As we consider further Luigi Mangione’s alleged criminal activities and assault on the insurance industry, let us again focus our attention on physician behavior. Medical practice has a dichotomous nature. On the one hand, it is legitimately a business or profession, and physicians have every right to earn a good, indeed a more than good, income in exchange for the prolonged training, high skill and hard work they are expected to provide to patient care. This is no different from any other profession or job. But, in addition, physicians from time immemorial have also been expected to adhere to a higher ethical standard that puts patient welfare above all else. This is manifest in the oath, Hippocratic or Maimonidean, that physicians recite at graduation. This distinguishes the medical practitioner from real estate or car salesmen who have no higher calling or special ethical obligations.
For example, it is improper for a physician to perform and bill unnecessary services (recollect the patient with cataracts from a prior article) in contrast to the insurance agent or stockbroker, whose goal is to sell you more than you need, but for them it is appropriate good business and caveat emptor. When I was a resident, one of my attendings, an internist whom I greatly admired, casually told me one day that he did an electrocardiogram on virtually every patient he saw because he felt the payments that he received for regular visits were inadequate. My estimate is that the accrued income for this (ECGs are not costly) was sufficient to pay for his annual Passover trip with his large family, where the proceeds from his felony could pay for him to listen to a rabbi lecture on whether quinoa could be eaten on Passover. My guess is that he did not consider it truly dishonest because it was the insurance company paying these costs rather than the individual patients. Exactly the point.
Such peccadilloes are rampant in medicine despite the ethical mores, especially when it comes to procedures, such as surgical procedures. If there is a situation where it is a close call on whether surgery is indicated, and one consults a surgeon regarding what should be done, does the surgeon not have the greatest bias in choosing the proactive choice and earning thousands of dollars versus a sit-and-wait approach? Thus, as I have counseled in prior articles, second opinions in non-emergent situations are almost always a good idea. Most studies estimate that at least one-third of surgeries are unnecessary.
I would opine that the majority of physicians are mostly ethical and aboveboard, but one could cite innumerable well-publicized or published examples of physician financial misbehavior. The one that perhaps stands out the most in recent years is the scandal that surrounded the use of the drug erythropoietin. To understand this, one must appreciate that the major obstacle to the use of high doses of most chemotherapy drugs is the suppressive effects of these drugs on the cells of the bone marrow, where white blood cells, red blood cells and platelets are produced. Thus, a major advance in oncology occurred when scientists isolated and synthesized the growth factors that stimulate the bone marrow to produce white blood cells; this factor, granulocyte colony stimulating factor (G-CSF or Neupogen/Neulasta) is now widely used in oncology to permit the more aggressive use of chemotherapy drugs.
Analogously, an erythropoiesis-stimulating agent (ESA) was isolated and synthesized for stimulating the bone marrow to produce red blood cells, approved by the FDA in 1989 (Epogen or Procrit; Amgen and Johnson & Johnson). It was envisioned that this would obviate the need for most blood transfusions, and was used both in oncology and for renal failure patients who have chronic anemia.
The drug was expensive—about $1,000 per dose at the height of its use around 2004-2005. The way the pharmaceutical companies structured the payments, the oncologists and hospitals administering the drug received about $300 of that in return for prescribing and administering the drug—many patients were administered dozens of doses. Thus, the drug companies cleverly (one might say sinisterly) created an enormous incentive for physicians to find any rationale for the prescription of the drug to patients. How could that happen? While the initial guidelines suggested that the drug be prescribed for hemoglobin levels below 7.5, once these generous reimbursement schemes kicked in, physicians found it justifiable to expand the threshold for use of the drug until ESAs were being routinely prescribed for patients with hemoglobin levels virtually up to 10. I believe there were some private practices in which the income from this drug exceeded seven figures, and not uncommonly constituted half or more of the practice’s income.
It became the most profitable drug ever, with sales in 2010 reaching $2 billion (almost $3 billion in current dollars). The problem was that the use of ESAs led to serious complications since inappropriately elevated hemoglobin levels resulted in an increased risk of heart attacks, strokes and thrombosis, as well as stimulating tumor growth. My own group published a paper in the Journal of the National Cancer Institute in 2009 showing that, among 51,000 cancer patients treated between 1991 and 2002, 27% received an ESA (this is truly unbelievable!) and of those, 14% developed deep vein thrombosis. Multiple studies confirmed the negative consequences of this drug. Ultimately Medicare and the FDA put severe restrictions on its use. Johnson & Johnson was later severely fined for its actions.
I do not put forth this story as a condemnation of physicians. In my view, they reacted precisely as the circumstances were created to encourage them to behave. Similar behavior was later observed with opioids and Purdue, and I could describe multiple other anecdotes of lesser misdemeanors.
My goal and intent are not to criticize my colleagues (including myself), but to allow us to explore further the three-way relationship between providers, patients and insurance companies. When left to their own devices, many (not all, but many) individuals take advantage and cheat. Systems that involve humans require checks and balances and, in healthcare, it is the insurance company that provides that. How it does that and how successfully it does that and how pleasantly it does that we can debate. But there can be no argument that controls are required over the behavior of the physician and hospital system, as well as over the patient. Who else or what else keeps them from overtaxing the system? Indeed, who or what inhibits the physician from ordering not just an expensive intervention, but an incorrect one? The insurance company authorization is at least one element in the provision of that control.
Once again, I would invite readers to email me their thoughts on the issues raised in these articles as they appear in the Link and, depending on the response, I will put together one or two articles with readers’ comments after my eight articles appear.
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: ain1@columbia.edu.
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
