Saturday, April 12, 2014

United Healthcare Strikes Again!

As I said in a previous post,*  United Healthcare is the worst in the rogue's gallery of modern health insurers. Last week, I got another confirmation of this fact. One of my patients came in for his history and physical exam and had not gotten his blood drawn in advance. Why? Because United Healthcare will not pay for labs that associated with a history and physical unless they are drawn on the very same day as the visit.

When my patients come in for a History and Physical, I try to have them get their labs drawn before they come in. That way, we can have a face-to-face talk about what diet might lower their cholesterol or why they might be anemic, or whatever. I can also get any follow-up labs drawn on that day. It makes everyone's life easier, and, sometimes, it even saves the insurer money. Some lab results might require a face-to-face discussion instead of a phone call, and, if I don't have the labs on the day of the physical, the patient will have to come in for another visit, which means another bill to insurance.

I don't know why United Healthcare does this. Probably, some deranged actuary has convinced them that it makes financial sense, even though none of their rivals appear to think so. I don't believe that United Healthcare is consciously vindictive, but they sure do good impression of it.

Saturday, April 5, 2014

Comment on "How Doctors Choose to Die"

This reminds me of one of my last nights in residency. (Details changed to protect privacy.) As I signed on, I saw that I would be responsible for a very sick, 100-year-old man. I had a sinking feeling that he was going to die that night, and, if he did, I would have to do horrible things in a fruitless attempt to bring him back. He was demented and unable to speak for himself, so I told the family what I thought might happen. I asked their permission to allow him to die if it came to that.

They refused. He was from a foreign country, and his family mistrusted our medical system, since, where they were from, doctors had abused people like them. They weren't about to let a man in a white coat stint on their venerated grandfather. So I went to the call room and tried to sleep, fearing the inevitable beeper interruption.

A few hours later, it came. The 100-year-old man had stopped breathing, and his heart had stopped. Someone had 'called a code.' I came downstairs to find my team around his bed. Looking at each other sheepishly, the interns, nurses, and I stabbed him with a large needle to place a central venous line, pounded his brittle ribs, and shocked his withered heart into a few more beats. As I jammed the endotracheal tube down his throat as gently as I could, his dying eyes glared at me, and his face contorted in a rhythmic, reflexic scowl of brain death. His heart stopped again. Finally, I decided we had played the charade long enough. I pronounced him dead.

I cannot dismiss the effect the family's collective history had on their priorities. Perhaps there was no other way for them, but, to me, this whole effort had been a horrible crime.

Calling a code is not always pointless. Chances of survival are bleak, but a previously vigorous person who makes it through a code has a reasonable chance of walking out of the hospital on their own two feet and in good mental shape. On the other hand, once someone is frail and fatally ill, cardiac resuscitation is practically useless.

Resuscitation for all cardiac arrests is still the default in fact, though not in law (at least in my state). This is for bad and good reasons. Doctors are afraid of lawsuits, and some salvageable lives have been forsaken out of prejudice or base motivations. A family's wishes cannot be dismissed lightly.

But, if you don't want this to happen to you, please plan for this. If and when you are fatally ill, make sure everyone in your family understands that you want to go peacefully when it is time. If you don't, some prodigal son might return and demand that everything be done to 'save' mom to assuage his own guilt. Or your spouse, not knowing your wishes, might be unwilling to deny you the 'best' care. Give them permission to let you go.