Doctored

by Sandeep Jauhar

  “I’m not doing it on purpose.”

  “Dad didn’t do it on purpose either,” Rajiv shot back. “Look, you asked me to set this up. I leaned on my friendship. I arranged all the meetings at the hospital. Now, why the fuck do you care how much he makes! You feel he is screwing you because he gives you work. You resent him instead of appreciating the opportunity you have been given.”

  I kept quiet. There was a grain of truth in what Rajiv was saying. I subverted my own goals and then obsessed over the consequences. Why did I wait for a calamity before trying to change?

  “He hired you only because you are my brother,” Rajiv taunted me, and he was right. Chaudhry had been raised in a culture where fraternal relationships are paramount. You put up with someone’s bullshit if his brother is your best friend. He was constrained by his traditions, and I had taken advantage of it.

  “This is the only way you can continue to work at LIJ and still pay your bills,” Rajiv said, calming down. “If you lose this, you have nothing. You will have to go into private practice full-time. You will have to do the same shit as Chaudhry and all those other doctors you despise.”

  “I know,” I said quietly. “I don’t want that.”

  Rajiv reminded me once again about his short time in private practice in Stony Brook, New York. “Remember that internist who called me in the middle of the night for that old lady with pneumonia? There was a rule that patients had to be seen within three hours of arriving in the ER. I told him I’d see the patient in the morning, and so he tells me, ‘If you can’t see her, I’ll call someone else,’ because he didn’t want to go to the ER himself, and the message was ‘Get your ass out of bed or you’re going to lose my business.’ I quit the next day.”

  I had heard this story many times. If Rajiv couldn’t handle full-time private practice, there was little hope for me.

  “It’s just hard to do this every weekend,” I said, my voice cracking. “I want to spend time with my family, too.”

  “This is for your family, Sandeep! Why don’t you understand that? Maybe I’m naive, or maybe I’m a bad father for not going to every soccer game; but I really don’t see the problem. You just have to do it. I mean, do you need the money? Maybe you don’t need the money anymore. I don’t know your situation.”

  “Don’t be an asshole. You know I need the money.”

  “Well then, you have your answer, right? You don’t have any options. Just remember where you were when we were playing basketball in my backyard. This is life. Nothing is free.”

  TEN

  Moral Hazard

  Passengers who insist on flying the plane are called hijackers!

  —Russell B. Roth, M.D., AMA president, “A Bankrupt Law,” American Medical News (1976), on the passage of the HMO Act

  When my family arrived in the United States from New Delhi in the winter of 1977, we moved into a tiny two-bedroom house in Lexington, Kentucky, with a creaky porch and a cracked footpath that ran like an artery through the front yard. We lived simply. My sister, Suneeta, and I shared a bedroom, while Rajiv had to sleep on a cot in the dining room, next to a clanging radiator, dozing off most nights to a Cincinnati Reds ball game on his tiny transistor radio. We ate meals on a scuffed table we bought at a garage sale, which doubled as a Ping-Pong counter after Rajiv and I installed a makeshift net made of twine secured by two pencils. The house was freezing, but I don’t remember our ever complaining. We took Dad at his word that President Carter had asked citizens to keep the thermostat below 65 degrees Fahrenheit to ease the energy crisis.

  The one luxury we enjoyed was that on special Saturdays my parents took us to an all-you-can-eat buffet called Duff’s. We’d starve ourselves until early afternoon and then pile into our white Ford Maverick compact for the drive into town. My father, dressed in polyester slacks and short sleeves, would be in the driver’s seat, while my mother, in a cheap sari and overcoat, would continuously admonish him to slow down and stay clear of big trucks. By the time we made it into the crowded parking lot, it was usually three o’clock. Duff’s had low wooden beams and stained-glass windows and was dark and cool, like a church. We’d wait in line, fidgety with hunger, as the savory smells drew us in. Dad’s and Mom’s tickets were two dollars apiece, Rajiv’s and mine a dollar, and Suneeta, who was three years old, ate for free. After Dad had paid the cashier, we sprinted over to the smorgasbord of fried chicken and potatoes au gratin and trout amandine and a salad bar that stretched to the horizon, and filled our plates. We’d fill them again and again. If the chicken got cold, Dad would tell us to throw it out and get more. He wouldn’t think twice about discarding an untouched piece of pecan pie if he decided he wanted a custard cream with his coffee instead. We gorged; we were wasteful; we took advantage—because it was (essentially) free. We’d eat so much that one of us would invariably get sick on the way home. When the price went up, we stopped going.

