Mr. Ken Buckley of Ocean Grove has been a regular commenter on Blogfinger regarding healthcare issues. He sent us the comment below after watching a segment of “60 Minutes” where a large hospital corporation, abetted by some ER doctors, appeared to be churning admissions in order to make more money, without adequate attention to the best interests of the patients. My reply to him is below his remarks, and below that you will find the AMA code of ethics for physicians.
Paul,
After watching the Sunday night program “60 Mimutes” I feel you you may have to raise anew the role of the physician in controling healthcare costs. They interviewed doctors who worked at HMA hospitals who were held to meet admissions goals of 20% for emergency room patients and 50% for those 65 and older (Medicare pays for them.) Those ER doctors who did not comply and did the “right thing” were fired or moved to other positions. — Ken
Reply from Paul Goldfinger, MD, FACC:
Ken: I saw that program and I was as disturbed by that as you were. But, a Justice Department investigation is currently ongoing, so we can’t come to definite conclusions by watching that presentation. It does appear that this large hospital corporation was coercing its ER doctors to admit patients who didn’t require admission — all in the interest of profit. Some doctors were fired who did not comply.
If theses allegations are true, it will mostly be a case of corporate billing fraud. If any doctors are found guilty of intentionally admitting people who didn’t need hospitalization, then that needs to be addressed; whether the charge for them becomes bad ethics, fraud, or malpractice, I can’t say.
But, to your point about “raising anew the role of the physician in controlling healthcare costs,” I agree that ordering unnecessary tests and treatment by doctors in order to make money, usually in office settings, does occur and is a component of the “fraud and abuse” aspect of wasteful spending for healthcare. This physician component, along with bad behavior by hospitals, medical suppliers, pharmaceutical companies, healthcare providers of all types, malpractice lawyers, etc. does need to be addressed in trying to reduce healthcare costs.
You should know that proper behavior by physicians is guided by the profession’s ethics in addition to the rule of law. All physicians know that they should always place the best interest of their patients first and that they should, above all else, do no harm.
Realist: If this anecdote is true, then the doctor was misleading you. No insurance company, private or government, mandates how much time a physician should utilize when seeing a patient. Medicaid has a history of ridiculously low payments for physician services, so many doctors refuse to see Medicaid patients. But once a physician agrees to see any patient, he is bound by ethics to spend whatever time is needed to do the job right.
I admit that some doctors rush through office hours so as to maintain income by increasing volume. This approach is wrong and may jeopardize care.
I asked my doctor once why I always had to wait even though I had an appointment. He said he has to double book all appointments because Medicaid requires him to see a certain number of patients per hour. He can not afford for an appointment slot to be unfilled. It is also why he spends less time per patient then he would want to.
Shorebookworm: Thank you for your insight. I agree with you. It seemed like the hospitals in question were smaller institutions in places like Oklahoma where perhaps safeguards are not as good as those we are used to around here.
But even here, sometimes you have to wonder about the money motive: I have had two experiences in local ER’s where, instead of being seen by a doctor, the care was provided, with no forewarning, by a PA.
In both situations, potentially serious problems were poorly managed in my presence, and both times the PA said that his/her care was “the same”as what a physician would do.(They didn’t know that a real MD–me– was observing them.)
And both times, the billing to Medicare was under a physician’s name; with no mention that a PA provided the service–in my opinion an inappropriate billing maneuver to get a higher reimbursement.
As the former Admissions Director for a large local hospital, I have some doubts about the accuracy of the allegations made in the “60 Minutes” report. Hospital corporations may be greedy but they are not stupid. CMS (Centers for Medicare/Medicaid Services) is more vigilant about fraud than ever before, and appropriate documentation is a facility’s only defense.
At our facility, documentation supporting the validity of an admission was paramount, and there was no such thing as quotas. Medical necessity is pretty black and white – if you cannot document the medical need for a patient to be admitted, you don’t get paid. Or, if by some slip up you do get paid, you risk an audit,fines in the multi-millions and even possible closure.
There are more than enough sick people who truly need to be admitted; the vast majority of facilities do not need to resort to fraud and quotas. There are plenty of problems in our health care reimbursement process today, but I don’t think this is one that is truly prevalent.
