January 3rd, 2011

Medicare: The MasterCard That Keeps On Giving

In the cardiac catheterization lab one Tuesday morning, I encountered a situation that made me reflect on a bit of 18th-century British history.

At that time, the British government was overburdened with prisoners. A plan was hatched for sea captains to transport many of them to Australia. Due to poor conditions, up to one third died on the voyage. Politicians and clergy members desperately urged the sea captains to improve the conditions, but survival rates changed little. But then an economist suggested paying the captains for every prisoner who made it to Australia rather than for each one who boarded a boat. Survival quickly improved to 99%.

Back in the catheterization lab, there were no British prisoners — just a slim, gray-haired man with bristling facial hair lying on a stretcher in front of me. With his chart in hand, I greeted this Mr. Johnson and asked him how he had come to the attention of Dr. Attending, an interventional cardiologist.

“I was seeing him for my cholesterol,” Mr. Johnson replied, “and then I started to get a little short of breath after going up a few flights of stairs. He ran some tests, and next thing I know I’m here. I’m sure that any blockages they fix will prevent the next big heart attack, so I’m not worried.”

I perused a note written by Dr. Attending: “Mr. Johnson, a 75-year-old gentleman, remains highly symptomatic from shortness of breath. Since this may be his anginal equivalent, I will recommend a cardiac catheterization for further evaluation and treatment.”

Struck by the disparity between the clinical situation and the note, I nevertheless passed the consent form to Mr. Johnson, who signed it. He was whisked away to the catheterization lab, and with Dr. Attending by my side, we began the procedure. The catheter engaged the left-main and then the right coronary artery easily and accurately. The contrast illuminated the arteries like glow sticks on a sobering night. The right coronary was totally occluded.

“Well, this is clearly the cause of his shortness of breath!” Dr. Attending exclaimed. “We need to fix it!”

In the ensuing hours, we deployed a balloon pump to push blood over the diamond drill of the roto-rooter. It cut through the cemented plaque with hydraulic precision along the tracks of countless coronary wires. After the procedure, Mr. Johnson was admitted for a brief stay in the ICU and, later, to the hospital floor. When I saw him walking about in his standard-issue navy blue slippers, I asked him how he was doing.

“Good,” he said. “Still a bit short of breath though. I’m happy to be going home today.” The case left me feeling uneasy.

Did our complex medical procedure decrease Mr. Johnson’s risk for morbidity or mortality? If not, did we improve his quality of life? Has caring for patients become more about the journey than the destination? Can we instead give physicians and health care providers incentives to focus on outcomes, as the 18th-century British sea captains eventually received? In the 21st century, my experience with Mr. Johnson’s care read like the script of a MasterCard commercial:

Complex medical procedure plus hospitalization: $63,535.00

Outpatient follow-up: $56.50

Navy blue hospital slippers: $5.50

Judicious medical care: Priceless

5 Responses to “Medicare: The MasterCard That Keeps On Giving”

  1. “You get what you pay for.” If we want good outcomes we must measure and pay for outcomes. If we want lower cost and good outcomes, we must measure both cost and outcomes and pay the doctors who generate better outcomes at lower cost more money. This is not rocket science, it is simple economics.

  2. Antony Hsu, MD says:

    Now, good thought – can we incentivize the patient to lay off the Big Macs and Indian Reservation Cigarettes? The patient and family need a bonus if they can change their lifestyle. If the Cardiologist can convince them, then he gets a bonus too!

    Good, Fast and Happy – the motto of the ED doc.

    • Agree completely. If a doctor spends the time and energy to educate his patients about a healthy lifestyle and thereby gets better long term outcomes he should absolutely be paid more. But for a doctor to just give it lip service and then blame the patient for not following his instructions is an abdication of responsibility. Patient education is the doctor’s responsibility, his effectiveness in this area should be measured and compensated for if he achieves better outcomes.

  3. I believe the point in the story told by Dr. Bansai have nothing to do with patient life style. It merely pointed to the fact that the procedure of opening up an occluded RCA for the symptom of shortness of breath is neither necessary nor indicated. However, the payment system of Medicare lacks a close scrutiny and therefore continue to pay regardless. That is why Judicious medical care is priceless. The story of transporting the prisoners to Australia is also emphasize the lack of closed supervision for the process of transportation and put the emphasis on the numbers of prisoners at the destination rather than the mode and method of achieving the result.

    Competing interests pertaining specifically to this post, comment, or both:

  4. ali valika, m.d., FACC says:

    was there a stress test suggesting reversible ischemia in the territory of the RCA, and was it a large sized defect?