Not What The Doctor Ordered
(Page 4 of 6)
As a gatekeeper, he spent his days saying no. No to patients who wanted to see an ear, nose, and throat specialist for their sinuses (“I can prescribe for you,” he told them); no to women who wanted to see a gynecologist ("I’ll be doing your pap smears now”); no to people who wanted to see an orthopedist when they could not walk after a weekend accident (Let’s give it a day and see what happens”). To a large extent, managed-care dictates are based on common sense: Most people don’t need specialists for routine procedures; most people who get sick get well on their own. But what about those who didn’t? Dr. B. felt that he was being asked to practice 1950’s medicine in the high-tech nineties. Every day new diagnoses, procedures, and medications were being developed. He couldn’t possibly keep up. Overburdened, he wondered what he was missing and which patient might suffer because of it. In his mind, the family practitioner was faced with the choice of making the patient happy or earning a living, and the two often appeared mutually exclusive. Like many people, he had a family to support and a mortgage. To lose his managed-care patients was to risk bankruptcy.
When he made referrals or used labs designated by insurance companies, he felt as though he had stepped through the looking glass. The old system of sending patients to doctors he knew and respected, or using labs he’d always trusted, no longer worked—they often weren’t on the same network as his patients—so he used only doctors and labs approved by the insurance companies and hoped for the best. And making any referral—to a doctor or a hospital—required getting approval from the insurance company, an act Dr. B. detested most of all. Along with mountains of paper, insurance companies seemed addicted to the telephone. If he wasn’t on the phone, his receptionist was, begging the insurance company clerk on the other end to approve a procedure. In the beginning he had spoken with nurses but not anymore. They had been too expensive, Dr. B. surmised. “And how much school have you had?” he had taken to asking, while the person on the other end of the line punched his diagnosis into a computer and waited for a yes or no answer. Most had never finished high school. This was the reality of modern medicine: a man with a medical degree getting permission to treat patients from someone getting a general equivalency diploma.
Foul-ups were inevitable. Once, a patient had come to him after cutting his arm in sewer water while cleaning out a gutter in front of his home. By the time he got to Dr. B.’s office, the gash was swollen with the red streaks indicative of infection. Fearing cellulitis, a dangerous infection of the tissue, Dr. B. called an infectious-disease expert, who advised an antibiotic that was very expensive but very strong. Dr. B. wrote the prescription. A few days later, he got a call from the patient: The insurance company wouldn’t authorize payment for the drug. Dr. B. called the company for him, working his way from clerk to supervisor, stressing the danger to the patient. A total of three days passed before the insurance company approved the prescription. By then the man’s entire arm was red and swollen. The guy could have lost his arm, Dr. B. knew.
He would come to work angry and leave work angry. He was spending an inordinate amount of time on things that had nothing to do with care of the sick—arguing with patients who wanted their old doctors back or battling with clerks who took their cost-control mission as seriously as he took his Hippocratic oath.
“You don’t have any regard for the patient’s health!” he had thundered during one particularly nasty encounter.
“Well, Dr. B.,” the clerk replied just as self-righteously, “you don’t have any regard for the patient’s financial health.”
Dr. B. wanted out, but there was nowhere to go.
The Truly Sick
AS SUMMER PROGRESSED, Dr. B. continued to see his Beneficent patients with the growing sense that he would soon be forced to give them up. It made him saddest to think of the patients who had been coming to him long before Beneficent had entered their lives. He wrote a letter of complaint to the company, asking it to reconsider. It was months before Beneficent responded; its answer was no.
Dr. B. was not the only one wrangling with the insurance companies. One morning a woman on a Sanus plan came weeping into his office. Her oncologist had been dropped from the plan, and she could not afford to pay him on her own. The man had been her doctor for a dozen years and had guided her through not only her own ongoing treatment but also the death of her husband from the same disease. “I cannot bear facing a recurrence without him,” she told Dr. B. But she would have to.
That same day an AIDS patient came in with similar news: The specialist treating his illness had requested admission to the patient’s Sanus plan and had been denied. The patient had the money to continue to pay the doctor on his own, but he could not afford the prohibitively expensive drugs the specialist would prescribe. What should he do?
