My neighbor, a man in his 70's, had mild epigastric (abdominal) pain. He was treated for ulcer disease, and when the pain did not disappear, he went to visit his cardiologist. The patient had several risk factors for heart disease, including high blood pressure, high cholesterol and diabetes.

The cardiologist was a conservative physician, and he suggested that instead of doing a coronary angiogram or a nuclear stress test, which are the tests usually ordered in this situation, the patient should have a CT angiogram. This is a procedure in which a dye is injected into a vein and a CAT scan is performed to visualize the coronary arteries. His reasoning was that the patient was asymptomatic, the nuclear stress test might not provide a definitive diagnosis, and the coronary angiogram was invasive with a small risk of complications. He also wanted to view the anatomy of the patient's coronary arteries, something a CT angiogram provides, so that he could look for blockages.

The CT angiogram required approval by Medicare before it would agree to pay. The cardiologist waited for several days after submitting his request and then received a denial. He then appealed to a "peer reviewer," a physician assigned to review claims, to explain his rationale for ordering the test.

Payment for the procedure was again denied. Needless to add, the cardiologist received no reimbursement for his time and effort in advocating for the patient. And the effort was not in his own financial interest. If the CT angiogram had been approved, it would have been performed not by him but by a radiologist. Yet he would have had the responsibility of taking the time to explain the results to his patient, time that he could not bill for.

After receiving the second denial, the cardiologist and the patient decided that the best course was to do nothing. I volunteered to review the Medicare reimbursement rate for each of the three procedures that the cardiologist had considered to try to divine the reason for the reimbursement denial. It is lowest for CT angiography, suggesting that the denial was based on a clinical decision made by a physician reviewer who was probably not a cardiologist, did not know the patient, and was following a protocol.

This incident raises an important question. Who should decide what is best for the patient? The cardiologist had a long-term relationship with this patient and was acting conservatively in what he saw as the patient's best interests. In denying payment for the recommended procedure, the Medicare program was telling him how to practice medicine even though the peer reviewer had never seen the patient.

This way of doing business threatens the autonomy of physicians. In doing so, it undermines one of the primary features of medical practice that led them to choose it as a career. As algorithms, order sets, and protocols extend their influence over clinical decisions, physicians will continue to lose autonomy, and dissatisfaction with their chosen profession will continue to grow.

If physicians are not allowed to make clinical decisions, what is the rationale for their long and costly training? Perhaps we will reach the point at which technicians are trained to do procedures that are approved by third party payers and physicians are no longer be necessary.  If that comes to pass, we will all suffer the consequences.

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