I Want to Put My Patients First

SPEAKING OUT offers responsible Christians a forum. It does not necessarily reflect the views of CHRISTIANITY TODAY.

I’m a Christian doctor. I work directly for you—the patient. My economic survival and clear conscience depend on giving you good service. However, outside forces are transforming medical practice into an impersonal business venture and changing the nature of the doctor-patient relationship. And that affects both of us.

It all started when the government, in a well-intentioned effort to curtail rapidly rising health care costs, took steps that are radically altering the way physicians deliver health care. Medical care has become a big business and is now marketed like soap with prime-time TV commercials. More and more physicians are going to work for profit-seeking third parties like health care chains and Health Maintenance Organizations (HMOS). In some ways, these organizations can provide more readily accessible or less expensive health care.

Traditionally, you employed your doctor. Now, a large corporation may employ your doctor, and you become a client rather than an employer. Sooner or later, the interests of the patient and the economic interests of the organization will come into conflict. This subjects the Christian physician to subtle pressures to compromise the interests of the patient.

For example, a Christian physician I admire works for a health care chain. Recently he came under pressure from his employer because a computer says he has not ordered enough lab work—specifically, a predetermined number of throat cultures (at about $10 a culture) per 100 sore throats. My conscientious colleague, who tries to keep his patients’ costs down, claims that not all those people need throat cultures. But for the chain, the bottom line is most important. Every sore throat puts him in a position of internal conflict.

An unbelieving physician may or may not be able to switch his loyalties to the organization’s balance sheet. A Christian physician must put his patients’ interests first.

Spending Less

Christians from all walks of life should ask what kind of health care we will have five years from now if trends in doctor-patient relationships continue.

Although I am in private practice, some of my patients come to me through HMOS, prepaid medical plans to whom they or an employer pay a monthly fee in return for medical care. The HMO contracts physicians like me to take care of their patients for a flat monthly fee. I am allotted X number of dollars and Y number of hospital days for those patients. Unlike my colleague in the health care chain, I benefit from spending as little as possible. But I, too, struggle with conflicts of interest in working for an organization that makes a profit only by spending as little as possible on the care of the patient.

Doctors working for HMOS learn to dread patients who need extensive treatment—one kidney dialysis case can blow all your projected funds. And you risk losing the HMO’s business. As an added incentive to save money, the HMO promises to split allotted but unspent dollars with you at the end of the year. Suddenly, physicians face pressures and temptations every time they plan a patient’s treatment.

So why are physicians working for HMOS or health care chains? Economic survival. As more and more companies contract HMOS for their employees, and a growing number of health care chains advertise “specials” on TV, private physicians are watching their long-term patients disappear.

Medicare

At this point, not all physicians have to cope with profit-seeking third parties. But they do have to cope with Diagnosis Related Groups (DRGS)—the reimbursement plan Medicare has been phasing in over the past year. Medicare, which insures more than one-third of all hospitalized patients, has brainstormed 469 possible diagnoses doctors can assign. Medicare reimburses the hospital a flat sum based on that diagnosis, without considering the severity of a patient’s condition. (Imagine body shops being reimbursed on the basis of whether cars had a front, side, or rear collision, regardless of the extent of the damage!) Doctors dealing with Medicare are only allowed one diagnosis per customer. If you admit Grandma to have a tumor removed, and I find gallstones while she’s in the hospital, I have to discharge her, then readmit her under a new diagnosis after a waiting period of several weeks.

Recently I had a patient in danger of losing a foot. His DRG allowed me to plan seven hospital days and $4,000 worth of treatment. We could have amputated just below the knee (a relatively easy procedure) and had the patient well enough to go home within my allotted time and budget. But because he was severely depressed, his family and I decided to try to save the foot, which involved complex treatment and a month of hospitalization. Financially, the hospital took a big loss.

But more and more often I find myself forced into becoming the agent of a government policy that says, “It’s going to take too long to save your foot, so let’s amputate it.” Doctors are pressured to discharge patients early, often before they are ready to care for themselves.

DRGS represent the government’s attempt to ration Medicare, whose budget was out of control. Most physicians would agree that somebody had to do something. But instead of politicians taking responsibility and saying, “We’re making it public policy to ration medicine, and here are the guidelines for doing it”—an unpopular step—they have set up an ingenious system that makes the physician the rationer of care. The problem with this arrangement is that the physician should be the patients’ advocate, not the agent for rationing care. They force us to make agonizing decisions by giving us tight budgets and no guidelines—which increases our already high chances of getting sued for malpractice and adds another stress to the doctor-patient relationship.

We cannot simply return to carte blanche Medicare and private insurance plans. Both encourage excessive spending—by the patient (who wants to take any long-shot measures, regardless of expense), the hospital (which buys the latest and most costly equipment to keep up with the competing hospital down the road), and the physician (who makes more money on more treatment).

DRGS were instituted to bring pressure on physicians and hospitals to spend less money on patient care, thereby decreasing the federal budget deficit. It sounded at first like a good idea, but its effect is to make physicians the rationers of medical care. I believe that the doctor’s medical judgment should not be subjected to pressures to make decisions that may be beneficial for the federal budget, but harmful to his patient. Physicians should be their patients’ unambiguous advocates.

Jesus is called both our advocate and our physician. I can’t imagine him having to tell Mary Magdalene, “I’m sorry, but your DRG ran out after six demons. You’ll have to keep this one.”

DRGS are an idea whose time has gone. Write your congressman.

JOHN TESTERMANDr. Testerman, a former university biology professor, practices family medicine in Glendale Heights, Illinois. with ROBERT KACHUR

Have something to add about this? See something we missed? Share your feedback here.