Paul, MD, FACC
I bet good old lobbying by the for-profit hospitals is responsible for this disparity.
I sympathize with the choices that consumers have to make in healthcare these days, for a variety of reasons. I have noticed a fairly new trend lately: long waits to see some doctors and doctors’ offices canceling appointments and rescheduling. When I was in practice, for most of my career, doctors competed with each other for patients, and we made sure that people got appointments quickly. We rarely canceled an appointment.
In the latest issue of Bloomberg’s Businessweek magazine, there is a piece about doctors who are forced (due to reduced reimbursements) to leave their practices to take salaried positions in hospitals. The article points out that Medicare pays more for doctors’ services as hospital employees than they do for physicians who are billing out of their offices. The net result, at least for the short term, will be higher costs for physician services—not lower as promised by the ACA.
The article was sent to me by a doctor who is closing his private practice at the end of this month. He will be looking for a salaried job.
The way to counter a business with questionable ethics is through an educated consumer base. With enough information and freedom of choice, bad doctors and hospitals will go out of business as consumers avoid their services. However, it seems medical choices are harder, not easier to make.
The notion of an ethical corporation is a tricky one. Once any business enterprise is owned by a large publicly-held corporation — such as HMA — it becomes subject to the overpowering demands of Wall Street investment funds held by stockholders who invest not for purposes of ethics but for purposes of maximum returns. Having worked for a newspaper owned by such a corporation, and having studied and written about the conflicts within such enterprises, I have seen how strong is the tendency for profit maximization to trump public service, high quality and other such values. The present level of profit is never enough; returns must be sustained and increased quarter after quarter.
Medical facilities would seem to be no more immune to this pressure than are the journalistic enterprises with which I’m familiar. Those enterprises underwent the transition from private to public ownership and control a bit earlier than have most medical enterprises. I’m struck, though, by the similarity between physicians who are losing their autonomy to corporate owners and journalists who have done so. In both cases, it seems, the fact that the practitioners are trained to follow high standards of professional ethics becomes irrelevant once those professionals have lost the power struggle.
I wish the medical profession well as it grapples with this problem. It’s an issue that certainly affects us all.
NYNutrDoc: Thank you for making the important point that turning doctors into employees does not necessarily reduce costs. I don’t think this sort of thing would happen in hospitals that have strong quality assurance programs. I can’t imagine it occurring in hospitals where I worked (or where you work)–all privately owned by ethical corporations and all with aggressive QA monitoring by physicians and nurses whose only interests are in the welfare of the patients. I doubt that it could happen in blue chip institutions such as Mayo or Kaiser which will be models for the future.
Please don’t hesitate to weigh in more often on BF. We can use more physician voices during our discussions. — Paul
Funny, I was going to comment on your prior post (about the number of docs who were now employees), that this was the way to control medical costs. Since we docs are an unruly bunch with a high profit motivation to do things of marginal (or no) value, my premise was going to be that doing away with private practice was a way to exert utilization control over practitioners. I’m glad I waited. And it occurs to me now that employment only works to cut costs when motivation of docs and hospitals are aligned. But, as our current story illustrates, that alignment can lead us toward the dark side of the force.
How do we resolve these issues? Doctors are reimbursed for what we do. So we do things. But will the best and brightest seek medical training without the promise of high wages? (not so much) Accountable care organizations will only incentivize the organization (albeit in the right directions of improved value = better quality and reduced cost). Is there someone smarter than me who could please fix this?
Further to this discussion, I recommend the cover story from this week’s Bloomberg Business Week Magazine, “Is Concierge Medicine The Future of Health Care?”: http://www.businessweek.com/articles/2012-11-29/is-concierge-medicine-the-future-of-health-care#r=hpf-s
Paul, Thank you for taking on the issue presented in the 60 MINUTES expose. My heart goes out to physicians who gave up a private practice only to be threatened with loss of income if they do not accede to pressures to violate what they know is the “right thing to do”
As for the D.of J’s ongoing investigation, I’ll believe it when I see results. Its performance during our financial crisis against “bad actors” has been so pathetic it almost makes them look in cahoots with the bad guys. I lack any real expectation that the Dept. of Justice will address this issue in a meaningful way.