Dr. Johnathon Ross, a board member of Physicians for a National Health Program, who for years has been working to change the healthcare system, uses a combination of manipulation and outright threats at his Toledo, Ohio, clinic. Recently an uninsured patient in the throes of an asthma attack needed twenty tablets of cortisone, and Ross did not have them in his sample room.
So he turned to the hospital pharmacy.
Could the pharmacist spare twenty pills for a patient who could not afford to pay? No, the pharmacist responded, but the patient could buy an entire batch. Ross recalls that, without missing a beat, he said, "You'd better get the guards, then, because I'm coming down and I'm just going to take them. Let them try to stop me if they want."
When he arrived at the pharmacy, the pharmacist handed him twenty pills without a word.
Ross says that when he perceives he has a choice between acting for the patient or obeying the system, he always chooses the former. He also games the system with procedural sleight of hand. For example, he books all his welfare patients for appointments at the beginning of each month. The clinic generates a bill of $55 for their visit but does not collect the payment. The bill gives his patients evidence that they are spending down their assets, so they can stay on Medicaid.
Ross's practice of evading government regulators and private insurers is increasingly common. As Dr. David Himmelstein, co-founder of Physicians for a National Health Program, acknowledged, "It's almost routine that you shape things in the chart to make it look like something the HMO is going to pay for. If a patient with a headache needs to know that it's not a brain tumor, you shape the story: 'Didn't you have a little numbness in your hand at one time?' The patient says, 'Yes, there was that one time when my hand was a little numb.'"
Sometimes the confrontations between doctors and managed-care reviewers occur over taped 800 lines, allowing a glimpse of the angry exchanges that have become common. When Dr. Barrett Hyman, a gynecologist in Louisville, Kentucky, attempted to get a hysterectomy approved for Karen Johnson, a patient of his with cervical cancer, the recorded conversation with a high-level claims reviewer for Humana Health Plan, Dr. Martin Swartz, went like this:
"You're kidding," said Hyman, when Swartz recommended a less expensive and less effective treatment called a conization.
"I'd do a cone on my wife," Swartz said, adding, "we're not suggesting that anybody wait for invasive cancer."
After a debate of several minutes, Hyman exploded, "I know good and well...you wouldn't have your wife do it. So you're working for the damn insurance company and I think you're an ass..."
"What did you say?" Swartz demanded.
"I think this is an asinine approach to patient care," responded Hyman.
Johnson ultimately borrowed money for the procedure and sued Humana, her lawyer entering the recorded conversation between doctors into evidence. Last year, a Louisville jury awarded her $13.1 million in punitive damages, even though her case did not involve either serious damage or death, and $100,000 for pain and suffering. (State laws restrict most patients from suing their HMOs, but she was allowed to sue because her husband was a federal employee.)