POLICY/THE INDUSTRY: Ethics 101, we’ve failed

Fred Goldstein, a health care veteran who believes in the free market, calls a spade a spade in a hard hitting call for ethical improvement in health care over at HealthLeaders. Go read his list of transgressions which we all know about individually but are hard hitting when read together. Bonus points if you can name the guilty. His point is that it’s pervasive because we’ve collectively let it happen. Here’s his conclusion.

Unethical behavior exists among healthcare organizations and professionals of all types. Organizations that try to do the right thing are often outmaneuvered by those that do not. Self-interest is often hidden behind a facade of patient concern. “We do this for the patient. If you withhold our services, you will hurt the patient.”Worse, these self serving behaviors have become so common that professional outrage has been dulled. But to save healthcare, we can’t just take these acts for granted. The prevalence of inappropriate actions in healthcare drives additional margins in the industry’s supply, delivery and financing sectors. It is at the root of our cost explosion and our healthcare crisis. And, it is based on an ingrained acceptance of unethical behaviors.The recent movement toward transparency and quality reporting will shine a bright light on some of these practices, and should tone down the environment of opportunism. But many of these behaviors have been well known for years. I have little faith that, with so much money at stake, any reforms can be substantial enough to turn around the industry. This is especially true if change does not support and engage much more participation from payers and consumers.

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  1. It is a “known fact” as they say on TV, that people, even physicians–are motivated by rewards. With all its abuses that is why are system works as well as it does compared with other economic systems. Which isn’t to say it is by any means a free market. Goldstein’s essay points to a number of ethical abuses and cites the need for greater transparency. With all the facts being known in advance, then we can have a truly free market. Monopoly capitalism and unethical behavior grow best in the shade. In particular, the American healthcare system defies “normal market behavior” because, in large part, of the lack of transparency.
    If we assume that physicians are motivated by incentives (sorry Ms. Tuteur), but at the same time should not be asked to weigh personal financial consequences against patient needs, then we are left to devise a system that aligns the physicians interests with patient outcomes. As Telllurian points out, at this point measures of quality and productivity are critical here. These are difficult and politically charged measurements but not impossible. Physicians should be able to make more money if they hit higher levels of productivity and maintain standard levels of quality and the reverse.
    Naturally all this becomes easier in a single payer system. It is easier to track productivity and quality in meaningful ways when only one payer exists for all providers. But within such a system providers would be free to compete for ever higher levels of productivity and quality.

  2. I just went to a Orthopedic Surgeon Prem K Rangala.
    Worst doctor I had ever been to. I went for some wrist pain with my X-Ray he just called me unnecessarily twice just to collect co-pay and fees. Says he can’t do anything and doesn’t to waste his time as he’s a knee surgeon. Then why did he call me twice and wasted my time just to get his fees / copay?

  3. Charging by the clock is exactly what we do in psychiatry when using psychotherapy as a treatment modality. The problem, of course, is that we do better financially when simply seeing a patient for a medication check (an untimed service) than we do for providing therapy. The insurance companies have pushed us into a situation where many psychiatrists simply write prescriptions, letting other clinicians provide the ongoing therapy. The alternative route that I and many colleagues have taken is to simply not accept insurance anymore and to charge a reasonable rate per hour. By the way, I’ve not seen any physicians charging non-procedural hourly rates such as those posted above. Perhaps I should reconsider my rates, which are a fraction of those.
    This, by the way, is the biggest problem with moving to a single-payor system. Many of the best physicians would simply opt out. All patients who could afford it would pay for this better care. And we’d end up with a two-tiered system. I don’t see the part about how that fixes anything.

  4. Tellurian,
    As a patient, I would love to pay doctors based primarily on the time they spend with me. I see both a cardiologist and a urologist on a regular basis. Both have many years of experience, practice in high cost New York City, and I think both are fabulous, and I trust their judgment absolutely.
    Rather than be billed for every little procedure, why can’t the insurers, perhaps as an agreed upon alternative to the current system, just allow them to bill based on time? Outside lab fees would, of course, be billed separately. For doctors of this caliber, payment comparable to senior partners at mid-size and large law firms ($500-$1,000 per hour in NYC) I think would be reasonable billable in minimum increments of 0.1 hour (6 minutes).
    I wonder if you would find such an approach acceptable to you, what sort of hourly rate you think might be reasonable, and what would it take to get insurers to at least try it on a pilot basis?

  5. I am not a lawyer, but the right to contract is constitutionally protected. That is why we could never have a Canadian style health care system that bans private healthcare here in the US. The CMS/Medicare system is unconstitutional but has never been challenged as yet. I am shooting from the hip here, but I believe it is illegal for insurers to offer primary (not supplemental) health insurance to those over 65yo. This is clearly unconstitutional. Where is the ACLU when you need them? You think they would be all over this one but I think they ignore this secondary to their librule agenda. The insurers don’t want to fight it b/c it is a lose lose for them b/c those over 65yo are liabilities in their eyes. Maybe someone else with better knowledge of this can shed some more light. Preferably a contract attorney or an attorney that specializes in insurance.

