Predatory Physician PracticesThursday, April 5th, 2012, 2:46 pm
A 32yo woman who complained of ear pain recently came to my office for a 2nd opinion. She went to a previous ENT who told her that her ear pain was from an infection and gave her antibiotics, but before she left he had asked her about her nose and if it had ever been broken. He said that it looked crooked to him and that he could improve her nasal breathing as well as straighten the cosmetic appearance. She quickly found herself sitting at a computer showing her current face and how some quick surgery could change her and make her nose more appealing. When she was brought to discuss all of these surgical options with the practices financial counsellor, she realized that this whirlwind had become overwhelming and she left that office confused, worried, and frustrated. She had never worried about her nasal appearance before although she at times felt it would be nice to breathe better.
I've become increasingly concerned about a growing trend in medicine. The mainstream media has started to catch wind of it and has been discussing it with more frequency. More concerning to me is that I have seen patients come to me now for 2nd opinions when they think that their original physician may be involved. It's a business decision where treatment options are offered based on the reimbursement only. I call it Predatory Physician Practice.
In my opinion, physician treatment should be based on a core group of principles. These should come as no surprise to anyone, especially physicians, because they are not original. However, after 10 years of practice serving the good men and women of the military as a physician and now serving in my community, I find that these 3 tenets allow a physician to practice safe, quality, and compassionate care.
First, do no harm. This is the initial pledge of the Hippocratic Oath--a vow that all physicians still take when they graduate from medical school. It means that whatever you do, try to make decisions and perform procedures that will not harm a patient. I believe that extends beyond physical harm, but also to mental, emotional, and financial harm as well. There are risks with all treatment options, but one should always try to favor those where the potential benefits outweigh the potential risks.
Second, use evidence based medicine. This means that the decisions are directed by medical studies that are verified as valid and reproducible. In other words, old medical myths like drinking 8 glasses of water a day have never proven to be beneficial over say 6 glasses so why advocate for 8? On the other hand, there is clear evidence demonstrating the dangers of smoking so that physicians should promote smoking cessation at any opportunity. Similarly, surgeons should suggest invasive procedures when there is evidence to support their efficacy, not when it is what they do. I'm skeptical when I take my car in to a muffler guy and the first thing he tells me is that it needs a new muffler. Likewise, I would be skeptical if I asked a surgeon about something and the very first words were, "You need surgery."
Third, use an escalating algorithm of risk. There are almost always options for the treatment of medical problems. Certainly in the world of otolaryngology, this is far more often the rule than the exception. One option is always do nothing. Another is non-invasive medical therapy. Another may be a minor procedure. And yet another is surgery. In most instances, I think if it's not an emergency and it's reasonable, the order of care should proceed in the order above with surgery being the last option offered unless circumstances indicate that it is the best initial option.
This third tenet of mine is where I think predatory practices occur most frequently. I'll give a couple of examples. A child comes in to the ENT clinic with a history of recurrent otitis media. He's 2. He's in daycare. His mom smokes. He is not allowed to lie flat with a sippy cup. He does not have any speech or other developmental delays. He is an otherwise normal child. His most recent infection was 2 weeks ago and there is still fluid in both ears causing some hearing loss on a hearing test, but the fluid is no longer infected. He has had 3 infections in the last 8 months. If an ENT suggested as a first treatment option the placement of tubes, I would consider this a decision based on the financial benefit to the physician rather than what might be best for the child. Absolute indications for the placement of PE tubes for children under 3 (meaning tubes should be placed) are 1) 3 episodes of acute otitis media (AOM) in 6 months or 4 episodes in a year or 2) the presence of fluid in the ears for 3 months or more with a hearing loss on an audiogram. This child does not yet meet these indications and actually has 2 of the most common risk factors that can cause OM and if eliminated may prevent further infection (daycare and mom smoking). Both or neither may be able to be changed. Nevertheless, both should be considered before surgical intervention in my opinion. Now if they child came in with 8 infections in the last 8 months then my recommendation would follow evidence-based guidelines--placement of PE tubes--because the risk of that child developing significant speech and language deficits is quite high.
