Rob was the last patient I was scheduled to see at the end of a busy day in my primary care medical practice. A 60 year old lanky fellow with diabetes and high blood pressure, he was not afraid to speak his mind. Rob told me why he didn’t want to receive what the medical profession considers to be quality care, to lower LDL cholesterol levels below 100 (the bad cholesterol that clogs blood vessels). His level was 115, the same range it had been for many previous visits. “But Doc”, Rob pleaded, “I know you want me to take that medicine to lower my cholesterol too, but I’m already taking two pills for my diabetes and two more pills for my blood pressure and aspirin too! The more pills I take, the sicker I think I must be. Can’t I try dieting again? Maybe it’ll work next time.”
It is a dilemma for doctors and patients alike. Do we have the same goals for quality care? And now insurance companies, and even the government, are getting into the business of mandating quality care. Some insurance companies are proud to publicize the results of quality measures, such as how effective the doctors are at keeping LDL cholesterols levels below 100 for their patients with heart risks. Further, some plans give doctors more money to deliver quality care and penalize them if they don’t, called “pay for performance.” How can that be bad? Medical research shows that statistically LDL cholesterol should be lower in people with diabetes, heart disease and other risks (at least below 100, but under 70 would be best), in order to reduce the risk of heart attack and stroke. However, people are not statistics. Treatment comes with no guarantee that someone will be protected from heart attack or stroke, even if all the proper medications are taken exactly as prescribed. How can Rob know if he will actually be helped by taking that pill?
And who can blame Rob for not wanting to take another pill, with all the warnings of possible side effects on TV ads or on information sheets given with prescriptions from the pharmacy? And the cost!! Just the co-pays alone can add up to hundreds of dollars monthly. With no insurance, one could easily pay $500 to $800 monthly for medications for diabetes and heart conditions. Fear, inconvenience, cost, denial….no wonder so many people don’t take the medications recommended by their doctors. In fact, less than two-thirds of patients actually take all their prescribed medication for on-going health conditions.
With today’s monitoring of health care the doctor is at risk for not delivering quality care for patients like Rob. Should I ask Rob to find another doctor, because he won’t accept my recommendation to take a pill to lower his LDL-cholesterol? After much discussion, Rob left the office with an appointment for 3 months from now, without the prescription for the pill that I was convinced would lower his LDL-cholesterol to quality levels. But he said he’d keep trying to diet and we’d re-check his levels for the next office visit. Quality medical care would just have to wait.
Paul Dolinsky, MD has been a primary care internal medicine physician in West Hartford for 23 years. He is a member of quality care committees for his primary care medical group, ProHealth Physicians, and the Hartford Physicians Hospital Organization.
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