procedures and don’t have a clue what it costs. Now, though, we get ridiculously inflated prices sent to us on our “Explanation of Benefits” from our insurer and are all too relieved, yes, relieved I tell you, that OPM has picked up so much of the tab for our health care.

That is, until the OPM goes away and we’re stuck paying the inflated price. Then we’re pissed. And maybe even bankrupt because, unlike the federal government, you and I can’t just print money. It doesn’t work that way. As the old Smith Barney commercial used to say in their thick British accent, “We have to earn it.”

So it was with some amazement and plenty of dismay that I read the very recently-released ”focused” 2009 Heart Failure Guidelines, guidelines that form the cornerstone of the American College of Cardiology and American Heart Association’s Hospital to Home (“H2H” as they call it) initiative to “reduce hospital heart failure re-admissions 20% by 2012.”

It’s a noble initiative, funded by OPM, to demonstrate our cardiology societies deep commitment to help President Barack Obama reduce health care costs.

But like most things with OPM, the details of the cost savings afforded by this initiative are quite vague: especially when the new guidelines include expensive medical devices to be used as therapy now, when in earlier guidelines, there were none.

Not to say that these devices may not have been shown to improve symptoms and longevity in heart failure. They certainly have. And to that extent, these guidelines are exceptional because they put the patient’s health first.

But at what cost?

When we use OPM, we don’t care about cost. OPM will pay for our guidelines’ implementation. Look how we’re helping our patients live longer! OPM will pay for the electronic medical record that will screen the chart for the patient’s ejection fraction and make sure the patient gets the proper test and therapy that is recommended by the guidelines. After all, our goal is to reduce heart failure readmissions by 20% in 2012! No need to worry what it will cost! What’s the risk? Hey, it’s OPM!

And unfortunately, just like the banking fiasco, this OPM will some day run out. The pot of gold is not limitless, but there are few doctors admitting this. We can’t. We are bound by ethics to preserve life that are in direct conflict with our duty to help our patients remain fiscally solvent.

And yet, with our children’s health care and our national economy on the brink, I wonder if we’re not being ethical to our future generations’ patients by not asking these tough questions right now.



Margaret Polaneczky, MD (aka TBTAM) said...

Great post, Dr Wes.

The cynic in me also wonders how much guidelines are influenced by special interests trying to get their piece of OPM. Device manufacturers lobby for guidelines that included use of their products. Makers or anticoagulants push for regulations that mandate their drug use instead of paying for nurses to get patients out of bed post op.

I do agree that the inflated costs would come down if we were not spending and receiving OPM.

The question is, of course, who is the AIG of healthcare and when do they go down?

Hal Dall, MD said...

Perfect analogy, thank you for the insightful post!

To continue the thought, are general IM and family practice sub-prime specialties?