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Commentary by Dr. Gene Dorio
| Monday, Dec 9, 2013

genedorio“Throw grandma under the bus” clearly conveys anger, sympathy and fear when healthcare decisions are made outside the realm of medical professionals. Within the doctor-patient relationship, alignment of physician expertise with an individual’s personal decision should keep insurance company executives, hospital CEOs and HMOs from interfering.

Are we naive to believe interference isn’t already occurring?

A doctor orders a breast MRI to further evaluate an abnormal mammogram, but the insurance company denies approval. Physical therapy after a broken hip must be done at a facility 60 miles away instead of down the street because “we don’t have a contract with them.” The physician-recommended, evidence-based cancer surgery cannot be initiated as it is not authorized by the insurance company. A mid-90s woman is told she must go to a nursing home because her “double” pneumonia is beyond the four days allotted to the hospital for her care.

Yes, we’re already throwing grandma under the bus.

The healthcare role of doctors is to heal, and for some it extends to end-of-life care to assure minimal pain and maximum comfort in the patient’s final days. Somehow, though, unscrupulous profiteers have found ways to intervene covertly, claiming patient benefit, when their real purpose is profit.

I wish to forewarn patients and caregivers of new threats against us and our loved ones, and possibly make you better able to question healthcare professionals.

As an internist and hospice physician, I was asked to see a patient with a “terminal disease” for end-of-life comfort care. She lived with her family on a ranch outside of Santa Clarita, and when I arrived, she was actively sweeping the front porch with no sign of debility or pain.

Being able to access her hospital chart, I found the HMO had not done the usual workup nor staging of her cancer. As Medicare funding is separate, by placing her on hospice, the HMO was able to “wash its hands” of the patient, saving money by not providing any further care.

I reported them to a state agency and advised the family of the problem, resulting in appropriate care and treatment.

In Henry Mayo Newhall Memorial Hospital, I now see aggressive questioning of families and older patients seeking a code status change to DNR (Do Not Resuscitate), coercing them into a lower level of care. Coupled with this, sometimes, is an attempt to place them on hospice.

Under certain circumstances I cannot disagree, but wouldn’t you expect those asking these questions be physicians? Unfortunately, they are not. Sometimes they are nurses, social workers and even case managers, maneuvering under the guise of “palliative care team.”

An unsettling problem at Henry Mayo is oversight of the Palliative Care Team by an administrative hospital committee that formulates policy away from the scrutiny of physicians. “Orders” have been placed by non-physicians asking for Palliative Care personnel to consult patients – which is tantamount to practicing medicine without a license.

Far before hospitalization, I discuss with my elder senior patients their sense of quality of life and expectations of how aggressive they want to be treated at end of life. No one lives forever, and everyone uniquely makes decisions based on personal relations, family, religion, experience, common sense and reality.

But hospitals abide by Medicare rules of payment and might lose money when a patient stays too long.

Reducing care by forcing code-status changes of patients under duress is inappropriate, especially when it is not presented by the physician. A new twist on the problem is at some hospitals, physician care is turned over to a hospitalist who has never met the patient nor the family. If these hospitalists are paid directly or indirectly by the hospital, you already know the tenor of their questioning.

Not to be misunderstood, there are many caring physicians, including hospitalists and Palliative Care Teams, focusing on the best interests of the patient. Again, sadly, who pays them determines the fate of many of our elder seniors.

The present medical system is too vast and complex for most to understand or read between the lines. Being aware of the unseemly profit-making tactics I’ve outlined here might help you and your loved ones ask questions and make better choices.

Personal decisions should not be twisted or coerced by insurance company executives, hospital CEOs or HMO profiteers. Ultimately we must demand to uphold the sacred relationship between doctor and patient.

Throwing grandma under the bus should not be an option.

 

 

Dr. Gene Dorio is a housecall geriatric physician on staff at Henry Mayo Newhall Memorial Hospital and has been engaged as an advocate in many community activities. The views expressed in this column as his alone.

 

 

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