[Here is a slightly edited version of an (as yet unpublished) letter I wrote to the editor of the New York Times, for your edification.]
To the editor:
I read with interest the article (“How One Hospital Benefited on Questionable Operations“, August 12) on the enormous fine Tenet Healthcare has just agreed to pay to the government to resolve accusations that doctors at one of its hospitals conducted unnecessary heart procedures and operations on hundreds of healthy patients.
You note that this is the largest penalty ever paid for accusations that a healthcare company billed federal health programs for unnecessary care. Criminal investigations of the doctors involved, although not the hospital or Tenet Healthcare, are underway.
Yet, such egregious cases are the tip of the iceberg of the abuses for-profit healthcare corporations commit in the name of patient care at the expense of those patients and the taxpayers, and they are by no means restricted to the notorious Tenet. ‘Benefiting from questionable practices’ is the name of the game in for-profit healthcare! In an era when community-based hospitals with an investment in quality care for members of their community struggle to remain afloat, the massive healthcare holding companies enjoy respectable growth and continuing returns on their shareholders’ investments. One would be hard-pressed to explain this distinction without suspecting questionable practices.
Mental health services, where the question of whether a patient requires care is more a subjective value judgment unsupported by laboratory or examination data, provide perhaps the greatest opportunity for a hospital’s owners to maximize Medicare reimbursement, and operating behavioral health facilities is the most fiscally healthy facet of for-profit corporate healthcare. As Medicare is the payor for our elderly patients as well as younger patients permanently disabled by major psychiatric illnesses, this results in exploitation of some of the most vulnerable in our population.
As until recently the medical director of a psychiatric hospital owned by a large healthcare corporation, I had a firsthand opportunity to see aspects of how this agenda is translated into operating policy. One example — it became clear to me that a concerted management policy functions to exclude clinical input from the loop when deciding which patients are to be accepted for admission. My name was routinely listed as the “accepting doctor” for cases I had never reviewed and would not have found suitable for inpatient admission (i.e., could the care they require be provided in a less expensive community setting? Could they be expected to benefit from the services of a hospital?).
Despite the perennial complaints of physicians and nurses at their facilities, the admissions offices of hospitals in this chain are staffed, as a matter of policy, with personnel who are not healthcare professionals and have no clinical expertise. Admissions policy amounts to, literally, nothing beyond filling vacant beds with paying patients as rapidly as possible. A similar climate shapes care after admission. Again, because justifying continuing need for inpatient stay is largely subjective in mental health care, utilization review functions to argue with payors for continued stay for as long as possible regardless of the clinical merits. Administrative consideration of the appropriateness of an admission does not occur until a patient’s benefits are exhausted and the hospital is no longer being reimbursed for continued treatment. Because Medicare is not “managed” and there is no prior approval or outside review of the appropriateness of hospital level of care, there is never any pressure for discharge of Medicare patients.
I was faulted for attempting to divert geriatric admissions to specialized geropsychiatry units or to psychiatry units in general hospitals where, as contrasted with a freestanding psychiatric facility, they receive more comprehensive and safer care for the medical and mental health problems which are often intermingled in a behavioral decompensation. A further reason for attempting to divert geriatric admissions from my hospital and other hospitals in its chain is that its corporate owners have a misguided risk management policy of not honoring patients’ advanced directives. Often, a patient and her family are not informed until after admission that the patient’s “Do Not Resuscitate” wishes will not be honored, i.e. that aggressive resuscitation measures will be initiated on all patients who have a cardio-respiratory arrest at that facility regardless of their wishes. But attempting to implement a policy of quality control assuring that the admissions department alerts potential admissions and their families to this policy results in lost admissions opportunities and empty beds.
Concerned about these practices after the corporate takeover of the hospital, the state regulatory agency responsible for its license and oversight placed the hospital under renewed scrutiny for these and other practices. As a result, the hospital was ordered more than a year ago to enhance the role of clinical leadership in making sure that all admissions were clinically appropriate rather than just a matter of managerial convenience. Instead of implementing the required changes, clinical management was replaced with more pliable personnel whose oversight has been pro forma.
This is a process I have seen repeated, with little variation, at a number of behavioral healthcare facilities in the for-profit sector. Those concerned with healthcare costs and any vestiges of ethical responsibility that healthcare providers have for their patients in our increasingly corporate-controlled healthcare industry would do well to look at the mental health sector and the “grey area” of practices which exploit Medicare reimbursement without on the surface of things being overtly fraudulent. Over recent decades, I shared most physicians’ concerns about the increasing intrusiveness of managed care scrutiny over their practices. My recent experiences have persuaded me, to the contrary, that such scrutiny may be the only hedge against the rapacious practices of the for-profit healthcare corporations. Those interested in cost containment would do well to advocate for a managed-care system for Medicare, the nation’s single largest underwriter of healthcare costs, similar to that which has made other insurers less exploitable by healthcare-for-profit. This would be a far more rational measure than focusing solely on fraud prevention and prosecution after the fact.
Sincerely,
Eliot Gelwan MDBrookline, MA