  6. Bravo, Amy! That was very well written. I have said the same thing many times, and I don’t understand why so many people can’t seem to get their minds around the concept. Physicians should have no financial incentives related to patient care, whether to overtreat or undertreat. Then, and only then, do you get a truly objective decision. It shouldn’t be so hard to design this; for example, pay physicians (a fair rate) for their time (or effort, or the work they do). Period. Why is that hard?
    Peter’s idea has merit. Many doctors are coming around to the idea of a single payer system; not because we like it, but because almost anything looks good compared to the monstrosity we have now. There are some problems:
    1. Who decides what and how physicians are paid? Since I am a physician, that is the big one for me. It may be less important for others, but – as Peter suggests – most people probably agree that we want the practice of medicine to be financially attractive enough to draw intelligent and competent people into the profession (and keep them there). So, given that the wrong decision could ruin the practice of medicine for at least a generation, the big question is: do you trust this Administration or this Congress to make that decision (or any decision)? If not them, then who?
    2. Despite much effort, we have made very little progress in developing meaningful measures of health care quality. In my opinion, there are none. The response of our leadership (same people who planned the war in Iraq, more or less) has been to make up a bunch of standards and rush them into practice ASAP, and then presumably to start penalizing physicians for not meeting the “standards.” Somehow, I don’t think that is going to be a positive step.
    3. We also have no meaningful standards by which to measure physician productivity (which gets to pgbMD’s point). Physicians who see lots of patients every day, for example, are not necessarily providing better care. In fact, most of them are probably providing lower quality care. They’re just churning to practice to generate revenue. So, how are they more “productive?”
    It may be simplistic, but I think there are just those three problems with single payer. Unfortunately, each of them are huge problems, and they embrace a world of complexity.
    The last post goes a little over the top, I think. It’s never a good sign when people start throwing “-isms” around. I didn’t realize that putting people on salary was the same thing as Communism. I didn’t realize that the right to contract was specifically protected by the Constitution, either, although I seem to have misplaced my working copy of the document. If so, then the current CMS rule which prohibits private contracting between physicians and patients must be unconstitutional, huh? Quick! Somebody call Pete Stark.
    The corresponent does have a point, though. I have no experience with Tricare, but the VA is much the same thing. Administrative overhead may be low, but there are problems with the system, believe me. Low productivity is certainly one of them, and it is rampant among all VA employees, not just the doctors. The administrators may be the worst of all!
    I think single payer is ultimately the way to go, but we need to come up with pragmatic solutions to these (huge)questions:
    How do you measure productivity?
    How do you measure quality?
    How do you set the rates to keep the system healthy while not providing perverse incentives to physicians (and other providers of care, including pharmaceuticals and equipment)?

  7. Peter:
    You do that and there will be no incentive to produce on the Doctors’ part. Welcome back again the doctors golf day on Wednesdays and get in line for your care b/c you will wait. Personally saw it in the military in the TRICARE system. That is what happens when everyone gets paid the same no matter what they do. It is called Communism. Fortunately this “eutopia” is also illegal in the good old USA with our Constitutionally protected right to contract.

  8. This is going to inflammatory but wouldn’t the best way to create doctors that respond to good practice and cost effective patient care is to have them employed by a single payer system with a fixed salary? Then they could concentrate on medicine not income generation. I believe they should be paid very well with good pensions and then you would know their medical decisions are only about care. As well you could structure the pay levels so that specialists and experience and outcomes could be rewarded on a fair scale. I read here that some docs weigh work load and compensation return when determining what area to practice in. Least time for most return so to speak.

  9. Bravo!
    I will point out that of the 14 separate charges that Goldstein makes, only 5 involve doctors at all: 3 are about doctors who take bribes from drug manufacturers, device manufactures and hospitals, 1 about Medicare fraud, and 1 about “evidence based” medicine.
    The interesting thing is that all 14 points are the inevitable result from insisting that healthcare is a business and not a profession. I’m hard pressed to understand the difference between “motivating” doctors with “financial incentives” and offering them bribes. The fundamental principle, that doctors SHOULD be motivated by financial incentives and SHOULD be manipulated by such incentives, is unethical.
    Any time you ask a doctor to weigh personal financial consequences against patient needs, you are creating an unethical system. Yes, yes, yes, the old unregulated system had incentives to over treat. Here is the crucial difference: in that system, a doctor following his financial interests instead of the patients’ needs is unethical. In this system, the same unethical behavior is intrinsic to the system.
    Until we acknowledge this fundamental fact, that attempting to manipulate physician behavior through financial penalties and incentives is unethical (and doesn’t even save money), we have no chance of improving the delivery of healthcare.

  10. “The recent movement toward transparency and quality reporting will shine a bright light on some of these practices,”
    This “movement” is, of course, completely voluntary. Self reported quality data in the new business world of medicine should at the very least be examined skeptically. Which ethics were being used when the information was selected? Business (Enron, or more appropriately, BP), or Medicine (Hippocrates)?
    When UHC in St. Louis decided it was placing on panel only those providers it(UHC) determined were of “high quality,” the only criteria it admittedly used was claims data.
    Transparency won’t be achieved until the Feds decide on a uniform billing standard. Without uniformity, transparency is meaningless.

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