First, Do No Wrong - Continued

In my blog of July 31, 2010 dealing with an experiment in which physicians' clinical notes are posted on the internet so that patients can read them (or possibly anyone whom the patient permits to see the notes can read them).  I mentioned patient and physician self-censorship with the comment that I would come back to the subject.

In my clinical experience, the most common situation in which patients withheld important information because of fear that it would be released to a third party, was spousal physical abuse about which California  physicians were (are) required to contact appropriate government agencies and patients did not want that report to be made. In spousal  physical abuse, there were telltale signs on examination which told the story even when patients' words did not. And I and other physicians would tell our doubly injured patients (physically and emotionally damaged) that we were required by law to report and that we would comply with the law. Should that information also  be recorded in a medical note to which the offending spouse might gain internet access even before the authorities intervened?

Less common patient censored information included sexual practices, sexually transmitted diseases, patient or familial mental disorders, childhood abuse,  alcohol and other substance abuse, and even the eating of food representing different ethnic practices which patients felt would lead to shame if disclosed to the physician or others. Physician inquiries about familial diseases were often responded-to with "I don't know" rather than the facts which (as time revealed) were well-known to these patients.

Physicians may censor information, which they know may lead to patient difficulties (i.e., advise patients to pay cash for certain tests because insurers might use the insurance-billing information, or information provided which might get back to an employer, in a way which might cause patients to lose insurance or their jobs) and make no mention of their advice or the conditions they were concerned about in their notes.

What do my readers think? For or against posting physician clinical notes on the internet? And why?

Cost Shifting: From Airlines to Health Care

The concept of cost-shifting is easy to understand: once upon a time, when you flew from New York to San Francisco, your fare included an edible meal. Then the fare went up. That was not cost-shifting. But when the airline took away the meal and made you buy it yourself or go hungry, the airline cost-shifted dollars you paid for your meal to its bottom line.

In health care, it's a bit more difficult to understand. If you incur a hospital bill and your payer has to pay more for the same services than another payer, part of the costs of hospitalization have been shifted to your insurer (and probably to you if you have a copayment requirement). If the government doesn't pay the full beneficiary bill, based on fancy higher-mathematical calculations (read - "guesses") to justify paying a lower amount, the government has shifted costs to your insurer and to you. If your HMO says that you have to leave the hospital on the second day after hospitalization, when you still are pretty sick and can't take care of yourself, and your family has to stay home from work to take care of you, the HMO has shifted costs from itself to you and your family and perhaps your employers. And if the uninsured in the emergency room can't pay their bills, you and your insurer and the government will have to subsidize their care. Neat, huh?

Now, let's take it a step further. If you work for a small employer and have several co-workers who have incurred high health care costs, the premium for health insurance at renewal time may go up disproportionately, making your employer look somewhere else for coverage. Not only has the initial insurer rid itself of what it considers an adverse actuarial risk, but if another insurer takes on your company, the first insurer may have moved an adverse risk to a competitor. A number of years ago, when an aggressive national HMO took on bartenders (and, if my memory is correct, grave-diggers) in one city, its competitors were joyful: they knew their insurance experience with those occupational groups was awful and were glad to get rid of them to the new competitor in town. Incidentally, the HMO eventually went into bankruptcy. Apply the same way of thinking to the decisions of hospitals to move from high-cost low-reimbursement areas (center city) to low-cost higher reimbursement areas.

So, in health care, cost shifting is a way to increase profits, move costs to someone else's pocket, disadvantage your competitor and game the system. Cost-shifting is a monetary concept, not a quality-related one.