Tuesday, October 4, 2011

Who Will Be Liable

The coming change for doctors is payment reform. For patients, could it be liability reform?
There is about to be a tectonic shift in how medical care is delivered, paid for, and controlled. Over the course of the next two years, if projections are correct, doctors will be forced to line up in teams (accountable care organizations or ACOs for short) for the purposes of efficiences and cost savings. These same forces likely will shift the equations of how clinical decisions are made.Those ACO derived efficiences that may save money are also supposed to free doctors to used evidence based medicine to make clinical decisions. Thats not how we make decisions now. Currently we collaberate with patients, hear their story, examine closely, make a provisional diagnosis, then talk through evaluation and treatment choices with the patient. There may be factors that influence us to move forward with more agressive evaluation that might be clinically called for. An example might be a middle aged man who sprains his back, doesn't get better in a few days, comes to the doctor mainly because he's worried his persistent pain may represent something more serious like cancer. While the chances of that are remote, he and his doctor may choose to go ahead and get the back xray at day 4 of pain just for reassurance. Not so with evidence based medicine. You see, good, scientifically based studies show that 98% of low back pain gets better  within 2 weeks regardless of evaluation and treatment choices. That's evidence. So, with evidence based medicine, the doctor or ACO Gods may choose to not allow xrays for this patient until or if he has waited two weeks for it to get better. A money saver, true, because if this evidence is forced on a large population of patients, thats alot of xray dollars saved. But what if the patient is an exception, and actually does have cancer. Right now the fear of potential lawsuit influences doctors to shade their plans in the direction of patients desires just in the remote chance cancer is present, thereby dodging any liabiity. With coming reform, as long as a doctor performs within evidence based guidelines, he likely will be exempted from laibility regardless of the outcome. Is this a good change?