[skwb]

1. There's an old saying in healthcare that patient care is always first, but money is a close second.

2. Sort of yes, but I've heard it more time from managers who use it more of an excuse for not wanting change rather than it being a legitimate argument (i.e. from people with little to no legal training).

3. This is changing slowly. The Affordable Care Act and it's little known cousin MACRA have started to shift the entire system (albeit slowly) towards more outcome based measures, primarily through Medicare. Major payers are following in their steps. Not happening overnight, but any major healthcare executive sees the writing on the wall and is taking these considerations into account for their investments.

[0]. https://www.healthaffairs.org/do/10.1377/hblog20180810.48196... [1]. https://www.healthaffairs.org/do/10.1377/hblog20180810.48196...

[VikingCoder]

3. No, it's not.

If you go in for a wonky heart, and you get some kind of imaging done on your chest, and then spot something in your lungs, they SHOULD ignore it. Outcome-Based Medicine says that's what they should do. They CAN'T ignore it.

Cardiologists actively want the lungs REMOVED from the images they order, because they don't want to accidentally notice any lung nodules. That's crazy!

And that's just one example.

We don't know how to properly ignore the things we should.

And if something IS there, and there COULD HAVE been action taken on it, then the people who looked at the images are potentially liable in court. Or at least in settlement.

The whole thing sucks.

[skwb]

Yes, it is. You appear to be conflating my point of how healthcare is changing with regard to payment structures with clinical guidelines which tend to have potentially more subtleties.

There are some areas of healthcare where it is very cut and dry what defines good healthcare management. These are where we've developed good reporting outcomes that tie closely to clinical and resource utilization outcomes from the published literature. Think of your high volume routines cases such as diabetes (monitoring of A1C)[0] and knee replacements [1] that make of a large portion of health care cases. These are certainly not covering all healthcare episodes, but represent areas where significant fat can be trimmed.

With regard to your above clinical case, there are specific approaches for (what I assume is an incidental finding from a coronary CTA) reporting lung nodules and requesting follow up studies [2]. However, this represents an area where there is significant good faith professional disagreement of reporting.

I will agree that high-evidence clinical guidelines are not always followed, and payment reform has not been influenced all medical professions equally. The way healthcare is delivered is changing, and is being highly influenced by national policy level decisions.

[0]: https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/f... [1]: http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-P... [2]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/

[VikingCoder]

The medical field doesn't have the discipline to ignore signals that it knows are meaningless. That's what I'm driving at.

Also, healthcare absolutely sucks at pain management, specifically in being disciplined enough to say no to opioids.