Proponents of managed care often point to customer-satisfaction studies that show managed care equal if not superior to indemnity plans. It may be true that for ordinary problems, the differences are slight. Like so many other aspects of American culture, managed care rewards winners—stay healthy and you’re fine. But, eventually, most people get sick. And then the health care picture under managed care changes dramatically. “It’s therapeutic Darwinism” is the way one physician describes the insurance companies’ approach to the seriously ill.
AIDS is the most glaring example. Even though the disease is terminal, the right doctor can make an enormous difference in the quality and length of time a patient has left. But ask an AIDS doctor about managed care and you get horror stories in return: stories of moderately innovative drugs that are denied, of patients turned away from emergency rooms and directed to insurance company-affiliated day clinics, of doctors fired from plans because they fought back. Many of the problems stem from the gatekeeper concept: Very few primary-care physicians can keep up with the latest AIDS treatments; it is hard enough for the infectious disease docs who have made the disease their specialty.
The situation familiar to many AIDS doctors in Houston is that of Joseph Gathe, Jr., a prominent infectious-disease specialist. A significant part of Gathe’s practice was devoted to AIDS treatment, which meant that his costs eventually caused him to run afoul of insurance companies. So, no doubt, did his attitude: In an effort to keep his patients alive, he often fought bitterly with the insurance companies over treatments and procedures. The result: One company, Cigna, dropped him from its plan in August 1993, citing the provision of their agreement that allowed termination without cause. A few days later, Gathe filed suit, alleging that he was wrongfully terminated, that Cigna had dropped him because he was a “high utilizer.” During a hearing in which Gathe sought a temporary injunction that would allow him to keep his patients until the litigation was resolved, testimony showed just how far an insurance company will go to control costs.
There were six patients in question. Gathe, who declined to be interviewed for this article because his case in on appeal, testified at the time that he was trying to offer his patients the best, most current treatments available in Houston, and he had the success rate to prove it. After two years under his care, most of his full-blown AIDS patients were still alive and still working. Gathe told the court of his professional associations and his ties to drug-testing programs. He tried to make the case that to transfer his patients to other doctors did the patients a disservice. He also chronicled his difficulties with Cigna; he contended that the insurance company frequently interfered with the quality of care he was trying to deliver.
Gathe also testified that Cigna had denied hospital admission to a patient who appeared at his office with active pneumonia, including a high fever and respiratory rate. After Gathe put the patient in the hospital anyway, the company allowed only a one-day stay—far less, expert testimony revealed, than is considered common and acceptable treatment for such a serious condition. In another case, Gathe tried to order a special bed that would have kept a patient out of the hospital, but Cigna refused to pay. But most chilling was the case of a registered nurse named James D. Bland, who was in the final stages of AIDS. Bland knew that the end was coming, and he had requested that no extreme measures be taken, but he also had asked that he not be taken off a respirator—he dreaded suffocating to death. Bland discussed his wishes with Gathe and, soon after, lapsed into a coma. Gathe outlined the treatment plan to the family—Bland would remain on the respirator until he died, but he would not suffocate.
About this time a representative of Cigna became interested in the case. Why was this patient still in a hospital when he could be moved to a less expensive facility? The answer was that it would require that Bland be taken off the respirator, which would immediately result in death. Gathe, meanwhile, signed off the case because there was nothing more to be done.
Within a few days, the medical director for the insurance company contacted the head of the ethics committee at the hospital, a pulmonary specialist who coincidentally had just applied for membership in the Cigna plan: Why was this patient receiving further treatment when Dr. Gathe had put him under a Do Not Resuscitate order? Subsequently, that doctor removed Bland’s respirator in preparation for moving him to a hospice. He did so without consulting Gathe, the patient’s family, or the attending physician on the case. Once off the machine, Bland struggled for breath—and died of suffocation. In court, the judge pressed Gathe to say under oath whether the doctor who removed the respirator had killed the patient. “I am saying that—yes” was his answer.