The 2nd example is with treatment of obstructive sleep apnea (OSA). There is without a doubt no argument that the single most effective treatment for OSA is a CPAP mask. A physician simply cannot argue that point. Study after study demonstrate it. Nevertheless, you will hear advertisements on the radio or in print or even on tv for the treatment of snoring and OSA. They will offer same day surgical intervention (albeit minor surgical procedures in the office) to "cure" your snoring and OSA. Many times, these are for cash pay only practices. The physician doesn't accept insurance and will charge a minimum of $1500 for a procedure that insurance will cover for far less. More importantly, they frequently will not assess for the severity of the OSA and will recommend the procedure or procedures first and then say if it doesn't work, they can get the sleep study to find out how severe the OSA is. The problem I have with that is that they are trying to collect revenue before getting the information to make the best decision for the patient at the outset. In the worst case scenario, I fear that an unsuspecting patient may have improvement in snoring, but not in their undiscovered OSA. Because the patient isn't snoring enough to cause the spouse to be concerned, the patient thinks they're healthy but continues to have OSA and a level that's dangerous and puts them at increased risk of stroke, heart attack, hypertension, and many other significant problems related to untreated OSA.
In the story from MSNBC below, they talk about upcoding (the equivalent to upselling in the restaurant or retail world). We live in a country where physicians are paid based on the services they provide. More service means more fees. More fees means more reimbursement. There are some physicians who will, therefore, try to increase their services for more reimbursement. Upcoding is even more nefarious. It is when a physician purposefully says that they provided more services than they did specifically in an effort to generate more revenue. It's unethical. It's also illegal.
I think I know why it's becoming more prevalent. Physicians are the only professionals who are paid by a 3rd party after services are already rendered. They are also the only professionals whose contracted rates have continued to decline over the last 30 years. Many professionals see their incomes roller coaster based on the economy, but physicians are unique in a clear and consistent decline despite whether the economy booms or busts. This puts tremendous pressure on them to maintain their desired lifestyle while trying to dig out of the enormous debt heaped upon them from college, medical school, residency, and fellowship, as well as then taking out loans to open a practice. Regardless of economic pressures, the 3 core values above should be the overriding influences on patient care.
So what would I recommend to patients?
Here's what I would look out for:
- a physician who offers one treatment option, especially if they can't explain why that's the only one available without being able to cite medical studies demonstrating that other options are not reasonable
- a practice where the physician doesn't accept insurance, but offers procedures for cash when insurance will cover those procedures in other practices who do accept insurance
- a physician who jumps straight to an expensive treatment option without offering others or at least evidence-based reasons why the lesser expensive options are not viable
- a physician who, when you come in to talk about your ear pain, spends more time talking about how they can straighten your nose that never really bothered you in the first place
- a physician who offers procedures before getting studies or required information from your history and physical exam to demonstrate that those procedures are of potential benefit
- a physician who tells you what you need, rather than offering recommendations they'd offer to their own family
- any physician and practice that while you're there you feel uncomfortable with what they are telling you to do. Keep in mind, you might not like what you hear because it's not good news about your health (you have cancer) or it's important to change an unhealthy habit that you might not want to change (smoking). Separate your personal feelings about your own condition from the bedside manner of the physician. If it's the physician who makes you uncomfortable, don't be afraid to get a 2nd opinion
- a physician who recommends getting a CT or other test in their office without explaining why it's important/necessary. In my opinion, diagnostic tests should only be done if it will change the management algorithm.
Here's what I would look for:
- well, anything that is opposite of the above
- a physician who takes the time to explain the indications, risks, benefits, and alternatives or various treatment modalities and can offer evidenced-based medicine to support their recommendations
- a physician who listens to your concerns and addresses those concerns first and foremost, without trying to influence you to consider treatment for elective (especially cosmetic) issues that were not of a concern before the visit
- a physician whose demeanor puts you at ease and makes you feel comfortable that they are competent and has your best interests in mind
- a physician who tells you it's ok to get a 2nd opinion. (One patient came to see me for a 2nd opinion specifically because the first doc told her that she shouldn't get a 2nd opinion because he was the best, he was right, and she'd just end up back in his office anyway asking for the procedure he offered her
I do believe that most physicians practice medicine with altruism. Physicians are human, and like in any business, there are some who can be influenced by less altruistic motives. It is worthwhile being aware of it so that you can make sure that you are actively involved in seeking the best options for your medical care.