When Patients Request Unproven Treatments

Casey Humbyrd and Matthew Wynia
medscape.com
Originally posted March 25, 2019

Here is an excerpt:

Ethicists have made a variety of arguments about these injections. The primary arguments against them have focused on the perils of physicians becoming sellers of "snake oil," promising outlandish benefits and charging huge sums for treatments that might not work. The conflict of interest inherent in making money by providing an unproven therapy is a legitimate ethical concern. These treatments are very expensive and, as they are unproven, are rarely covered by insurance. As a result, some patients have turned to crowdfunding sites to pay for these questionable treatments.

But the profit motive may not be the most important ethical issue at stake. If it were removed, hypothetically, and physicians provided the injections at cost, would that make this practice more acceptable?

No. We believe that physicians who offer these injections are skipping the most important step in the ethical adoption of any new treatment modality: research that clarifies the benefits and risks. The costs of omitting that important step are much more than just monetary.

For the sake of argument, let's assume that stem cells are tremendously successful and that they heal arthritic joints, making them as good as new. By selling these injections to those who can pay before the treatment is backed by research, physicians are ensuring unavailability to patients who can't pay, because insurance won't cover unproven treatments.

The info is here.

Ethical behaviour of physicians and psychologists: similarities and differences

Ferencz Kaddari M, Koslowsky M, Weingarten MA
Journal of Medical Ethics Published Online First: 18 August 2017.

Abstract

Objective 

To compare the coping patterns of physicians and clinical psychologists when confronted with clinical ethical dilemmas and to explore consistency across different dilemmas.

Population 88 clinical psychologists and 149 family physicians in Israel.

Method 

Six dilemmas representing different ethical domains were selected from the literature. Vignettes were composed for each dilemma, and seven possible behavioural responses for each were proposed, scaled from most to least ethical. The vignettes were presented to both family physicians and clinical psychologists.

Results 

Psychologists’ aggregated mean ethical intention score, as compared with the physicians, was found to be significantly higher (F(6, 232)=22.44, p<0.001, η2=0.37). Psychologists showed higher ethical intent for two dilemmas: issues of payment (they would continue treating a non-paying patient while physicians would not) and dual relationships (they would avoid treating the son of a colleague). In the other four vignettes, psychologists and physicians responded in much the same way. The highest ethical intent scores for both psychologists and physicians were for confidentiality and a colleague's inappropriate practice due to personal problems.

Conclusions 

Responses to the dilemmas by physicians and psychologists can be categorised into two groups: (1) similar behaviours on the part of both professions when confronting dilemmas concerning confidentiality, inappropriate practice due to personal problems, improper professional conduct and academic issues and (2) different behaviours when confronting either payment issues or dual relationships.

The research is here.

The Curious Case of Informed Consent for Egg Donation

by Alana Rose Cattapan
BMJ Blogs
Originally posted March 17, 2016

As Michael Dunn writes in a recent editorial for the JME, “no medical ethicist worth their salt would deny that consent is a foundational concept in contemporary medical ethics,” and it is an extraordinary understatement to say that much ink has been spilled on the topic. The spaces between consent in theory and in practice is the subject of Dunn’s editorial, where he describes the ways that scholarship about consent fails, at times, to account for the messiness of the real-life process.

Obtaining consent for egg donation is a particularly messy endeavour. We still know relatively little about the long term effects of egg donation, and donors are sometimes seen as secondary players while the recipient of the eggs – the woman carrying a pregnancy and having a child – is viewed as the primary patient. Like other corporeal donations – blood, organ, bone marrow – egg donation presents a curious case of medical treatment in which there are no physiological benefits to the donor.

The blog post is here.

Penn study: Pay patients to take their pills

By Tom Avril
Philly.com
Originally posted November 8, 2015

Here are two excerpt:

While the field of medicine has moved increasingly toward paying doctors for performance, there has been little controlled research on whether it works. Studies of patients, meanwhile, have found that incentives can encourage healthy behaviors such as giving up cigarettes.

But in a study of 1,503 patients announced Sunday, the Penn team reported that the most effective approach, at least where statins are concerned, may be to reward both patient and physician.

"In some respects, it takes two to tango," said lead author David A. Asch, a professor at Penn's Perelman School of Medicine.

(cut)

Even if money helps, the notion of paying people to do the right thing may rub some the wrong way.

"We shouldn't have to," said Bobbi Cecco, president of the Hackensack, N.J., chapter of the Mended Hearts patient support group. "But if that's what it comes down to . . ."

