Other people’s money: Ethics, finances, and bad outcomes
Article Outline
It costs a lot of money to die comfortably, unless one goes off pretty quickly.
Samuel Butler (Notebooks, A Luxurious Death, 1912)
A middle-aged, otherwise healthy patient underwent a straightforward open infrarenal aneurysmectomy 6 months ago. He succumbed 4 weeks after surgery following one of the most turbulent, complication-laden postoperative courses you have been called on to manage in your entire career. He had an excellent commercial medical insurance plan, with 85% coverage of hospital and medical expenses. Today, his wife, a practicing tax attorney, visits your office carrying a cardboard carton of accumulated unpaid medical and hospital bills and letters from the insurance company notifying her that payment has been denied and inquiry sent to the hospital for such things as “exorbitant charges,” “failures to code properly,” “failures to bill promptly,” and “failure to pre-certify.” She is highly agitated and is grieving deeply for her husband. She demands to know why she has received such extensive charges and why she has been charged so much by physicians whose names and functions she doesn’t know. She insists that you as her husband’s attending surgeon explain, “Why I am being charged so much to watch my husband suffer and die.” How should you respond?
None of the options offered will fully resolve the grief and frustration the widow is expressing in her complaints about the high cost of her husband’s futile care, and no accounting for the accuracy of the invoices she’s received will replace the one priceless thing she has irretrievably lost. The enormity of her financial burden is real nonetheless. Even though most high-quality commercial insurance plans cover all but about 15% of hospital charges and cap catastrophic expenses, the thousands left due on a half million dollar hospitalization would be an almost unbearable blow to nearly everyone, the more so when it just happens to fall at the same time as funeral expenses and the loss of the patient’s regular income. Can the value of what we do as surgeons possibly be equal when we discharge a preoperatively functional patient to a mortuary or long-term care facility and when we release him for return to work and full activities? Should adjustments be made accordingly?
Most patients and their families pay the amount due on their medical bills without question, so much so that many hospitals no longer itemize the statement of co-pay charges they send home after insurance settles unless they’ve specifically been asked to do so. Even if they did, the patients would understand little of what went on and whether most listed items were reasonable. Certainly, few patients make distinctions between the surgeon’s charges, anesthesiologist’s charges, consultant charges, and hospital charges. Most don’t understand why they receive several different statements for a single episode of surgical care, but they pay them all, trusting to the integrity of the medical care system, even when the outcome of treatment has been disappointing.
Likewise, many surgeons are relatively naïve about the sometimes complex finances of the care we provide because office or hospital business staffs handle this dirty work for us. The price of our surgical procedures is effectively fixed by Medicare and the insurance companies that follow its lead, and our fees are unbundled from other charges associated with a patient’s care, including those posted by other physicians working in support of our care during a patient’s hospitalization for surgery. Many of us have been further insulated from confronting the high cost of co-payment by the ancient customs of professional courtesy (now taboo but sometimes still quietly practiced) when we need care ourselves.1 As a result, we are poorly prepared to decipher the vagaries of 20-page invoices for the few patients who want explanations.
In many functions of Western culture, determination of compensation is closely associated with the buyer’s degree of satisfaction with what is provided. Low-cost disposable goods like groceries, clothing, and small household articles have well-defined criteria for acceptability. Meat must be unspoiled, clothing must fit, and toasters must toast. When these standards are not met, merchandise is typically replaced or the cost refunded without loss to the customer. Refunds or replacement of larger, more expensive products like automobiles or new homes are less likely, but there is an expectation that suitable repairs will be provided to a dissatisfied buyer.
Customer dissatisfaction is necessarily managed differently by providers of custom services or products that are individually rather than mass-produced. Not only should a cabinetmaker’s product be of the correct size, shape, and ornamentation, it should also satisfy the aesthetic expectations of the buyer. But if the cabinetmaker met the terms of their pre-manufacturing agreement, the buyer must accept a measure of dissatisfaction. If the buyer did not specify the finished cabinet’s appearance, the negotiation may involve some cosmetic carpentry, but full payment will still be required.
Compensation in other service industries is based variously on time spent, piecework, competitive bidding, fixed salary, or achievement of milestones and goals. The customs influencing professional compensation are different still. When not working on contingency, trial attorneys bill, and are typically paid, the same hourly rate whether the client goes home or is hung. Because the final arbiter is a judge or jury, the attorney bears responsibility only for the technical and intellectual quality of the advocacy. Only the contingency lawyer guarantees a favorable outcome or no fee, and does so in exchange for hugely inflated compensation if the case is won. Otherwise, the trial attorney’s fee is based on the training, experience, time, effort, and physical resources invested on each client’s behalf, with the understanding that the case’s resolution may be heavily influenced, but not wholly determined, by the work of the professional. Likewise, physicians.
Because surgical fees are essentially charged at a flat rate per specified operating room procedure, postoperative care is bundled with payment for the operation. The more difficult cases require more, sometimes immensely more, effort and time, but payment is the same as for routine cases. Nevertheless, surgeons characteristically take pride in their mastery of complexity, and the differential between effort and compensation has generally not resulted in difficult cases being turned away. Complex cases may be transferred to tertiary care centers, but the referral is usually made because superior expertise or facilities are required, not over grievances about the reimbursement per unit of time.