  I often think of Duff’s when I think about waste in health care. Someone else appears to be paying for it, so who cares how much it costs? In 1867 the Aetna Guide to Fire Insurance introduced the concept of moral hazard into actuarial science. The publication warned that generous insurance policies could make some people careless about preventing fires. Protected in part from the consequences of their actions, those people were more likely to engage in risky behavior, like not clearing their yards of brush or leaving their houses without adequate ventilation. The guide made a revolutionary and counterintuitive point: insurance in some cases can increase risk.

  Moral hazard undoubtedly plays a role in health care, too. When people complain that their rising insurance premiums are funding others’ irresponsible behavior, they are complaining about moral hazard. When patients with low-deductibility insurance go to the emergency room for a hangnail, they are succumbing to moral hazard. When a nurse in the ICU criticizes a family for refusing to authorize a DNR order (“They would never do this if they had to pay for it”), she is talking about moral hazard. The moral hazard hypothesis was put to the test in the 1970s with the RAND Health Insurance Experiment. For a decade it followed eight thousand people who had been randomly assigned to one of five types of health insurance plan: an HMO-style group cooperative or a traditional plan that covered 100 percent, 95 percent, 50 percent, or 25 percent of costs. Predictably, the study found that medical spending was highest when 100 percent of costs were covered. If health care is perceived as free, patients will demand more of it.

  Moral hazard is at play on the provider side, too. Chest pains? Why not order a stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor—and throw in an echocardiogram for good measure. It is too easy to prescribe tests when you know an insurance company will pay for them. “Supply may induce its own demand [when] a third party practically guarantees reimbursement,” wrote the authors of the Dartmouth Atlas Project, and there are strong data to support this assertion. For example, the number of freestanding diagnostic imaging centers owned by doctors or private investors has more than doubled during the past decade. A doctor who owns a nuclear scanner is seven times as likely as other doctors to call for a scan. The growth in the volume of imaging services has far outstripped the growth of all other physician services. In 2006, Americans were exposed to seven times the amount of radiation than they had been in 1987, primarily because of CT scans, which now number more than seventy million per year.

  Of course, many forces, including new and expensive technology, the aging of the population, and the rise of chronic diseases, are behind increasing imaging costs. But moral hazard undoubtedly plays a role. Managed care, with its reliance on high deductibles and capitation, in which physicians are paid a set amount per assigned patient, whether or not that patient seeks care, came of age with the idea of controlling moral hazard. In the 1970s many insurers adopted co-payments to increase the price of medical care to consumers in an effort to reduce inefficient spending. In the 1980s and 1990s, economists promoted fixed payments and utilizati
on review, in which payers approve or deny requests for medical services, to further reduce moral hazard. The managed care system that we know today is largely a product of this theory. And though it worked for a while—health expenditures slowed significantly in the 1980s and 1990s, the heyday of managed care—patient and physician revulsion against third-party interference in medical decision-making eventually forced many insurers to back away from these unpopular cost-cutting strategies. Health care spending has accelerated once again over the past decade.

  * * *

  After the blowup with Rajiv, I committed myself to changing my standoffish ways. Rajiv had been urging me for some time to meet socially with his physician friends in a relaxed atmosphere away from the hospital, and so there I was a few weeks later at a doctors’ party in Manhasset, a tony suburb on the North Shore of Long Island. The host, a Sikh internist with a bright red turban, greeted me warmly when I arrived. “Rajiv is my best friend,” he said, putting his arm around me and showing me to the foyer where shoes were stowed. “We have heard so much about you.”

