Consent Activity

CASE 1:

You are a primary care physician at a not-for-profit health maintenance organization (HMO) that serves 500,000 members, paid for by capitation, a monthly premium paid to the HMO by the members’ employer, Medicaid, or Medicare. The premium revenues create a budget to care for the entire HMO population.

Susan Jackson, a 28 year old office worker, consults you about headaches. For the past month she has had frequent headaches at the end of the work day. The headaches are much less frequent on the weekends. She describes the headaches as a dull, mild to moderate pain, that feels like tightness or a band around her head. She is otherwise healthy. Her neurological examination is normal. She identifies clear stressors at work.

You explain that this is a classical pattern for tension-type headaches and give practical advice on what to do. You predict that the headaches will improve as Susan learns to master the stressors and to build more relaxation into her day. Susan thanks you, but says that a friend who had headaches received an MRI, which showed a tumor that required surgery. With some urgency she says “unless you can guarantee that there is no possibility whatsoever that I have a tumor, I want an MRI. What harm can an MRI do?”

You know that the likelihood of a tumor is vanishingly low, and that established standards of care do not recommend imaging studies in a situation like Susan’s. There is no medical contraindication to getting an MRI, but you know that it would cost between $1500 - $2000, which would come out of the budget for the HMO population. You reflect on what to do, and how to explain your thinking about the MRI to Susan.

CASE 2:

The next day you see Michael Johnson in your office at the HMO. He is 40 years old, married, with two children and a job he likes. His complaint is poor sleep – falling asleep and staying asleep. He has no signs of depression or any other illness. Physical exam and routine laboratory studies are normal. Michael exercises regularly and has good sleep hygiene. He does not use drugs and has alcohol only in social situations on the weekends.

He wants a sleeping medication – specifically, Lunesta, for which he saw an advertisement. He tells you “Lunesta helps you fall asleep and stay asleep, and it is approved for long term use.”

You see on your tablet that 30 Lunesta costs $150. Two generic medications commonly used for sleep – zolpidem and trazodone, cost $15 and $12 respectively for 30. The cost of the drugs will come out of the budget for the HMO population. You are not convinced that there are any significant differences between the medications. If Lunesta has any advantage your guess is that it is small.

You reflect on what to do and how to explain your thinking to Michael.