There is no storage shelf of organs awaiting handout after insurance company approval.  At any given time, there are 100,000 Americans waiting for donated organs.  Due to a chronic shortage, only a small fraction of those will ever get a transplant.  For liver transplantation, there are more than 17,000 people on the waiting list with only about 5,000 liver transplantations available each year. After years of experience, there has evolved a fair but painful system to deal with transplantation issues.   The transplantation selection process takes place thousands of times a year by volunteer committees trying to fairly pick the best patient for each donated organ.

The goal of transplantation is to give replacement organs to patients with the best chance of survival and a long productive life.  With major breakthroughs in surgical technique and anti-rejection drugs, this miracle can be delivered.  In otherwise healthy patients, the one-year survival for liver transplantation approaches 90% and five-year survival is over 75%.  Patients who are extremely sick with multiple organ failure or other diseases are often denied. It’s not to play God, but a necessity to give the limited supply of donor organs to patients with the best chance of survival.
 
Deciding who needs a transplant and how to procure donor organs offers a major ethical challenge.  There has evolved a process of compartmentalization of each step of the transplant evaluation.  The process starts when the patient’s doctor believes a transplant will help.  A formal Transplant Committee reviews the request and determines if the patient will be put on the transplant waiting list.  It also assigns a priority score reflecting the urgency of the need.  The patient’s doctor usually does not sit on this committee because each doctor should naturally favor his own patient.  The transplant committee may be separated into organ donation and procurement sections.  The procurement section does public education for the need for organ donation and sponsors events  showcasing transplant recipients.
 
After the transplant committee has carefully reviewed each case, it decides whether or not to place the patient on a list of those awaiting a transplant usually through central organizations like the United Network for Organ Sharing.  The transplant committee also creates a score for each patient indicating how critical the need is.
 
Insurance companies including Medicare have a less well-defined role in the transplant process.  They don’t directly decide who needs a transplant or who will get one.  Their decision is to agree to cover the cost of the transplant if they have a contractual obligation to do so.  This does indirectly exert great influence on the transplantation process
Cynics will say insurance companies only decide transplant issues on the basis of economics.  Proponents say decisions are necessary to spend money wisely and to keep health care cost down.  Bankruptcy of the medical system would occur if every possible transplant need were met without regard to outcome.
Many would argue that the transplant system crisis shows the need for government control.  Statistics don’t support that.  Countries with government-controlled health care appear to do far less transplants than the United States. The United States is the transplant leader in the world doing about 52 kidney transplants per million population.   Canada does about 33 kidney transplants per million, Europe does only about 27 per million, and Asia does only 3 per million.

Many practicing physicians perceive a major disconnect with the academic community over this issue. In the rarefied atmosphere of academic medicine there is frequently an abundance of physicians. Many patients have multiple caregivers with medical students, interns, residents, and staff physicians assigned to them. Also, in a few large urban areas there is an oversupply of physicians. But in most of the United States there is a chronic physician shortage, which is compensated for by the available physicians working long hours.

Residency training offers the opportunity to learn to condition yourself to combat fatigue and improve performance under stress. Many perceive the training period to be the ultimate boot camp preparing physicians to serve under the most adverse conditions. To adapt a phrase from the military, practice like you train, and train like you practice. For most physicians, artificially limiting work hours is not a realistic simulation of the real world. You can’t train for a marathon by limiting training sessions to a couple of miles. Artifical limits on training hours would condition young physicians to expect the same conditions in their future practice.

In the real world, much of medicine operates in the crisis mode. There is no obstetrician who has not worked over 30 continuous hours doing multiple complicated and unpredictable deliveries. There are not many trauma surgeons who have not worked over 30 hours treating mass causalities from sequential or large accidents. Limiting work hours in training seems like a good idea, but until it translates to an adequate physician supply to staff real world challenges it will be largely meaningless and counterproductive.

Everyone would agree that under ideal circumstances a physician should be completely rested and alert. We would also agree that in a crisis, physicians should not abandon patients because of arbitrary work rules. The problem with work limit rules is that much of medicine is practiced in the crisis mode. Until the physician manpower shortage is solved, physician work limits are an empty promise.

The new group moves away and starts a place using new ideas. Most of the time this new group fails but sometimes they are successful and the new place becomes much better than the old place.

The new place thrives and becomes powerful and strong. They resist outside influences but eventually need people from the old place to help out. People from the old place flock to the new place because of better conditions. The new place is glad to have the help.

The old place may feel threatened and try to take over the new place by force. This usually fails because the new place is stronger and has better Technology. The new place may also try to take over the old place and exploit its remaining resources.

The people in the new place become very satisfied and happy. They become soft and complacent and no longer willing to fight to protect their way of life. People from the old place take over more and more of the affairs of the new place. Eventually the people from the old place feel they are being exploited. They revolt and usually take over the new place.

The old group now starts running the new place like they ran the old place. Things get bad again. Eventually a group of people gets unhappy about the way things are and starts causing trouble. The story repeats over and over again! Just look at human history.

