"I had begun to feel that we were part of some psychology experiment whose design was to see how quickly we could abandon our humanity."
--Dr. Linda Peeno, an ex-medical director and claims reviewer for HMOs, confessing why she quit, in U.S. News and World Report, March 9, 1998.
Back in the twentieth century, the United States of America enjoyed the most extraordinary economic growth, the most incredible scientific advances, and the most successful global empire. Nothing could threaten the mighty nation--nothing, that is, except an enemy within. The nation's health care system grew and grew, until finally the nation's leaders realized that it meant to devour the entire national economy.
After decades of failed reforms proposed by economists, policy analysts, and other social-science wizards, the leaders turned at last to the Grand Psychologist. He alone, they thought, might understand the psyche of the health care monster and know how to tame it. The problem, he explained to the leaders, was people. Human beings have an unlimited, incurable desire to help sufferers. When humans take care of other people--especially vulnerable, frightened, sick people--a strange love overcomes their reason. They develop bottomless sympathies, delusions of kinship, and fierce loyalties to the people they care for. They will do anything to help.
The Grand Psychologist believed he could save the country if he could conduct a bold experiment. He would need to stifle human compassion. But he knew the leaders would be upset by his plan, since they needed to present themselves as compassionate in order to get elected. So he told them instead that he would use simple economic tools called incentives.
First, he asked for authority to change the way healers get paid. He would pit the financial self-interest of healers against their emotional impulses. He would penalize them for excess generosity.
He started with the hospitals, the biggest gobblers of medical dollars. He outfitted Medicare--the biggest supplier of hospital cash--with a new reimbursement system. Henceforth, every patient was assigned a diagnosis (never mind that most people have more than one thing wrong with them). For each diagnosis, Medicare set a firm limit on how many days of care it would pay for. If hospitals can't stand to see their patients suffer when the Medicare jig is up, the Grand Psychologist said, let them eat the costs of their soft-heartedness. Having to think of each patient as a diagnosis with a price tag instead of a person with life, he reasoned, would soon dampen hospitals' compassion.
And sure enough, hospitals reacted by evicting Medicare patients before their Medicare money ran out. They also tried to squeeze higher rates out of other insurers. But very quickly, these other insurers felt suckered--so they, too, adopted tougher controls on what sorts of treatments could be lavished on the sick. Nurses and doctors had no choice but to stop doing as much for sick people. They shuttled sick patients off to somewhere and somebody else--to nursing homes, rehab centers, or relatives--and they called it "discharge planning" to convince themselves they were actually still doing something for the patients.
Riding high on his success making hospitals less hospitable, the Grand Psychologist urged the nation's leaders to use his new "prospective payment" plan everywhere that people take care of the sick--nursing homes, clinics, mental health hospitals, private homes, and even doctors' offices. The leaders obliged.
But the Grand Psychologist soon realized that financially squeezing medical institutions didn't pinch healers hard enough to curb their costly compassion. Everywhere, the healers were breaking rules, committing minor acts of fraud or disobedience in order to get their patients' care covered. They were lying to insurers, fudging patients' records, exaggerating symptoms, upcoding illnesses, stretching the truth to fit reimbursable diagnoses, concealing either too much progress ("insurer has determined that care is no longer necessary") or too little ("hopeless case--care not medically effective"). Sometimes, they just gave care without billing for it. In poverty-stricken neighborhoods and public hospitals, doctors and nurses even knowingly allowed people to use other people's Medicaid cards to get treatment. Home care nurses and aides visited their clients on their own time, after hours, to provide help and comfort that insurers refused to pay for. Primary care doctors, who were supposed to act as gatekeepers to other services, were advocating for their patients instead.
The Grand Psychologist saw these healers as so many addicts to altruism, unable to stop caring and abide by the law. So he ratcheted up the pressure. The government slashed its Medicare budget, ensuring that hospitals, nursing homes, and home care agencies had to slash theirs, too. Meanwhile, he proselytized about unnecessary care, waste, and inefficiency, so the people would believe their healers were doing something wrong by caring so much. He planted the seeds of distrust between sick people and their healers.
As institutions cut personnel to stay within their straitened budgets, caseloads for the remaining staff increased. Nurses and aides were allowed less time with each patient. Managed care companies began paying doctors on a per capita basis, no matter how sick or time-consuming the patients. They said they were adjusting payments to account for the complexity and severity of cases in each doctor's practice, but they used a formula they knew accounted for only a tiny fraction of the differences. They started giving doctors bonuses for denying care. HMOs, whose doctors were captive employees, imposed productivity quotas: See so many patients per hour, or else.
Having little time to spend with each patient, healers were less likely to develop those intractable feelings of affection, compassion, and dedication to which they were unfortunately so prone.
Just to sever the bonds between primary care doctors and patients a little more cleanly, managed care plans required patients who needed hospital care to be treated by fulltime hospital staff doctors instead of their primary care doctors. These "hospitalists," as they were called, were sold to the medical profession and the public as specialists in complex and acute cases--better qualified and more efficient than mere generalists. Family doctors were no longer paid for visiting their patients in the hospital, providing the reassurance of a familiar face and the expertise of a long-term relationship. Hospitalists, after all, could treat--or not treat--with detached objectivity. And anyone who complained about the new worship of efficiency was tarred as a lazy slouch or a parasite on the social good.
Still, there were complaints. People resented being treated like parts on an assembly line or debits on a financial statement. Their legislators posted daily sob stories on the congressional video monitors. The newsweeklies profiled victims of insurance denial and screamed things like "HMO HELL" across their covers.
But the Grand Psychologist had other strategies to discredit healers and turn professional altruists into deviants. He declared that doctors hadn't sufficiently proven the effectiveness of their treatments, then accused them of practicing by habit, tradition, conventional wisdom, sympathy--everything but science. He espoused "evidence-based medicine," as if it were something new and most of what the healing professions had been doing before his dictature was witchcraft. He pumped ever more funds into randomized clinical trials to expose placebo effects. (Never mind that the placebo effect might represent the healer's true power, the power to give patients hope and enable them to heal themselves.) He aimed to deny reimbursement for any care that hadn't been scientifically proven in a large-scale randomized study. By challenging the scientific basis of medicine, the Grand Psychologist undermined people's trust in medical care and justified insurers' refusal to pay for it.
Alas, people continued to seek treatment for their suffering, and healers refused to give up on their patients. They continued to offer unproven therapies and comfort measures with no medical impact. The Grand Psychologist had no choice. He had to make compassion a crime.
He mounted a campaign against fraud and abuse, sending government auditors into hospitals, nursing homes, and home care agencies to scrutinize their records. The auditors found some genuine fraud--indeed, plenty of it. But predictably they also found zillions of clerical errors, incomplete forms, and other technical irregularities, for which the institutions were slapped with humongous fines and punitive damages. Inevitably, too, the auditors found zillions of cases where applying insurance rules called for professional judgment. They used the authority of the federal government to declare healers' pro-patient decisions wrong--and fraudulent. At last, those overly compassionate healers were exposed as the criminals they were. And finally this little reign of terror made healers think twice about helping their patients.
After a long day, the Grand Psychologist tidied his lab, sank into his armchair, lit his pipe, and admired his work. The experiment had been a complete success. ¤
