When the tail wags the dog

Have you ever had a conversation that rattles around in your head for days? Maybe, it changed what you thought you knew about the world.  Perhaps the ideas or comments did not make any sense.  I had a discussion last week and it seemed that logic stood on its head.  The means was defined by the end, with no connection to the beginning, or more exactly, the tail wagged the dog.

A skilled, respected physician and I were considering a challenging case.  The patient had an unusual problem and the therapy was not obvious. We boiled down the therapeutic possibilities to three.  The first choice was a standard, the most used, best-studied treatment. The second was a little radical with a small track record, but had been reviewed in two publications.  The third made theoretical sense, but had rarely, if ever, been used to treat this disease and we could find no supporting research.

I was in favor of the first treatment, the old standard.  My colleague, who is naturally more aggressive than I, suggested the last, the unproven, despite a lack of data.  I said, “But, there is no information, no research, no real proof it could work.”  To which he countered, “Maybe, but Medicare has approved it and will pay for it.”

This is a staggering piece of illogic.  It suggests that medicine has evolved to the place that doctors take their lead in making decisions from insurance companies, in this case the federal government’s Center for Medicare & Medicaid Services (CMS).  Payment “approval” is the same thing as being medically appropriate.  This doctor did not say, “Well, I think the third choice is right because it has a real chance to work with the least side effects, and, by the way, I think CMS will pay for it.”  Rather he said that primary reason to choose a medically questionable treatment is that the government has deemed it worthy, and therefore agreed to lay-out precious dollars.

Ergo; the therapy is right, because government and insurance actuaries can never be wrong and guarantee of payment is the same as guarantee of clinical benefit.  Money = cure.

Apparently, this doctor, like many others, has been beaten down so long by the insurance industry’s pre-approval process, the constant need to beg an anonymous insurance representative to give that warm and fuzzy “OK” to the doctor’s care, that things have gotten flipped in his head.  Now, at least some of the time, we do not start with what the patient might need, but what the insurance industry will support, and choose therapy from that restricted list. 

Once upon a time, the differential was a list of possible diagnoses, which might explain the patient’s symptoms.   Then doctors studied the list to determine the actual disease and then, and only then, the physician picked possible therapies.  Now the differential is a limited number of the treatments which have been chosen by the insurance industry, possibly because they work and definitely because they are what the corporation, stockholders and taxpayers can afford.

There is a warning here for patients and doctors.  If your doctor is recommending a treatment, confirm the logic that lead to the diagnosis and understand the data. Be careful that the therapy is not second best, because the indicated treatment is not on the insurance company’s “formulary.”

More important, doctors must endeavor to command the logical high ground, based on a system of medical analysis as old as Hypocrites, which is designed to produce the best care.  Only when we have made the diagnosis and our recommendation of the best treatment, should we play the insurance game. We must end at the “formulary,” not begin, and we must be ready to fight for payment for what is medically necessary and right.  If we make our decisions based on solid science, we will eventually prevail.  Otherwise, we will find that we are simply dogs, being wagged by our tails.


  • At the end of this month, if the government is not made to see reason, that doctor may not be able to afford that patient. The government may not effect another "patch" to postpone cuts to what your colleague will get for treating Being ready to fight is good, but some of us are sick now.And we're paying for Medicare from our social security. And this patient should be thrilled to have a doctor who even takes Medicare! Last week a friend recommend a doctor. I called. He,does not take Medicare. I asked my surgeon to suggest another doctor who does. He cannot think of a single one. If the payments to doctors go down, where will we go?
  • So true....for low income persons this is nothing new.....
  • Kathleen Denny
    But the larger point here is that, to many docs, insurance or insurance fund reimbursement dictates treatment, not medical benefit or need. That is distorted, but a result of insurance administration of the medical-care-for-profit system in the US. That will only deepen with the ACA regulations - aka Obamacare. And this observation is coming from a supporter of universal health care. Staff at the medical office of my opthalmologist tell me that they could run that office with one person if they did not have to deal with the multiplicity of insurance companies and plans, as well as all those routine delays and denials. Instead they have 3 times that many doing what is necessary, but entirely unproductive work.
  • D Someya Reed
    This is a rather daring post and I'd tip my hat to you if I wore one. I must agree with the others that things are likely to get worse with ACA. However, you left out a couple other things that have been taken out of their original context and given additional (reimbursement) importance by both insurers and the government: Evidence-Based Medicine (EBM) = Cure Standard of Care (SOC) = Cure Evidence-Based Medicine has been degraded into number of peer review papers and number of participants in clinical trials as a means to strengthen "efficacy" dollars. We've all seen how some of those papers, trials, statistics have been purposely skewed all the way to falsified. Standard of Care has NO medical definition, only a legal one. I'll never forget the doctor who told us that there was no more he could do because the "standard of care" and the hospital (bureaucracy, aka the insurance company) tied his hands to allow him to do only what the hospital could definitively get reimbursed for. This is not "a jab" at you but I suspect it won't be long before we can add Electronic Medical Record (EMR) = Cure to that list. Then if you don't have EMR, you won't likely get reimbursed. Anything that can be written as an acronym seems to gather far more importance than it should. Of the three college buddies and I who began our medical school path, "how much money we could likely make" was the driving force for 75% of our quartet. That same 75% were willing to pay others to do their classwork for them. Kind of soured me on the whole thing. If I may say, there is an interesting article from last year on one of your links (Kevinmd.com) titled, 'Medical malpractice: Equating standard of care to best practice.' It's worth a read.

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