Not What The Doctor Ordered
(Page 5 of 6)
Bland’s case makes a perfect target for critics of treatment at any cost: He was a very sick man with very high bills, kept alive artificially at a high cost with no hope of recovery. In the coldest light, it could be argued that the doctor who turned off the respirator was doing the rest of us a favor. But Bland’s case also evokes the messy moral dilemma of weighing the sanctity of life against the cost of prolonging it. Now insurance companies are involved in what were once intensely private and highly emotional decisions. Clearly insurance company health plan administrators are ready to make the hard choices for us.
In the end, the court too was unswayed by any moral or ethical arguments raised in the hearing. The judge ruled only that Cigna’s contract allowed the company to take Gathe’s patients away at any time; whether his patients wanted to remain with his was irrelevant. Gathe’s suit against Cigna is on appeal. The family of James Bland has also sued the insurance company, and that case is set for trial later this year.
AIDS is not the only condition that brings out the worst in the insurance companies. Any long-term, life-threatening illness represents a threat to their bottom line. “When we started seeing insurance companies trying to shaft these guys,” says one physician who has been treating AIDS patients for more than a decade, “we knew they were going to extrapolate that to cancer patients or heart patients. They’d do it to anybody.”
Oncologists, who also treat sick and expensive patient populations, have almost the same complaints as AIDS doctors. (Woe to the cancer doctor who treats both kinds of patients—one or two AIDS victims can easily mean a failing grade on his economic report card.” Often an insurance company will only pay for treatments in its own approved clinics, even if another treatment center is closer to the patient’s home but isn’t on its plan. Patients who have spent several months under the care of one oncologist must give the doctor up if he is dropped from the managed-care plan—unless, of course, the patient can come up with the money to pay the doctor himself. Every time a patient wants to see his oncologist, he must get permission from the primary-care physician (who, you’ll recall, could suffer financially for approving the referral). The same procedure must be followed each time an oncologist orders a lab test or an x-ray. “They’re micromanaging the care and have created a whole layer of middle management to control what you do,” says one Houston oncologist. Delays can run into days—small eternities for sick people. In what is becoming standard procedure, an insurance company representative will call the patient or the patient’s family, ostensibly out of concern for the patient’s progress. If the representative learns the patient is terminal, he begins pressuring the doctor to transfer the patient to a hospice. “They call the family, and then they hard-ball the doctor,” explains an oncologist with twenty years of experience.
The most disturbing effect is felt at the institutions devoted to medical research, like Houston’s M. D. Anderson Cancer Center, long an international innovator in cancer treatment. From 1993 to 1994 the hospital’s revenue from patient care dropped 6 percent, or $27 million, a decline hospital administrators ascribe largely to managed care. As a rule, managed-care companies do not reimburse for experimental treatments. They only want to meet the community standard—the average level of care in a given locale. Hence, a place devoted to experimentation is put at risk—fewer patients available for research, less money from paying patients—even though it is the place likely to come up with new treatments that save lives. “The managed-care plans show an increasing reluctance to pay for anything that isn’t standard medicine—even if it’s cheaper,” says Dr. Martin Raber, the physician in chief at M. D. Anderson. “They would rather pay for care that has proven to be ineffective than for a promising experimental therapy that would cost the same amount of money. Where is the incentive to innovate? We don’t want in the year 2005 to be stuck with 1995 medicine.
The Investigation
AT THE END OF THE SUMMER, Beneficent representatives finally told Dr. B. that the reason he was being dropped from the plan was “patient complaints.” After numerous requests, Dr. B. received copies of the forms that made up the case against him. There were a handful of them—out of his 350 Beneficent patients—spanning the three and a half years he had been with Beneficent. Dr. B. was not surprised to find that the bulk of the accusations came not from longtime patients but from those who had found his name in the company provider book.
Some of the complaints were a matter of style. Several people griped about reaching an answering machine instead of a person when they called his office at particular times of the day. Another woman simply wanted to change doctors but couldn’t without filing a complaint with Beneficent. When badgered on the phone to come up with a complaint she finally noted that Dr. B.’s office furniture was not up to date.
Two patients complained after he refused to give them the drugs they wanted. One had been angered when Dr. B. refused to prescribe an antibiotic over the phone on a weekend because the patient had previously suffered an allergic reaction. Another was furious when Dr. B., who had not seen the patient for at least a year, would not call in a prescription after her roommate described her symptoms. A third complained after Dr. B., concerned about the patient’s heavy and erratic use of steroids, wanted to try a different kind of allergy therapy. All of these requests went against Dr. B.’s best instincts as a physician—in his view, to grant them would have been bad medicine.
Other cases had less to do with patients care than with corporate culture. Because he argued with Beneficent’s clerks, he got a reputation for rudeness. They lobbied for his firing. In one case, while trying to get treatment approved for a patient’s enlarged prostate, Dr. B. had refused to go into detail with the clerk on the phone; the elderly man was standing next to him, and Dr. B. thought it would embarrass him to hear his symptoms discussed extensively with a stranger when the clerk could just as easily read treatment notes that were already in his file. (A person with a medical background would have known that the symptoms were obvious from the diagnosis.) In another case, Dr. B. referred a patient to a doctor who was not part of the Beneficent network. “Met with office for re-education” was the way a staffer described resolution of that problem.
The complaint that angered Dr. B. most of all had to do with a patient who had ocme to him complaining of exhaustion. He was a single parent who was trying to survive on three hours of sleep a night after his workweek had been increased from forty to sixty hours. He asked Dr. B. for a letter to his employer, requesting a cutback in his work load. Dr. B. obliged. Subsequently, the employer called to verify the letter, but Dr. B. was not comfortable discussing the patient’s condition with his employer and kept his conversation brief. The employer called the insurance company to complain that Dr. B. had been rude on the phone. Dr. B. saw the complaint as punishment for siding with his patient and against his employer, who was, after all, the insurance company’s client. The episode served as one more reminder that to the insurance companies running modern medicine, doctors and patients are less important than clients and costs. As best Dr. B. could tell, he was being fired for practicing medicine the way he’d been taught.
It has been difficult for most physicians to grasp their new, much reduced status in the world of managed care. Insurance companies do what all companies do: run their businesses according to profits and losses, making decisions accordingly. If it is easier for them to hire a certain kind of doctor—one who is cost efficient, to be sure, but also one who is compliant, in agreement with their methods—then that is what they are going to do. And if there comes a time when there are more doctors than necessary on a single plan in a given part of town or too many specialists on a given plan, the company will simply lay some of them off. The company’s only obligation is to provide a doctor, not a particular doctor. Skill is irrelevant. One man who had been chosen by Aetna as doctor of the month in Houston was fired two months later—and reinstated only after the doctor found computer errors in the company’s cost calculations.
Most doctors are too frightened and/or financially burdened to fight back. Paul Farek, a general surgeon in Corpus Christi on a Humana plan, was one who did. On call in the emergency room at Bay Area Medical Center one night in 1994, he admitted a youth who had been in an automobile accident and had been taken to the nearest hospital. It was Farek’s medical judgment that the patient should be kept there for observation, rather than moved immediately to a facility run by Humana, through whom the man was insured. When the patient submitted his bills, Humana refused to pay. “Transfer of this patient to another facility would have been inappropriate and not in the best interest of this patient’s care,” Farek wrote Humana, helping the patient appeal the decision. When the company again refused to pay, Farek recommended to the family that they write a letter reporting the incident to the Texas Department of Insurance. Subsequently, Humana informed him that his contract would be terminated. It was only after Farek talked to the director of the plan that the company backed off.
