Liberal Values Defending Liberty and Enlightened Thought

One danger of health care turning into a political issue is that we are seeing people who have little understanding of health care making recommendations for how medicine should be practiced. Two such examples can be seen from Dave Snow, benefits manager of Medco, and Arnold Kling.

Snow believes that “the time has come for doctors to follow set protocols on how to treat patients, and to be paid based on whether they do it.” 

On the surface, to those who know little about the practice of medicine, this view might make sense. Doctors should definitely base their treatment decisions upon what has been proven scientifically and should consider the treatment protocols of specialty organizations for the treatment of their patients’ problems. What people like Snow fail to understand is that the practice of medicine goes far beyond this.

The Covert Rationing Blog takes this argument to its logical conclusion that there would be no need for primary care doctors if heath care consisted of merely following evidence-based treatment protocols. For those who do have not figured out the problems with this approach from this mockery, others have more explicitly criticized this belief.

Richard Dolinar recently presented a strong argument against over-reliance on treatment protocols imposed by third parties back in December, concluding:

It is absurd to think that a third party, operating at a distance in time and space from the patient being treated, is able to make a better medical decision than the treating physician and therefore should be allowed to preempt the treating physician’s decisions.

Arnold Kling disagreed, arguing without any real basis that  “a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.” The Covert Rationing Blog debunked his views in further detail here.

DB’s Medical Rants provided a quick summary of the problems in allowing  insurance companies or other third parties to dictate medical care as Kling believes is possible:

I see three major flaws in all these arguments. First, these arguments always assume correct diagnoses. Correct diagnosis is a major problem in medicine. Second, these arguments focus on treating a disease, while many patients have multiple diseases. We have no evidence base on the management of multiple diseases. Third, these arguments discount the healing relationship which great physicians provide. Patients respond to reassurance, encouragement and empathy. The physician really can help improve quality of life independent of the specific prescriptions.

The first two points can be seen in a recent experience I had with an insurance companies which thinks it can dictate medical care based upon evidence based medicine alone. I had a patient who had multiple problems, but the most significant were advanced Chronic Obstructive Pulmonary Disease (COPD), with the patient spending a considerable amount of time on a ventilator, and end-stage renal failure. During the course of treatment the patient ocassionally had elevated blood sugars due to the use of high dose steroids which were sometimes used to treat the COPD. He also was had a low blood pressure and therefore had testing for heart disease, with this being trivial compared to his more serious lung and kidney problems.

Somehow Humana picked up on the elevated blood sugar and cardiac tests and this remote third party reviewed his care based upon treatment protocols for diabetes and heart disease. The protocols were perfectly valid when applied to the right patient, but they did not apply at all to this patient. Since Humana believed he had heart disease, they complained that I was not treating him with beta-blockers. Beta-blockers are excellent medications for those with heart disease, but are contra-indicated for those with COPD and could have precipated respiratory failure on those days when he wasn’t already on a ventilator.

Believing the patient had diabetes, Humana also argued that he should have been on ACE inhibitors, basically claiming that all diabetic patients should be on these medications. The vast majority of my diabetic patients are on ACE inhibitors or medications with equivalent benefits, but there is no evidence that they are beneficial for all diabetics (even ignoring the fact that this particular patient did not have diabetes). ACE inhibitors have multiple benefits, including slowing the progression of renal failure. They are indicated when there are very early signs of renal failure, but not when there is zero evidence. While ACE inhibitors are beneficial in those with early renal failure to prevent progression, they can also impair renal function in those who do have renal failure. In the case of this patient the ACE inhibitors likely would have done more harm than good, reducing his already impaired renal function.

Both ACE inhibitors and beta-blockers lower blood pressure, and are commonly used in the treatment of hypertension. However, as this patient’s primary cardiac problem was hypotension, the use of both of these medications could have been catastrophic for the patient.

If the patient really had both diabetes and coronary artery disease then beta-blockers would have been strongly considered. However beta-blockers cannot be used in some diabetic patients as they reduce the symptoms of hypoglycemia, placing some diabetics at risk of having serious hypoglycemic reactions without having advanced warning. The use of beta-blockers in diabetic patients must be decided by a physician who knows the individual patient, not by third parties in some distant place.

Humana thought they were following good medical practices in telling me this patient should be on ACE inhibitors and beta-blockers. Following their advice could have been fatal for the patient. Regardless of what insurance executives like Dave Snow and economists like Arnold Kling believe, treatment decisions must ultimately be made by physicians who have examined the patient and are monitoring the course of treatment.