Friday, November 15, 2013

An ICD: A $30,000 mistake that shows what's wrong with health care

So I previously wrote about a patient of mine who got an Implantable cardioverter-defibrillator (ICD).  To recap, he was a 92 year old gentleman, with metastatic melanoma (choosing not to pursue chemotherapy), Class 3, Stage D heart failure (end stage CHF) and worsening frailty with a fall and minor hip fracture (no surgery required).  When he was in the hospital for a CHF exacerbation, his ejection fraction was found to be less than 30%.  When someone's ejection fraction is less than 30%, they are at increased risk for sudden cardiac death and insurance will cover the cost of an implantable defibrillator (ICD).

In my previous post, I discussed the utility of an ICD for this patient.  To summarize, his cardiologist had visited him in the hospital (for a CHF exacerbation) and told him an ICD would "help his heart."  The patient understood this to mean that it would help his heart pump and he would feel better.  The doctor meant it would help restart his heart were he to die of an arrhythmia (which was not something the patient was trying to avoid).  When I saw the patient, his wife and daughter, listened to their goals and explained this to them, they realized it was a mistake and they wanted it shut off.  The patient actually wanted to sign on to hospice, prioritize having a peaceful death and feeling as good as possible.  None of these could be accomplished by an ICD.  In fact, an ICD would be an obstacle.

Geriatricians (apparently), are known for complaining about the health system, and well, yes, I am going to do that.  So what did this "oops" cost?

Well the hospital gets a fee of $26,000-30,000 for the 10 year device.  Some of that is profit.  Some goes to the device manufacturer.  The consulting cardiologist gets paid a fee of about $100.  The cardiologist inserting the device gets paid a fee of about $1,500.  I get paid $80 for having a 45 minute conversation with the patient, wife and daughter, to explain the risks and benefits, discuss goals and help come to a shared decision about the appropriateness of an ICD.

Again, I get paid $80, everyone else gets >$30,000.  For the "oops," everyone keeps their money and profit  No one has to pay anything back to Medicare. The hospital, the device company and the proceduralist make out like bandits.

Reimbursement needs to change in order to achieve good quality care for patients and minimize waste.

Specialists who do procedures get paid too much (yes I said it) and need to be held accountable for wasting resources.

Somehow I (and geriatricians in general) need to get credit/paid for helping patients achieve their goals through appropriate medical interventions and saving money while doing so. What would have happened if I had met with the patient before the placement of the ICD so that when the cardiologist suggested it, he said no?  The hospital would have lost money, the cardiologist, the proceduralist and the device company would have lost thousands.  Medicare would have saved >$30,000 but none of that would have been credited to me or even recognized that I had a role.  Everyone gets paid thousands for a 2 second statement "this will help your heart," but I get paid $80 for a 45 minute discussion.  In other words, guiding the medical care that a patient gets, to make sure it is appropriate, does not get reimbursed.  Saving money (not that that is necessarily the main goal but it's not a bad secondary goal), is also not reimbursed.  Doing more, risking more, spending more gets reimbursed tens of thousands.  This is why sometimes older adults feel like they are on an express train of medical care that they can't exit.

Good communication should be reimbursed.  It leads to better care.  It is a skill just like putting in an ICD or consulting on a patient or making a device.  I would argue that for this patient, the key skill he needed was communication.

What is wrong with health care in the United States is how medical care gets reimbursed.  They system is geared to providing inappropriate, useless care.  And nothing being proposed in Washington is changing this disaster.


bnug said...

Amusing that there's an ICD ad under this blog entry

PhillyLady said...

I would love to believe that wise and heartfelt statements such as those Dr Uy has the courage to make would receive the broad exposure they deserve. These are crucial conversations, too rarely encountered, unless you (and/or your family) are lucky enough to have them with geriatricians such as Dr. Uy.
My husband and I were guided through my husband's Alzheimer's disease until he passed away, in peace. I will be eternally grateful for the care and compassion we both received.