Protocols versus Individualized Care

By Marcy Zwelling-Aamot, MD FACEP

We have started to see the downside of government interference in the patient/doctor relationship.  No surprise, it is not what doctors have warned their patients about.

Recently United HealthCare announced a new way to pay for cancer treatment —  “The new fee is meant to encourage doctors to follow standard treatments rather than opting too often for individualized and unproven courses of therapy.”  (New York Times, 10/19/2010).

Like every relationship, the patient/doctor relationship is complex.  But in medicine it is further complicated by a financial relationship that removes the patient from any decision making process. Third-party payers, particularly the government, distorts any opportunity to offer direct accountability and responsibility for our work.

The government payer system is predicated on a pot of money that must be divided among all doctors.  It is further complicated by political pressures.  In the end, doctors who do procedures have always been paid much better than those of us who only have our brain and time to sell.  Most private insurers follow the government when it comes to doctor payment.

Oncologists have never been paid for their consultative services.  To keep their offices open, they have had work directly with pharmaceutical companies to save their patients’ lives, keeping large inventories of drugs in their office at huge expense.  With this as background, medicine and genomics has advanced to the point where we can create individualized treatment strategies in cancer management that saves our patients’ lives.

Protocol management has dominated oncology therapy.  Cancer therapy is so risky, protocols move slowly to prove themselves successful. But, our thinking about cancer management has changed with the evolution of genomics.  We have proven that some patients are not genetically able to metabolize certain therapies. Now individual patient management dominates the discussion and lives are being saved.  No sense in wasting time and money on treatment that brings only risk for a specific individual patient.  This is a huge advancement.

Now, insurers, in order to save money, are asking my colleagues to participate in nothing short of blackmail.  An oncologist may get paid a bonus to ONLY use the protocol management rather than individual treatment strategies when treating patients with cancer.  No one anticipated things would disintegrate so far so fast after the passage of “ObamaCare.”  Who could dream up such a nightmare?

No, there are no death panels.  And, technically, the government has not mandated that patients not see “their” doctor of choice.  Rather, they have subversively applied blackmail to the marketplace of life and death.

The difficulties that result from a patient/doctor relationship that is complicated with third-party payers are the root of many of the distortions that add cost and a “dys” use of our limited resources in the U.S. healthcare delivery system.  This subversive interference with complicated life and death decisions demonstrates the immediate need to repeal ObamaCare in order make the right reforms.

The first reforms need to be about solidifying what is best about the delivery of health care in any system and that is an uncompromising trust in our relationship with our patient.