People come to us for good outcomes and we prepare very hard, work very hard, and expend enormous resources in trying to provide them. Every surgeon, every physician, grieves the loss of every patient we have watched spin out of our control and die. Although it is fully appropriate to empathize with the widow’s loss, it is unseemly to ask her to feel the additional weight of our own emotional burden, or to attempt consolation by outdoing the depth of her sorrow. Although a co-payment waiver may seem like the best redeeming gift you can make in these sad circumstances, it isn’t. Furthermore, such a waiver unethically violates the terms of the contract you signed with the patient’s insurers and unfairly imposes on others who provided care an expectation that they should do so as well. Option A should be rejected on all counts.
The insurer’s notification of billing errors is certainly the responsibility of the hospital’s billing office to resolve, but it is unnecessary to direct the poor widow with her box of invoices there or elsewhere around the hospital like a prep school freshman sent to retrieve a bucket of steam. As a matter of gentility and kindness, you might more reasonably ask your own administrative support staff to call the billers and make certain that they have received the insurer’s notices and have initiated routine steps to resolve them. You may then reassure the widow accordingly. Coding errors and other filing mistakes are ordinary events in the tortuous communication between care providers and insurers and are routinely resolved with amended filings, but unless someone tells them otherwise, they can seem like yet one more catastrophe to a patient’s family. Option B can be set aside, for the time being at least.
Hospital Risk Management offices ask providers to advise them if they have reason to believe that a malpractice claim or other lawsuit may be impending. Although you might feel a little extra wariness because the widow is an attorney, she has made no such threat, asking only for an explanation of some complex material that could well bear explanation. It would be an act of bad faith to adopt an adversarial posture toward a lost patient’s family member who has come seeking your guidance. Option C should be rejected.
As a practicing attorney, the patient’s widow normally understands the concept that professionals are paid on the basis of the services they provide, that it costs you a great deal to provide that care, and that you must be fully compensated, irrespective of unforeseen complications or an ultimately unhappy outcome. Although it would not be factually inaccurate to remind her of this, it would clearly be heard as callous and unfeeling were you to recite it so baldly under the circumstances and would certainly deepen her current sense of disaffection for the medical profession. Option D would be a poor choice.
The widow’s anguished question about why such a bitter disappointment comes at so high a price can be accepted as an entirely appropriate opportunity to pursue Option E, which may be ethically viewed as part of an ongoing process of informed consent. Reviewing with her the changes in her husband’s condition and what responses were made, then inviting her to ask detailed questions about his hospital course and all the measures that were taken to arrest the heartbreaking process of his decline, will give her a better sense than she came in with of “Why.”
You may make it clear that while you do not determine the charges submitted by critical care and infectious disease specialists, radiologists, and pathologists, it was you who sought their consultation in her husband’s care, just as it was you as the attending surgeon who referred him to the intensive care unit, which has accounted for many of her charges, in the interest of saving his life. You may reassure her that the acumen and performance of all these professionals in her husband’s care was entirely consistent with what you asked and expected of them. You may explain in more or less detail what services her husband’s care required from each. Such a discussion may in fact repeat things she was told on a day-by-day basis during the hospitalization, but a consolidated retrospective is likely to give her a better grasp of what occurred, help her to come to terms with her loss, and effectively help her to understand what it is that she is now being asked to pay for, which is what she came to you to ask. You may be inclined to articulate what you both acutely feel in different ways, a sense of helplessness when the abilities of medicine make hard contact with their limitations.
The concept of variable fees based on patient outcome has a glimmer of rational attraction, even justice, to it. Almost everyone tries harder when the rewards are increased, so might such a system not insure better patient care from harder working surgeons?
Upon first reading the harsh retributive strictures upon surgeons in the ancient Babylonian Code of Hammurabi, most medical students ask, “Who would want to be a surgeon if it means risking the loss of your hand?” It’s a good question. The glimmer quickly fades from a system of outcome-based payment upon recognition that it could mean enormous outlays of money and energy with no payment at all for care of complex or high-risk patients. Surgeons would necessarily protect the basic financial interests of themselves and their families by declining to operate on diabetic, geriatric, far-advanced, or otherwise increased-risk patients, who could find themselves totally without access to surgical treatment. The masters at the pinnacle of our craft who accept referral of the most difficult patients might no longer do so. Surgeons might elect to withhold referral to the intensive care unit or decide not to seek consultation when patients develop postoperative complications, lest they run up expenses that won’t be reimbursed. In short, the patients who need us most could be systematically shut out of our practices if we depended upon guaranteed good outcomes to replace our spent resources and provide us with a livelihood. With our current fixed-price system, surgeons are already disproportionately underpaid for managing the most complicated and work-intensive cases. We are best-paid in caring for the easiest and least complicated cases and for the patient who is so terribly ill that he dies quickly after surgery. A revised compensation system that demands the modern equivalent of a sacrificed hand when our ministrations fail could ultimately incite us to less, not more, effort.
Modern surgeons have never offered to work on contingency, with a very high fee if the patient lives and no fee if he doesn’t. None of us took the hard road into this profession with the intention of doing anything but good for the people who come to us, and we know that we cannot function at all without the absolute trust of our patients. To maintain that intent and that trust, almost all of us work at consistently full effort, with no sliding scales. It is in everyone’s interest that we continue to do so.
Reference
James W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor
PII: S0741-5214(06)00206-0
doi:10.1016/j.jvs.2006.02.001
© 2006 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