Wei, the Michigan physician, said she already is motivated to help her patients stick with their medicine.

"Financial incentives wouldn't change my values or patient care," she said. "I am also an idealist."

The entire article is here.

CPT and ICD: What Are They? Where Do They Come From?

By Samuel Knapp, EdD, ABPP, Director of Professional Affairs
The Pennsylvania Psychologist
May 2013

The Current Procedural Terminology (or CPT) codes are developed by the American Medical Association (AMA) to ensure a common parlance and unitary language for describing services and procedures by physicians and other health care professionals. The CPT coding manual is copyrighted and published by AMA. CPT I Codes are the five-digit codes used to describe medical procedures; CPT II Codes are supplemental codes used to facilitate data collection about the quality of services provided; and CPT III Codes are for experimental procedures where data is still being gathered. HIPAA requires the standardized use of ICD and CPT codes across insurers. Although CPT codes were widely used before the HIPAA requirement, this HIPAA requirement ended the use of local codes.

A panel of the AMA (the Editorial Panel) creates the CPT codes, although it accepts advice from advisory panels. The Editorial Panel consists of 17 members including 11 physicians nominated by specialty groups within AMA; one physician each from the Blue Cross/Blue Shield Association, America’s Health Insurance Plans (a trade association), the Centers for Medicare and Medicaid Services (CMS), and the American Hospital Association; and two other members from the advisory committees to the Editorial Panel. One of the advisory committees is the Health Care Professional Advisory Committee, which consists of 12 organizations whose members are eligible to use CPT codes (audiologists, chiropractors, registered dieticians, nurses, occupational therapists, optometrists, physical therapists, physician assistants, podiatrists, psychologists, social workers, and speech therapists).

The deliberation process is secret. There is no public comment period for the adoption of these codes and no consumer input. All participants are obligated to follow strict standards of confidentiality, and the punishment for breaking confidentiality is to be removed from the process. The AMA is under no obligation to accept the recommendations of groups impacted by the changes in the CPT codes.

Although the Editorial Panel recommends the particular CPT codes, another committee within AMA, the Relative Value Scale Update Committee (RUC; rhymes with truck) recommends Medicare fees to CMS. The recommendations of RUC are based, to a large extent, on surveys conducted by impacted organizations on the relative work effort involved with the procedure. CMS typically accepts 90% to 100% of the recommendations of the RUC. Often commercial insurers set fees by paying a percentage of what Medicare pays.

Medicare payments are based on the resource-based relative value scale (RBRVS), which consists for three factors: work product, practice expense, and professional liability. Work product involves the time, technical skill, and mental effort required to perform a certain procedure. For physicians as a whole, work product consists of 48%, practice expense consists of 47%, and professional liability insurance consists of 4% of the RBRVS. For psychologists the work product is almost 70% of the RBRVS and professional liability is around 1%. Because the portion of the practice expense component for psychologists is so much lower than for physicians, minor changes in the reimbursement formula can impact psychologists quite differently from physicians.

The American Psychological Association (APA) has a representative on the Heath Care Professional Advisory Committee and had input into revising the CPT codes and the RUC process. Representatives from APA are bound by the very strict standards of confidentiality concerning their participation in the process. I have spoken briefly with APA representatives who can describe their involvement only in general terms. Participation in the process should not be interpreted to mean agreement with the recommendations concerning CPT codes or acceptance of payment.

Diseases are classified according to the ICD (International Classification of Diseases), which was developed by the World Health Organization (an affiliate of the United Nations) to gather information world-wide about the prevalence and incidence of diseases. The United States uses the ICD-cm-9, which means it is the 9th edition of the ICD. The cm refers to “clinical modification,” which is a modification of the ICD for the United States. The rest of the world uses the ICD-10, and the United States will adopt it by October 1, 2014.

Currently, the diagnostic numbers in the DSM-IV correspond to the ICD-9 codes (with a few exceptions). So psychologists can use the DSM-IV coding system and still conform to the ICD-9 system almost all of the time. However, at this time, the coding system in the DSM-V does not correspond to the numbers that would be used in the ICD-10. Although psychologists may wish to learn about the DSM-V as a way to keep abreast of new developments in the area of diagnostics, they will continue to bill only with the ICD-9 (DSM-IV-TR) numerical codes even after the DSM-V is released. Psychologists and other health care professionals will begin coding with the ICD-10 in October 2014.