A common refrain against a fee for service medical system is that it encourages unnecessary testing and procedures. The theory is that if someone gets paid for the more that they do, they will do more.

Dartmouth Medical School has been on the forefront of examining differences in cost around the country. They have found for example that it costs 50% more to die in Portland than it does in Miami.

Some of the drivers are cultural. World data shows that differences in religious beliefs can lead to more or less agressiveness towards the end of life. Those same factors can be at play inside the United States.

Miami has more ICU beds than Portland. A patient is more likely to see a greater number of doctors at the end of life in Miami. A patient is also more likely to die in the hospital rather than in hospice. Miami is a costlier place to die than Portland.

Is it cultural? Is it because services are available? Are those factors mutually exclusive? Is one place practicing wrong? Does it make a difference?

The last question is the only one with a solid answer from the data. No.

Physicians play a role in the decision making process. If a patient is brain dead or has no meaningful chance of recovery the painting of the picture can trump culture. A family may view a 5% chance of meaningful recovery after 6-12 months of intensive care in different ways. The spin placed on the story by the physician with the numbers becomes a medical culture issue.

One of my mentors in fellowship used to start with a question when it came to percutaneous gastrostomy tube (PEG) consults. His question was, "PEG or no PEG?" His question was one of utility. He wanted to know if we were going to really serve the patient with the intervention.

PEGs are an intervention that can allow patients to stay alive even when brain activity is absent. The resulting convienence makes it easy to forget that there is a patient behind the feeding. The Terry Schiavo case reminded me of many I have seen over the years where a patient was being kept alive despite no long term chance of meaningful recovery.

A couple of years ago when I was tuning up for the boards I came across guidelines for PEG placement after brain injury or stroke. The guidelines stated that a minimum of 2 weeks should be waited to assess any return of brain function and do testing. I have not had a consult for a PEG tube that has waited 2 weeks in at least 5 years. In fact, I have received consults within days at times.

The motivation behind the request? There will not be meaninful quick recovery so why wait. It makes it easier for nursing staff. It makes it easier to transfer the patient to a long term care facility. It prevents the complications of long term nasogastric tube (a feeding tube placed down the nose)placement.

The guidelines are there because predicting recovery is an issue. Convience for nurses and placement is not a medical reason. And PEG tubes have serious complication results that can approach 1% including perforation of bowel, damage to other organs, and infection.

In cases where the patient will not recover makes the consult more difficult to assess. What is the motivation. It conjours up visions of Miami vs. Portland?

The monkey wrench is the very rare case where somebody wakes up against the odds. It gets media attention and provides unrealistic expectations to patients.

The New England Journal of Medicine ran a study I thought was ridiculous when I was an intern. It compared resuscitation success rates at Massachusetts General Hospital with the television shows ER and Chicago Hope. Not surprisingly, the television doctors were far more successful at saving patients. They must have stayed at a Holiday Inn before filming. All joking aside, I now actually think the study was a valuable one 18 years later.

Physicians have to be careful to not get caught in the expectation game. It is one that has financial implications as well. The system is making more money off the additional costs in Miami vs. Portland. It is a tough conversation to have even physician to physician. The argument that "the family wants it" has problems when the case is futile. Lines get blurred in the examination.

The case that is more common for patients is they wonder whether a procedure is necessary or not. Patients often try to come up with reasons to avoid gastrointestinal procedures. It can be emotional or financial fear. And there are studies that suggest some gastroenterologists do more procedures per new patient seen than others. There could be demographic patient factors behind the data but the question lingers. Are there different motivations?

It lingers with me all the time. I follow guidelines that a patient with a pre-malignant condition of the esophagus called Barrett's should have a repeat upper endoscopy at 1 year and every 3 years after. The risk is 0.4-0.5% per year. Outcomes data suggests at that risk a procedure every 5 years would be adequate.

What were the motives of the guidelines? The party line is we used to do annual endoscopies before we had more data and an extreme change would not be tolerated. There is a nagging thought in the back of my mind that the motives may have been financial. still, I have to follow guidelines or be at risk.

Guidelines can be a trap. They have to be followed to be legally protected. Many years ago the medical community started developing them as a legal protection. The problem is studies suggest guidelines are used against physicians legally twice as often as they are used to protect them. A point made once to me during a Cardiology presentation on cholesterol medications.

There is plenty of Medicare data that certain areas of the country utilize more tests than others. It is typically rural areas. There is also data that a cut in reimbursement never meets saving goals because hospitals and physicians upcode in response.

Coding is a motivator at times. An article in the New York Times just this week detailed how HCA, the parent of Alaska Regional Hospital, increased revenue at least partially with coding techniques. With endoscopy techniques can lead to a coding bonanza. Is it motivated by patient careor upcoding. That is not a slam on any system, it simply a question about motivation and what drives it.

It is a discussion that health care providers need to have more. What are the reasons behind what we do? What are the motivations behind guidelines? Is coding often a function and motivator to game the system? And how do we change cultural views and should we?

Ethics in such matters are not well established. They are questions I have touched in past blogs from a financial standpoint. Those in charge of trying to follow the system often use raw data without understanding. Shoot, not even the people who do it day to day understand all of the implications.

This is going to be the first in a number of articles trying to get at the ethics in medicine and how it affects finances. It is safe to say that, "Do no harm," is a phrase that may need to have different meanings. The exploration here is to try and define it better.

Cutting through the weeds to get at real motivations is a difficult process. It is one that will draw ire from those inside the system when differences are apparant. Trying to guess motives is nearly impossible and causes discomfort. The conversation though has to be had.