1. A doctor has a name.
.. A health care provider has a number.

2. A doctor makes decisions based on years of training and experience.
.. A health care provider must call for authorization and approval.

3. A doctor attends those in need.
.. A health care provider requires a valid insurance card.

4. A doctor prescribes the best drug available.
.. A health care provider must use the insurance company formulary.

5. A doctor brings comfort to the patient and family.
.. A health care provider cannot bill for these services.

6. A doctor does what’s best for the patient.
.. A health care provider must follow insurance company guidelines.

7. A doctor delivers care exceeding expectations.
.. A health care provider delivers the services specified in the
.. contract.

8. A doctor is rewarded by the patient.
.. A health care provider is reimbursed by the fee schedule.

9. A doctor is chosen.
.. A health care provider is assigned.

———— The Editor

Visit Pennsylvania Hospital

Visit Johns Hopkins Medical Institutions

Children’s Hospital of Pennsylvania

Recognizing the special needs of sick children, The Children’s Hospital of Pennsylvania opened in 1855. This followed the groundwork of Dr. Benjamin Rush, a signer of the Declaration of Independence and Professor of Medicine at University of Pennsylvania: 1789-1813. Dr. Rush had a special interest in “Diseases peculiar to children” and is considered one of the founders of the specialty of Pediatrics.

Visit Children’s Hospital of Pennsylvania

Bellevue Hospital

The first health clinic started in New Amsterdam as a infirmary for soldiers and slaves. It was established in 1658 by Jacob Varrenvanger. In 1794, the original facilities were inadequate to deal with a yellow fever epidemic so a new hospital was built. An estate was purchased about three miles from town, to isolate these patients. The “Belle Vue” mansion was used as a pesthouse and its name was given to the hospital built on this site.

The staff of Bellevue Hospital introduced small pox vaccine to New York and performed some of the first vascular surgery cases in America. The hospital was also the site of the first hospital-based ambulance service. Hospital based horse and buggy teams were sent to area disasters. The first school of nursing in America was started at Bellevue in 1873.

Visit Bellevue Hospital

In our age, health care has become one of the top issues to all citizens. It ranks with concerns for defense, education, and transportation. Imagine, if through some crystal ball, the founders of the country could have foreseen the new importance health care has assumed in our society. Perhaps we would have seen the creation of a special branch of government called the “Supreme Doctors”. This act would have recognized that medicine is so complicated that many years of specialized training are necessary to make intelligent government decisions about it.

The “Supreme Doctors” would be the highest medical authority in the land. Its members would be appointed for life by the President of the United States and chosen from outstanding members of the medical profession. The “Supreme Doctors” would have equal footing with the legislative, executive, and judicial branches of government. It would review all legislation for its public health impact. The nation’s health would always be placed as a top priority. Any action deemed detrimental to the health of the nation would simply be declared unconstitutional. The medical liability crisis would have never existed. The cigarette industry would have been closed down the day after the first Surgeon General’s report in 1964. Medical research would have been placed at top priority by total constitutional authority. Preventative vaccinations, seat belts, and health screenings would have all been mandated years sooner by the “Supreme Doctors”.

Every citizen of voting age would be subject to periodic calls for “medical duty”. People would be chosen at random to serve a one week stint working in an assigned hospital or clinic. People would be proud of this activity and consider it their civic duty. Any patient unable to pay for his own medical care would have a public physician appointed by agents of the “Supreme Doctors”. This public physician would enjoy complete control of the case and could use the full and unlimited resources of the United States government in delivering the necessary medical care.

Many things would be better under the control of the “Supreme Doctors” but other things could be less than ideal. The entire health care system would be tightly controlled by doctors who would supervise workers freely supplied by the government. Utilization review, managed care, HMO’s, and prior authorization might be terms that never existed.

There would be no alternative sources for health care. Everything, including the taking of a person’s blood pressure would be done under the direct supervision of a doctor. It would be a federal crime to deliver any form of health care product or advice without a doctors written endorsement.

Doctors would have complete authority over all medical licensing and professional discipline. They would enjoy complete immunity for any medical opinion. Impeachment by a panel of physicians would be the only way to remove the “Supreme Doctors” from office. There would be a natural tendency to abuse power. There would be a strong temptation to make it illegal to publicly speak against another physician. Disgruntled patients could be prohibited by law from any negative comment about a disciplined physician..

Thoughts about this system are far fetched but don’t completely dismiss them. In the future, the health of our citizens could become so important to society that they will preferentially elect those with a background in medicine. Its sounds like science fiction now but in the future the legislature could be composed predominantly of doctors!

There’s no question the health of our nation has become a paramount issue. The time of the “Supreme Doctors” may yet come.

After having the prescription filled, your pharmacist asks if you want to purchase the supplemental “Pill Insurance”. Noticing your confused look, he offers the following explanation.

“This will automatically cover serious adverse reactions caused by the medicine.” He looks up the drug in the premium book and finds a 1 in 10,000 risk of serious side effects for this medication. At first you are alarmed, but after some reflection you conclude that these odds are more than acceptable for the chance to return to a normal life.