  I found Rajiv in the dining room playing an Indian card game called teen patti. He was cracking jokes, holding court, acting every bit like the Indian mensch he was reputed to be. When he saw me, he bounded over, obviously tipsy. “I’m glad you came,” he said, giving me a hug. He handed me an empty tumbler. “My bro is here,” he cried to the host. “Break out the good shit!”

  Rajiv went back to his card game while I stood awkwardly in the middle of the room. Turning to the oncologist sitting next to him, he said, “All right, asshole, now place a real bet. It isn’t even one co-pay.” When the doctor quickly folded, Rajiv said, “Don’t worry, the next bone marrow biopsy is on me.”

  Someone piped in: “The next anemia consult is on me.”

  I went to the kitchen and poured myself a Scotch. Out in the living room, a group of mostly male doctors were relaxing on couches and foldout chairs, drinking Black Label and chatting comfortably. I sat down next to a lanky Gujarati doctor in private practice whom I’d met several times on the wards at LIJ. “Haven’t seen you in a while,” I said, trying to sound pleasant and familiar. He nodded politely and turned his attention back to the conversation.

  “I tell you, medicine has been taken out of our hands and put into the hands of uneducated people,” a Punjabi internist perched at the edge of the sofa was saying. Apparently he had sold his practice about a year prior and was now working part-time at a hospital in Brooklyn. He recalled some of the annoyances when he was practicing full-time. “Insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an MRI, I’d have to explain to a clerk why I wanted to do the test. It was a big, big headache.”

  When he decided to work for a hospital, he figured there would be more freedom to practice his specialty. “But managed care is like a magnet attached to you. They say you didn’t take authorization for this test. I tell the girl, ‘Why should I take authorization from you? You’re not a doctor. You just read about this in some book.’”

  “It is getting so bad,” someone responded. “They want us to practice perfect medicine, but they put up barriers at every inch.”

  “I have to spend hours on the phone getting precertification,” a Jewish family doctor said. “I order a drug and the patient calls me up and says the insurance company won’t approve it, and somehow it is my responsibility to fight the company for them. Part of me wants to say, ‘I ordered the drug; I did the right thing. Now fight your own battles.’”

  “People think we are greedy,” Dr. Oni, the Nigerian internist with “consultitis,” declared. “But look at these insurance companies. For some of them it is written into the medical director’s contract to deny every fourth admission.” (I had heard a similar charge from a billing clerk at my hospital.)

  “Thirty percent of my admissions are being denied,” the Punjabi internist replied. “There is a forty-five-day limit on the appeal. If you don’t bill in time, you lose everything. You’re discussing this with some guy on the phone, and you think, You’re sitting there, I’m sitting here. How do you know anything about this patient?”

  “It is all about the money,” Oni asserted. “Look at these capitated insurance programs. They say they will pay fifteen dollars a year per patient. Now, can you see a patient for fifteen dollars? Even if you see her once a year, is that enough?”

  “Why did you sign the contract?” someone demanded.

  “Because doctors are not united,” Oni replied to murmurs of agreement. “If you say no, you know Dr. B or Dr. C will say yes. They will get the contract and the patients. It is still money, even if it is not a lot.

  “An internist like me,” he went on. “Let’s say you want a certain salary to meet your family’s expenses. That means you have to double it to pay your overhead. I used to have a nurse. That’s one hundred thousand dollars a year. A physician’s assistant is ninety thousand. A nurse practitioner is one hundred and ten thousand. Who can afford it? You have to bring in half a million just to achieve your salary goal. I used to see fifteen patients a day. Now reimbursement is so low I have to see at least thirty. If I stay in the room more than ten minutes, my assistant will call me and tell me to hurry up.”

