Communitarian, Medicine, Medicare, doctor patient relationship,physician bonuses, meaningful use, PQRS

The Rise of Communitarian Medicine



The Rise of Communitarian Medicine

© 2012 Dr. Dale Peterson & drdalepeterson.com

Statistics play a major role in American medicine. They are used to determine whether the outcome of a study was due to a particular treatment or whether it occurred by chance. They are used to predict the outcome of an illness such as cancer by looking at the 5 year survival rate. They are used to analyze the effectiveness of public health measures. They are also used to determine treatment goals, such as blood pressure and cholesterol numbers.

Statistics can be helpful in many ways. When using statistics, however, one important fact should be kept in mind. Statistics do not apply to individuals. The statistical probability of experiencing a serious adverse effect from a drug may only be 1 per 100,000, but the incidence for the unfortunate 1 is 100 percent. The 5 year survival rate for a particular disease may be a mere 3 percent, but that means that survival is possible.

Physicians in the United States are rapidly forgetting that statistics do not apply to individuals. They are being bribed to treat patients by statistical norms rather than assessing each person and determining what approach is in that individual’s best interest. While some may be helped, a significant number of patients are being harmed in the process.

In 2011 the Centers for Medicare and Medicaid Services began paying bonuses to physicians who demonstrated “meaningful use” of an electronic health record system. The incentive program, under which a physician can receive up to $44,000 from Medicare and $64,000 from Medicaid, was created by the American Recovery and Reinvestment Act of 2009 (the “stimulus package”). Meaningful use refers to many things, one of which is taking part in the Physician Quality Reporting System (PQRS).

The PQRS requires physicians to report data regarding their evaluation and treatment of patients. To qualify for the incentive bonuses they must demonstrate that patients are being treated according to governmental guidelines.

I was recently consulted by a 74 year-old woman who had received prescriptions for a cholesterol-lowering statin drug and an anti-hypertensive medication. The reason given by the prescribing physician was that her LDL cholesterol and systolic blood pressure were outside of the governmental guidelines and that failure to get them into the acceptable range would jeopardize his financial bonus.

Filling the prescriptions and taking the medications were clearly not in her best interest. There is no evidence that lowering cholesterol is of any benefit in people over the age of fifty and ample evidence that lowering cholesterol after the age of seventy will lower life expectancy. Beyond that, the most significant measure of whether someone is at risk of arterial damage on the basis of cholesterol is the ratio of LDL cholesterol to HDL cholesterol. A ratio of 3.5 represents average risk. The lower the ratio the lower the risk of cholesterol-related arterial disease becomes. While the woman’s LDL cholesterol was 129, above the 100 level needed to meet the governmental guideline, her HDL cholesterol was 101. Her LDL/HDL ratio was a mere 1.27, one of the best I have ever seen. There is no conceivable way in which lowering her LDL cholesterol could be of benefit to her. If she chose to take the drug she would not improve her risk of heart attack or stroke, she would simply place herself at risk of experiencing one or more of the many adverse effects associated with statin drugs.

She had originally come to see me because she was feeling weak and tired and was unable to exercise. At the time of her first visit she was on six different blood pressure medications! Her systolic blood pressure was running in the 150s, above the 140 demanded by Medicare officials, and her diastolic blood pressure was in the 50s and 60s.

If you have been following my articles you know that the risk of stroke and heart attack rises sharply when the diastolic blood pressure falls below 80 and that the risk is increased fourfold if the diastolic pressure is 60 or less. You also know that the risk of dementia becomes much greater as the diastolic pressure falls.

With my approval and encouragement she had been able to discontinue three of the anti-hypertensive drugs. Her systolic pressure was averaging 160 and her diastolic numbers were no longer less than 60. Her energy had returned and she had been able to resume activities she enjoys.

Given the fact that a combination of six medications had been unable to bring her systolic pressure into the mandated range of 140 or less even though they had driven her diastolic pressure to dangerously low levels, increasing the number and strength of blood pressure medications is not in her best interest and could very well have fatal consequences.

Many American physicians have already sold out to the demands of governmental agencies. Nearly all will soon follow as bonuses give way to financial penalties for non-compliance by 2015. I am deeply disturbed by what the future is likely to hold. Physicians who are more interested in pleasing governmental panels than in the well-being of individual patients are unlikely to take a stand against more onerous guidelines.

As the example I have given demonstrates, the current guidelines may not be in the best interest of some individuals. Those responsible for implementing the guidelines have written extensively about the need to ration medical care. They have stated that physicians must change the way they view patients, switching from individualism to communitarianism. It is their goal that physicians cease to ask the question, “What is in the best interest of this individual?” to “What is in the best interest of the community?” I believe it is only a matter of time before guidelines restricting care to disabled and aging individuals appear. Physicians accustomed to marching to big brother’s drum will almost certainly continue to do so no matter what the consequences may be for those who have entrusted themselves to their care.

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