Diagnostic Incentives And Their Implications

[tex]

Hi All,

As we all know, an incentive is something that incites, or tends to incite, to action or greater effort. The greater the incentive, the more likely we are to spend more time working on a project, (because we expect a greater reward if/when we finish).

So a diagnostic incentive would be an incentive to reach a certain diagnosis, (over alternative possible diagnoses, or over the option of no diagnosis at all). In a perfect world, there would be no diagnostic incentives. In the real world, though, insurance companies, (and/or government regulators), set the incentives, for the most part, inherently destroying objective diagnostic practices, in the long run.

IOW, since the medical profession is a business, rather than a hobby, a doctor has every incentive to reach a diagnosis that will allow him or her to be paid what they consider to be a fair price for their work. The result of that situation is that, like it or not, insurance guidelines/rules provide the incentives that ultimately, (in many cases, at least), determine the diagnosis. Doctors are less likely to diagnose a disease for which the insurance companies will not pay, when it is much more lucrative to reach a diagnosis that may not fit quite as well, but pays much better. (Can we blame them?)

This is presumably the primary reason why diseases are "created", (why "non-diseases" are redefined as "diseases"). This is why an ND is much more likely than an MD to diagnose a case of candida overgrowth, (because the odds are high that no insurance companies will be paying for his or her work, anyway, so they are free to diagnose as they see fit, without "incentives" influencing the issue. I'll venture to guess that this is also one of the ultimate reasons why IBS was "branded" as a disease, because once a common syndrome is defined as an official disease, then it can be recognized as legitimate, and be sanctioned by the industry.

If you doubt that this trend has reached the point where it is significant enough to affect any of us, and/or our health, see the example at the following link.

http://www.osteoupdate.co.uk/news_item3.php

I'm guessing that's not an isolated situation - it's only the tip of the iceberg, and can only get worse as insurance companies and governments jockey for position, to see who will ultimately determine diagnostic incentives.

I have no idea how significant this issue might be, but obviously it is more likely to be a problem where doctors are underpaid, and individual integrity as always, will be the final test.

Tex

[TooManyHats]

I've seen this in action firsthand. My son's actual diagnosis is PDD-NOS, but back when he was diagnosed, that wasn't a payable diagnosis, so he was diagnosed as autism instead, which indicates a more severe impairment. While autism is a spectrum disorder, where you fall on that spectrum does indicate the level of impairment. But the diagnosis did get the bill paid.

[Gabes-Apg]

Tex
even vitamin and supplement companys have 'incentives' for health food or pharmacy outlet staff when new products are being launched.......

there has been some recent media here in australia that Pharmacys/Chemists as we call them, should only sell products that there is substantiated proof the product does what it claims.......
(i wonder who is going to define 'substantiated proof')

quite often it is these products that consumers look at and will consider buying while they are waiting for their script to get filled, they have reasonable margins so for the pharmacy it is 'easy money'

[tex]

Incentives are everywhere. For many years, the U. S. Government paid incentives to farmers, (among many other groups), so that they would continue to overproduce certain crops, to guarantee low market prices, (below cost of production), in order to fit the government "plan". In recent years, though, those incentives to farmers have sort of fallen by the wayside, as the usage of corn by the government-mandated ethanol production industry, has sucked all of the surplus out of the supply chain, and thereby created an artificial shortage of acres available to be planted to other crops. Of course, the government continues to pay an "incentive" to ethanol producers, to ensure that it will be produced, even when the price of conventional fuels is low enough to make the production of ethanol unprofitable. The net result is that we now pay high prices for food, in addition to high prices for fuel.

Leave it to the government to improve everything in our lives, until we can no longer afford anything.

It just strikes me as highly inappropriate for "artificial" incentives to play a significant role in the diagnosis of health issues.

Tex

[TooManyHats]

[starfire]

Me Too!!

Love, Shirley

[TooManyHats]

As another example, I've inquired about my insurance coverage for acupuncture. Unfortunately, I was honest and said my diagnosis was IBD. No coverage for that DX. Now perhaps if I had been involved in a car accident, I could get treatment covered. I guess they'd rather pay for the GI doc I'm going to next week and the 900 Pentasa capsules I need every 90 days. Oh well, it's their money.

On the other hand, if I'd like to help my body actually recover, it's my money I'll be spending.

[sarkin]

Arlene,

Years ago I was baffled because my MD (or someone on his staff) put 'headache' as the Dx on my routine physical when submitting to insurance. I hadn't talked about headaches, and thought it was a mistake... and a few weeks later my EOB came from insurance and included a form so I could report fraud. That's when I recalled that my insurance wouldn't cover a routine checkup. As you say, they'd rather have waited till I really had something wrong, and pay a fortune for procedures or ongoing meds. And it's not as though I never had a headache, plus, I liked my doctor (who seemed to be on my side here) a little better than the faceless drones at the insurance company I had to fight for every submitted bill.

I wonder what Dx would inspire them to pay for acupuncture. I bet some of the symptoms you've experienced as a result of the IBD *would* be covered.

I have a $300 Resperate machine my friend bought and never used. It is quite effective at lowering blood pressure, and is non-invasive, pleasant to use, and FDA-approved for the purpose. Of course my insurance would never pay for this; but they'd pay for someone to go on medication for the rest of her life, though many patients have reduced their dosages or gone off meds altogether using the Resperate device. And then they'd pay for a medication to counter the side effects of the first medication. Et cetera, et cetera, et cetera...

Sara