- Del Meyer, MD - http://delmeyer.net -

Medical Practice & the Geriatric Patient

Not to optimally relieve pain is tantamount to moral and legal malpractice according to Dr Edmund Pellegrino in the May 20, 1998, issue of the Journal of the AMA. New York’s Governor George Pataki has signed a bill eliminating much of the red tape doctors encounter as they prescribe painkillers for severely ill patients. Doctors will use a standard single prescription, rather than the current triplicate form, to prescribe controlled substances such as narcotics, barbiturates and amphetamines. The pharmacist will electronically relay that information to the state. To allow doctors to prescribe higher doses of medications and relieve their anxiety, an “addict,” previously defined as anyone who habitually used a narcotic drug, has been redefined as a person who unlawfully uses a controlled substance. And a habitual user is redefined as someone who repeatedly and unlawfully uses a controlled substance.. . . Looks like New York is more sympathetic to doctors and their patients than California.

Surviving old age includes avoiding disease. After morning rounds, my professor of neurology would always take a break with the senior students in the washroom before discussing the day’s cases. He made a point of washing his hands before he emptied his bladder contending that with the type of patients at University Hospital, you never knew what diseases you might pick up. After his bladder was decompressed, and the students had finished washing their hands, he once commented while he was washing his hands a second time, “I don’t know why I’m washing them after I go. That was the cleanest thing I’ve handled all morning.”

HMOs scramble to cut Medicare as they are allegedly losing money on the old folks. Some HMOs are actually pulling out of a number of counties and large geographic areas. HMOs are eliminating pharmacy benefits in some counties and increasing the copayment in others–sometimes to 50%. They continue to treat doctor’s visits as almost valueless–usually only a $5 copay. Some HMOs even brag about no co-pay for office visits. It’s just a free-for-all at the doctors’ trough.

Meanwhile the National Health Service in the UK, celebrating it’s fiftieth anniversary, is toying with the idea of a £10 (~$18) copayment for office visits and a £50 (~$90) copayment for a day in the hospital. It took them 50 years to figure out that “free” medical care is too expensive to afford and that they must make patients aware of the costs at the first interface with healthcare. Will Americans slog through the same fifty years of experiments, or will we take note and implement a significant copayment for each office or hospital visit or stay?

Governor Lamm of Colorado caused outrage when he announced that not only were we doing too much for old folks, but they had a duty to get out of the way for the next generation. Now comes John Hardwig who says that modern medicine and an individualist culture have seduced many to believe that they have a right to health care and a right to live, despite burdening their families and society. His article in the Hastings Center Report describes the circumstances under which we have a duty to die.

Mildred Culp, a syndicated columnist, reports that 2/3 of physicians making less than $50,000 per year are considering career changes. However, only half of the physicians earning more than $125,000 feels the same way. Sheryl Gay Stolberg, in the New York Times, writes that one of our own board members has never earned $100,000. The number of physicians who put $300,000 on the books, of which $200,000 eventually comes in, and who may take home $100,000, seems to be rising. Culp says physicians may opt to become executives with MBAs where the salaries generally start at $100,000.

Dr Charles Krauthammer, a columnist for the Washington Post Writers Group, declares that doctors are drowning. He says people believe that doctors having a hard time means they’re having a hard time making the payment on their yacht or the mountain chalet. “What I’m talking about here, however, is the money to keep a practice–perhaps your doctor’s–from going bankrupt.” He says that lawyers, accountants and consultants of every ilk bill by the hour, not just for office visits, but for phone calls. Doctors are an anomaly, who traditionally have given away phone consultations for free. To keep practices from collapsing, he suggests a nominal telephone consultation fee of, say $1 a minute for a nurse consultation and $2 a minute for a physician. At a 20% copay (20 cents a minute), he figures it’s not much different than making a phone call “to Aunt Sally in Topeka.” Krauthammer suggests we call it the Physicians Rescue Act of 1998.