When Doctors Have To Choose Between The Health Of Their Patients And Their Own Financial Interests

Patients expect that their doctors will make the choices that are best for their ongoing health and wellbeing. And doctors, to be fair about it, usually want to do what is best for their patients. But financial forces are eroding the relationship of trust between doctor and patient. 

• Pay for performance provides cash payments to doctors whose patients meet preset goals regarding certain health outcomes, such as cholesterol levels in the general public and HbA1C in diabetics. If patients meet their treatment goals, the doctor gets extra money from insurance companies or an HMO. If patients do not meet their treatment goals, the doctor gets just the small fee negotiated for office visits and other services. The problem with this kind of compensation is that not all patients respond to treatment at the same rate or with the same results, and the payer does not take into account different interpretations of lab results that experienced doctors may hold.
• Higher doctor ratings are held out as a reward for doctors whose patients achieve the numbers rewarded by an insurance company. If patients get their blood pressure down, or they get their cholesterol down, the doctor is recognized for "physician excellence" or some version of providing a "bridge to excellence" on the insurance company website. The doctor gets more patients, and these patients also may be billed lower co-pays. When the doctor's patients don't have good numbers, the doctor may lose recognition, and get fewer patients, and the patients may also have higher copays. (Not every plan penalizes patients by raising or failing to lower their copays on the basis of what the doctor's other patients do.)
• Metrics, metrics, and more metrics are required of doctors in all of their activities. Insurers and regulators tend to look at cut and dried numerical data, causing doctors to "treat the numbers." Focusing on lab results rather than patient happiness is inevitable in today's fast-paced medical technology. It can take 10 to 20 years for doctors really to know whether a given medication successfully prevents or treats a disease. In the meantime, doctors rely on the numbers they get in lab reports as a surrogate for wellness. To get the right numbers, doctors may withhold treatments they really think would work better, and give treatments that may cause serious side effects. Sometimes doctors prescribe drugs that get the right numbers because they know that insurance companies will not pay for the medications they believe are more appropriate.

Insurance companies also influence the specific medications that doctors prescribe. Most companies create a disincentive for patients to be treated with certain drugs that are new or just expensive.

On the other hand, some companies pay doctors to prescribe specific drugs. One company pays oncologists $350 per month per patient to prescribe a specific drug, which may or may not be the best choice for the patient.

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And no insurance company rewards doctors who refer their patients to the best medical care if that care happens to be out-of-network.

Navigating The Moral Dilemmas Of American Medicine

What is reasonable for patients do expect their doctors to do? Should patients always expect their doctors to recommend what is best for them, no matter what? Or is the reality that doctors don't have the authority that they once did because insurance companies have taken it away from them?

Choosing What Is "Good" For The Greatest Number Disastrous For Individuals

Although it would seem unappreciative of a patient to raise the issue, there are grounds to criticize the idea that doctors should always do what is in the best interest of their patients.

They should be made on the basis on what is good for the country as a whole.

If a baby born prematurely needs delicate heart surgery, maybe it would be better to let the child die than to spend resources that could help a greater number of people. Or maybe it is not moral to give an old man with dementia medication for his bladder infection. Just let him die slowly from the infection. It's not like he knows what is happening.

Generalizing "doctor knows best" to the general population results in grotesque inequities for individuals and cultivates insensitivity to patient needs. But "doctor knows best" has been largely replaced by "insurance company knows best" and "HMO knows best" that have the same effect.

The Tyranny Of "Best Practices"

One major US insurer, United Health Care, has advertised its insurance policies with the slogan "Health in Numbers." Just trust their data and their expert opinion, and you are guaranteed to be as healthy as possible.

But the fact is, not every patient reacts the same way to every course of therapy. And the more patients know about their conditions, from personal experience, from participation in forums, from support groups, from articles and books, and from the Internet, the more choices they demand--at the same time the bureaucrats of the insurance companies are insisting on lower costs by providing everyone not just with the same level of care, but the exact same care for the same diagnosis.

No doctor knows the course of disease in every patient or every side effect of every medication. The path to health is not the same for everyone. Personal preferences really matter.

So what is the way for a patient to navigate the system? Probably it is a good idea to avoid doctors who are "minimalists," inclined to be skeptical of any treatment, eager to stay within the rules. It's probably better to find a doctor who is a "maximalist," who will offer every treatment that holds potential to make you better, as long as it does not produce serious side effects that you do not have an opportunity to accept or reject.

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Even better, however, is to find a doctor whose staff has the energy and tenacity to get you the treatments you need with the coverage you have. Treat these rare doctors and their staffs with care. They are your best allies in finding the medical treatment you need in a country obsessed with cost.