He offers to quote a price for the insurance.

“For $1,000,000 coverage the rate is $500.00 for this prescription. If you want
$10,000,000 it will be $5000.”

“Wow that’s very expensive”, you say. Using some 6th grade math you ask why something with a 1 in 10,000 risk doesn’t cost $100 for $1,000,000 in coverage. The pharmacist explains that 80% of your premium is needed to pay the operating expenses in the system. The premium cost includes expenses averaging about 20% for insurance company and agent fees, 30% for your plaintiff lawyer, and 30% for the drug company lawyer. These “expenses” make the insurance premium cost about 5 times the desired coverage cost. “Its all been sanctioned by the government as a compromise between the insurance companies, drug manufacturers, and the trial bar.”

“Doesn’t my existing health and disability insurance cover most of the expenses of a drug reaction?” you ask.

“Why yes but this supplemental insurance guarantees you an additional large fixed amount to aid your recovery.”

After pondering the offer you conclude that it is prohibitively expensive and besides you just want to get well and not become a student of insurance underwriting.

“I’ll decline any insurance”, you state.

“Oh, you can’t do that”, he says. “You can decline the supplemental coverage but you have to pay the basic risk coverage. It’s already including in the high price of the drug. The only way you can avoid this expense is to move to Canada and buy your drugs there.”

“What’s the difference between the basic coverage and the supplemental coverage?”, you ask.

He replies, “The supplemental coverage guarantees payment but the basic coverage is like a lottery system. Only a small percentage of people ever collect under the basic coverage plan but the awards can be huge - in the $10 to $200 million dollar range. But to win you have to prove the scientists that made the drug are greedy criminals who knowingly manufactured a faulty drug and sold it to you just to make a profit. The chances of winning are small but the awards can be tremendous.”

“This is too complicated for me!” you reply. As most people do, you pay for your prescription and walk out.

Neurosurgeons are considered by their colleagues to be the “Green Berets” of medicine. They have one of the longest training programs and perform some of the most technically difficult surgery. Neurosurgeons frequently operate against long odds for success. The nervous system is vulnerable to trauma and damaged tissue has only a limited ability to heal. Many of their cases meet the category of “medical disasters”. Thankfully these cases are interspersed with many patients who have a complete and amazing recovery. Because of the characteristics of their specialty, neurosurgeons are among the most frequently sued doctors in America.

Surprisingly, our judicial system has been added to the long list of obstacles facing neurosurgeons in restoring the health of their patients. The State of Florida recently passed a constitutional amendment titled “Public Protection from Repeated Malpractice”. This amendment prohibits medical doctors who have been found to have committed three or more incidents of medical malpractice from being licensed to practice medicine in Florida.

During the past 25 years, 26 physicians have provided the majority of neurosurgery care in Palm Beach County. According to data derived from the “Professional Liability Closed Claims” database maintained by the State of Florida, there have been 75 malpractice claims lost by this group of neurosurgeons. The dates of occurrence of these claims range from 12/24/74 to 11/14/2001. The dates of settlement range from 7/8/77 to 11/21/2003. The interval from occurrence to settlement ranges from 0.9 to 10. 4 years with an average of 4.5 years. This database does not monitor lawsuits won by the physician or claims that are still in progress.

22 of the 26 neurosurgeons in the county appear in this closed liability claims database. The first neurosurgeon to practice in Palm Beach County had no recorded claims in the database. Several of the newer arrivals in the county also show no closed claims to date. but pending lawsuits will become a certainty.

The range of malpractice claims lost by the county’s neurosurgeons is from 0 to 15 claims per physician with an average of 2.9 closed claims per physician. Since previous studies by the Physician Insurers Association of America have shown physicians win about 4 out of 5 malpractice claims, an estimate of the total number of malpractice claims defended by these physicians would be in the several hundreds (about 400 cases using the above information). The total payment for the 75 closed claims in this group was $21,010,207. The average claim was $280,136. The largest claim was $2,500,000.

The average neurosurgeon in the county appears to accumulate a malpractice claim every one to two years and loses a claim every 4 to 5 years. The time spent and cost of defending these lawsuits is unknown but is certainly significant.

Of the original group of 26 neurosurgeons, 2 are believed deceased, 2 are retired, 4 have only limited practices, and 7 are known to have left the area. This follows the trend for many neurosurgeons to leave the county after only several years of practice. This is particularly critical because the county has had significant and steady population growth including a marked increase in the need for medical services of an aging population.

Data from this study clearly shows that the practice of neurosurgery in Palm Beach County Florida will become severely limited or impossible as long as the existing medical liability system remains intact and if the recently passed constitutional amendment is upheld and enacted.

_________________________
By Joseph F. Phillips, M.D.
WMed

References:

1. Florida Department of Financial Services, Professional Liability Closed Claims, Web Address: http://www.fldfs.com/Data/Liability/disclaimer.htm

2. Physician Insurers Association of America, Web Address: http://www.thepiaa.org/public_home.asp

(c)2005 Copyright. WMed. This article may be reprinted or quoted if reference is given.