Breaking The Rules For The Sake Of The Patient
Nearly 40% of physicians surveyed by the Institute of Ethics for the American Medical Association reported using at least one tactic in the last year to bend reimbursement rules for their patients. Since what services physicians decide to offer their patients affects around 80% of all health care expenditures, this admission strikes at the heart of the medical system.
The study sought to determine how frequently physicians manipulate reimbursement rules to secure coverage for their patients. Previous studies had simply asked physicians if they condone bending rules. This study was unique because it asked individual physicians if they had broken rules and how often. While 61% of physicians reported rarely or never exaggerating patient's severity of illness, changing patients' billing diagnoses or reporting signs or symptoms the patients did not experience in the last year, a full 39% did report engaging in one of these activities at least once.
The physicians in the study reported that they were receiving more requests from patients to be dishonest on the patients' behalf. Physicians treating large Medicaid populations were significantly associated with having broken the rules. These same clinicians, when guilty of breaking the rules, were likely to hold the belief that working against the current system was necessary to provide high-quality care and to hold the belief that it was ethically acceptable to deceive the system.
The authors of the study felt strongly that as pressure to control health care cost increase, so will the manipulation of the reimbursement system. Current efforts to tightly control utilization of services will likely increase the perception on the physician's part that he must break the rules to perform his job.
You may read the full-text version of this study at the Journal of the American Medical Association's Web site.
Less Is More: Lower Tidal Volumes Safer For Patients With Acute Lung Injury And Acute Respiratory Distress Syndrome
The Acute Respiratory Distress Syndrome Network suspended a recent clinical trial early when it became apparent that acute lung injury patients treated with lower tidal volumes were experiencing significantly lower mortality rates. In keeping with the New England Journal of Medicine's editorial policy, the journal made a rare early release of the study, the full-text of which can be found at http://www.nejm.org/content/brower/1.asp.
It has been suspected for some time that approaches to mechanical ventilation that use tidal volumes of 10-15 milliliters per kilogram of body weight may be harmful to the ventilated patient. The high tidal volume may cause stretch-induced lung injury in patients already suffering from acute lung injury and the acute respiratory distress syndrome (ARDS).
Normal tidal volume, in healthy subjects at rest, ranges from 7 to 8 ml per kilogram of body weight. The higher rates of 10-15 ml used for injured patients on mechanical ventilation were thought to be necessary to support normal values of arterial carbon dioxide and pH levels. Instead these higher volume settings may cause excessive distention and thereby lead to stretch injury of the lung and may not be necessary to adequately support the blood gas needs of the patient.
Currently, the recorded mortality rate from acute lung injury and the acute respiratory distress syndrome is between 40% and 50%. In the study, patients on lower tidal volume ventilation experienced a 31% mortality rate. In addition they spent fewer days on mechanical ventilation when compared to patients on the higher settings. Except for tidal volume settings, all ventilation procedures, including weaning, were identical in the two groups. The study concluded "in patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use."