From Medical Decision-making to Medical-cost-comparative Decision-making.

WHEN A PHYSICIAN GATHERS A PATIENT’S history, runs diagnostic tests and performs an evaluation, he or she is performing medicine’s most fundamental act: medical decision-making. Patient care is all about physicians bringing their education, training and personal experience to bear with a particular patient and his or her particular symptoms, disease or injury. Frequently, the course of treatment is clear, for the cure immediately follows the diagnosis. Other times, there may be a range of treatment options from the tried-and-true to newer, more recent interventions, surgery or medication. The question for the doctor is: “What is the best plan for this patient?” This is as it has been and as it should be. This is the defining act of the medical profession. Simultaneously, we Americans are used to getting the care that we want. More specifically, we are accustomed to obtaining the care that we choose with our doctor’s recommendation and explanation. Well-insured patients, including Medicare beneficiaries, are comfortable with a health care system that honors (and reimburses) according to the decisions made between a physician and patient. In our tradition, care is planned, implemented and paid for because it is what the doctor ordered. Historically, neither the patient nor the physician has given much thought to the payer (whether private insurance or Medicare) in the intimacy of the exam room. This changed somewhat with the dawn of managed care in the 1990s, but as reimbursement reform advances, payment (or refusal of payment) will increasingly become a determining factor in treatment. Care that is thought best will no longer necessarily be care that is reimbursed. This already is becoming more commonplace on a patient-by-patient basis, creating confusion and anger among patients and physicians alike. As difficult as all of this may be for physicians and patients who are denied reimbursement for the treatment they planned, we have yet to see the true impact of reimbursement reform. In the not-too-distant future it is likely whole treatment options/technologies will be taken off the list for Medicare reimbursement — leaving those providers no option other than to seek full payment from the patients themselves, which of course is unlikely. Worse still, if Medicare deems a treatment not sufficient for taxpayer dollars, private companies likely will follow suit. Some doctors may see this coming; patients and the public certainly do not. As a country, we are about to see a widening gulf between medical decision-making and care actually received. This promises to be a challenge to individual physicians and physician leaders alike, so it may be helpful to review how we got to this point.