  He said he was doing a plethora of tests—eye exams, audiometry, pulmonary function tests, even Holter monitoring—to generate revenue in the office. “You ask yourself, which doctor would you want to go to? One who does every test, never mind that they are normal”—he laughed bitterly—“or one who doesn’t do such a thorough job? A lot of this is also being driven by patients asking for tests.”

  I’d heard a similar assessment from Chaudhry. Quietly listening, I nursed my drink.

  The Punjabi internist said that he used to work with a pulmonologist. “To bill for lung spirometry, he would have the patient quickly blow into a tube. He didn’t even look at the results. We did stress tests, too. We knew who was going to be normal. We avoided the high-risk cases, the asthmatics and the hypertensives.” He laughed. “Those we would send to a cardiologist.”

  A gastroenterologist with waxy brown hair said: “If a doctor doesn’t do excess testing, forget it, he isn’t going to be able to live. This is the only profession in the world where you can provide a service and not know if you are going to be paid for it.”

  Oni said he had received payments from a mobile echo company for referring patients for cardiac ultrasounds. Though he no longer participated in these contracts, he was open about the fees—about $100 per patient, paid in cash—and he saw nothing wrong with it. “As internists, we don’t do procedures, so we have to figure out another way to make money. But it isn’t hard once you figure out how to do it.”

  “We don’t clock the number of minutes when we talk with our patients,” someone said. “We don’t hang up the phone as lawyers may do if they are not going to get paid. No, we listen to patients and answer their questions, however long it takes.”

  The family doctor suggested that patients call a toll number if they wanted to speak to their physicians. “Sure, I’ll talk to you,” he said. “Just call this 888 number. I’ll talk to you as long as you want. I’ll even talk dirty to you.” People laughed. “My lawyer always tells me, ‘If I’m thinking about your case, even while I’m taking a leak, you’re getting charged three hundred and fifty dollars an hour.’”

  Oni said, “I have a cousin who is an ob-gyn. He is paying one hundred and fifty thousand dollars a year for malpractice insurance. As an obstetrician, you have to earn five hundred thousand dollars just to make ends meet. That is why people don’t want to do it anymore.”

  “I did obstetrics,” someone replied. “They used to pay fifty-five hundred dollars for fourteen office visits plus a delivery when you stay up all night. Now they pay twenty-four hundred. You think that’s reasonable? Your wife delivered. Is that enough money to make it worthwhile?” He shook his head,
disgusted. “The problem is, they cut the money, they took away the autonomy, but they didn’t take away any of the responsibility.”

  “It is getting tougher and tougher,” the only female doctor in the room declared. “Everyone is looking for procedures. I feel sorry for the patients. We’re sending them here and there, for this test and that. Sometimes I tell them, ‘Go home. You’ve had every test. There is nothing more for me to do.’ I said to my husband, in a few years, when the mortgage is paid off, I want to do something else. This is not the concept of medicine I had when I started.”

  Back in the kitchen, I poured myself another drink. Rajiv came over. Now drunk, he slapped me hard on the back. “You should talk to Dr. Shah,” he said. “Give him your card, your cell phone, your beeper. Tell him to call you anytime.”

  I nodded and looked away.

  “I still can’t believe you came,” Rajiv said. “Are you having a good time?”

  * * *

  A few months later, in the midst of the global financial crisis of 2008, I went to Parents’ Night at Mohan’s preschool on the Upper West Side. The party had a Polynesian theme, and the gymnasium was replete with luau decorations and hula dancers. At the tiki bar I ran into an old friend, Stephen, who had dropped out of medical school at Cornell twenty years earlier to pursue investment banking. Whenever we meet, Stephen always seems to find a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.

  That night we talked about the tumult on Wall Street. Like many of his colleagues, he was worried about the future. He did not foresee continuing rewards for what he had been trained to do.

  “It’s a good time to be a doctor,” Stephen declared. “I’d love a job where I didn’t have to constantly think about money.”