Monday, April 02, 2007

April 2, 2007 - Profit Center

“Have you ever wondered why hospitals offer free cancer screening tests?” asks Shannon Brownlee, in an op-ed piece in yesterday’s New York Times. “Hospitals would like you to think they are doing this out of the goodness of their hearts, that free cancer screening is a public service intended solely to improve your health. But there may be another motive at work here: providing free screening brings in new cancer patients, and cancer generates profits."

Now there’s a curious thought – that I’m a potential source of profits for my local hospital. Recently, as part of my volunteer work as a member of the Community Advisory Committee of Ocean Medical Center, I’ve been part of some discussions about how to raise the public profile of a program the hospital provides, called “Oncology Navigators.” These Navigators are hospital employees who speak on the phone to cancer patients, providing them with general information about the disease and connecting them with various medical services. The one experience I had with one of the Navigators was when I was beginning my physical therapy. I called her, on Dr. Lerner’s recommendation, and she made the connection for me with Life Fitness (a hospital affiliate), where I received my therapy. I thought she was very helpful.

I have no objection to this set-up – in fact, I think it’s to be applauded – because it’s important to refer people to hospitals for auxiliary services. Hospitals, by law, must provide a lot of charity care for uninsured people, at a financial loss. So, if they can earn a little extra scratch through “profit centers,” then that’s a good thing for us all. I don’t think hospitals need to apologize for having auxiliary enterprises. It’s a matter of simple survival, in the constantly-changing, Kafkaesque world of health-care financing.

Now that I think about it, I realize that a great deal of my own cancer testing and treatment has been provided outside the hospital setting, by for-profit business concerns. Dr. Lerner’s office, where I received tens of thousands of dollars worth of chemotherapy drugs, is a for-profit operation. So is Atlantic Medical Imaging, where I’ve received my most recent scans (I would have preferred to go to the hospital for these, myself, but they don’t yet have a PET/CT fusion machine).

Of course, questions could be raised about hospitals’ non-profit status, as well. Even the smallest community hospital is a multi-million dollar concern, and is often the largest employer in its community. Some hospital staff members, particularly senior executives, are handsomely compensated. True, hospitals don’t have stockholders, and are governed by volunteer boards of trustees, but still there are ways in which the boundary line between profit and non-profit seems to have gotten a little fuzzy.

“Could it be,” wonders Ms. Brownlee, “that at least some of the $100 billion we spend each year on detecting and treating this disease is used not to improve the health of patients, but rather to prop up hospital finances?” Well, I’m not so sure I’d be as ready as she is to separate the functioning of a hospital from “improving the health of patients.” Isn’t that a hospital’s principal mission, in the first place?

Her concern, though, is that some hospitals may be too aggressive in steering patients towards costly therapies, because they bring in more money. Inasmuch as doctors have control over treatment decisions, and doctors aren’t generally hospital employees – rather, they’re independent professionals who are credentialed to serve on the hospital’s “medical staff” – I think there are adequate checks and balances. Actually, I think the temptations may be greater in the for-profit clinic setting, in which doctors are prescribing medications, then turning around and acting as a pharmacy, selling those same medications to patients.

Back when Washington Post reporters Bob Woodward and Carl Bernstein cracked open the Nixon White House, their rule of thumb was to “follow the money” – the assumption being that greed is a consistent and predictable motivator of human behavior. Is this also true in the world of medicine? Shannon Brownlee seems to think so.

I think the jury’s still out, on that one.

As for me, I’d prefer to think that my doctors, as well as the administrators of the local hospital, don’t hear “ka-ching” when I walk through the door. Medicine – that profession that connects with human beings on the most intimate level – is meant to operate from higher motives.


Shannon Brownlee said...

In a better world, we wouldn't have to question the motives of our doctors and hospitals. But under the current system of payment, where we reward both hospitals and doctors for delivering more care, rather than better care, it's reasonable to ask whether or not the treatment being recommended is for our good or theirs. I'm not suggesting that doctors are rubbing their hands together dreaming of all the money they're going to make by treating us. Most doctors genuinely care about their patients as well as for them. But we know that a great deal of care in this country is unnecessary, and that one of the forces driving overtreatment is economic in nature.

A better reimbursement system would pay physicians a salary, and it would measure the quality of care they deliver. The best health care systems in the U.S. do just that -- the Veterans Administration, for example, which has transformed itself from one of the worst systems to one of the best.

Carlos ("Carl") said...

Well, Shannon, I certainly didn't expect the writer of a NY Times Op-Ed piece to show up here in my lil ol' blog, but I'm glad you have. Thanks for your comment.

In the article, you lament that medical providers have "few incentives to hold back," in providing costly (and often futile) cancer treatments, "even if that’s what the patient might prefer." It's a concern I tend to resonate with, because my wife is a hospice chaplain. She and I seen firsthand the benefits to patients, in their last days, of doctors having recognized the inevitable, and having made the move from curative to palliative care.

It's hard to get some doctors to throw in the towel, though. So many of them have been schooled to see patients' deaths as a personal failure on their part. (That's not true of my own doctor, incidentally, who - in addition to being an oncologist aggressively treating patients like me, who can benefit from such approaches - is also medical director of the hospice program. He seems to be able to take one hat off and put the other on, without too much difficulty.)

I'd be interested to learn of what incentives might be built into the funding system, in order to reduce the number of patients who are dragged into harsh and marginally effective therapies, against their own wishes in some cases. It's hard to conceive of a funding agency (medicare, or a private insurance company) calling the shots, in a situation in which medical judgment is clearly called for. But maybe you have some ideas on that.