Mandated care requires a careful balancing act

Physicians and other health care providers are operating under an increasing number of restraints, guidelines, regulations and laws.

These “mandates” are coming from multiple sources: state and federal governments, the courts, insurance companies, regulatory agencies and independent health care organizations that accredit and certify facilities and programs.

The motives behind these mandates are varied and generally valid: containing rapidly rising health care costs, reducing medical errors, providing for legal redress when errors may occur,  protecting the public health and ensuring patient safety.

Oversight in the practice of medicine is certainly warranted and needed, but each mandate has a consequence, some unintended, whether for the practice of medicine, the doctor-patient relationship or in some cases, the costs to our health care system.

The proliferation of mandates raises some key questions: How do these requirements affect the physician-patient relationship? Do they ever conflict with clinical standards of care? Does the increasing time and administrative work physicians spend on mandates detract from the quality of care? Are we micro-managing our providers in the delivery of health care? And are we unwittingly spending more money than we should by duplicating care or providing care that’s not indicated for patients?

Pediatricians perhaps see more of these mandates because their patients are children.

The U.S. Department of Health and Human Services has since 1967 required EPSDT –
Early Periodic Screening Detection and Treatment – a program to address the physical, mental and developmental needs of low-income children under Medicaid.

The purpose of EPSDT is “to discover, as early as possible, the ills that handicap our children” and to provide “continuing follow up and treatment so that handicaps do not go neglected.”

In Massachusetts, state laws mandate vaccinations and testing for vision, hearing and “physical and postural” defects. Behavioral and mental health screenings are also now mandated by multiple directives.

The case of Rosie D. v. Romney, decided in 2006 in federal court, and more recently, a mental health omnibus bill called Yolanda’s Law, passed by the legislature this year, create mandates for behavioral and mental health screenings that will affect how physicians, schools and hospitals care for hundreds of thousands of children up to age 21.

The EPSDT and Massachusetts goals are noble and important.

Some mandates, however, are less well-defined. Though not yet required in Massachusetts, a recent example is state-mandated “culturally competent care.”

Now existing in a handful of states, this requirement addresses the growing ethnic diversity of the nation and tries to ensure that providers are trained in “cultural competency.”

In California, the law goes so far as to require an element of cultural and linguistic competency in every Continuing Medical Education course. In New Jersey and New Mexico, medical schools must provide such instruction as a condition for the M.D. degree.

Specifics are still in flux, and states are treading carefully in deciding how they’ll quantify and define this “care” and judge whether the mandate has been met.

Mandates are not inherently bad. I make this distinction: Those that protect and enhance the public or individual health (vaccinations for school children, for example) are good; those that hinder the practice of medicine (excessive documentation to support an imaging test a physician believes is necessary) are not.

Further, mandates that cause duplication of services, such as pediatric tests for scoliosis by both pediatricians and schools, may be inappropriate and wasteful.

Imposed care can also create disproportionate burdens on small or solo medical practices, particularly if such mandates are unfunded, putting added financial pressures on medical practices.

Mandates can also significantly raise the cost of health care and have the unintended consequence of creating disparities in care, for example, between children covered under EPSDT and those who are privately insured and hence not mandated for screening.

Mandated health care can be prudent and effective, filling critical gaps in care and providing care for those who wouldn’t normally receive care. It can also be an impediment, duplicative and wasteful.

In essence, mandated care is a balancing act, especially as health care costs rise relentlessly. It is incumbent on those who have the power to create such requirements to ensure as much as possible – before mandates are issued – that quality of care is improved, that a need is filled that isn’t otherwise addressed, that no additional burdens are placed on the provider and that the means to pay for such care is available.

Carole Allen, M.D., specialty director for pediatrics at Harvard Vanguard Medical Associates, is president of the Massachusetts Chapter of the American Academy of Pediatrics.