I once spent a few months working in an internal medicine practice that had purchased its own stress-test machine. After the purchase, the number of stress tests ordered skyrocketed. Many were for patients who didn’t really need them.
Conflict of interest has been in the news a lot lately—the Trump/Kushner White House and business dealings have taken ‘conflict of interest’ to new heights. (It has also become one of the president’s favorite phrases.) The naked rapaciousness in our new administration would make even Rod Blagojevich blush. But the thing about political conflict of interest is that it can feel oddly distant to the very people it harms.
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Medical conflict of interest, however, is a far more intimate affair. The doctor-patient relationship is a one-on-one interaction, and so conflicts of interest are concrete and directly personal. If there is any sort of external influence that compels a doctor to prescribe a particular statin, or to refer a patient to a specific radiology center, or to implant a certain brand of artificial knee, then medical decision-making will be tainted. The harm an individual person stands to receive is obvious.
Most doctors, though, do not think they are influenced by anything other than their patients’ needs. The doctors who purchased the stress-test machine honestly believed they were offering a convenience to their patients who would no longer have to travel across town for their tests. But as I watched patients undergo a test for which they had only the mildest of indications, I could see that the medical decision-making was influenced at the very least by the sheer accessibility of having the stress-test machine in the next room over.
What’s the harm of over testing? More testing means more false positives—and the percentage of false positives goes up in the patients who are least likely to have a disease to begin with. Beside giving someone the fright of a heart disease diagnosis, a false positive stress test can send a patient to the cardiac cath lab, and a percentage of patients who undergo cardiac catheterization will experience harms: arrhythmia, heart attack, stroke, bleeding, anaphylaxis, or death. That risk may be worthwhile for a patient who really needs it. But for a patient who didn’t need the test and experienced terrible harm, that’s about the worst kind of medicine we can give. And of course, all the patients—and their insurance companies—ended up paying more for care they did not need.
Medical conflict of interest, of course, extends beyond the exam room to research, medical education, practice guidelines and medical advocacy. The journal JAMA found enough out there to devote an entire issue to the topic. For most patients, though, most relevant part is what might be influencing the person on the other side of the stethoscope. Patients can now look up how much money their doctors or hospitals have received (and from whom) on sites like ProPublica’s Dollars for Docs or the federal government’s Open Payments database. It can be jaw-dropping to see how much money pharmaceutical companies and device manufacturers pump into the medical system. While some of this money is directed toward education, it’s no secret that companies “invest” in the medical community because it pays back in spades. Doctors’ prescribing patterns can be influenced even just by a free lunch from these companies, even though most doctors remain staunchly convinced that they are not swayed by such tactics.
A natural experiment took place in 1997 when Medicare reorganized its geographical pricing system. This 1997 consolidation, which adjusted reimbursement rates to account for variability of costs around the country, meant that some regions experienced a sudden change in reimbursements.
In areas that lucked out and found themselves getting paid more for the same medical care, there was a concomitant brisk increase in medical services rendered. It’s unlikely that these Medicare patients suddenly got sicker—there wasn’t much change in things like dialysis or cancer treatment. Most of the spike in medical services was accounted for by elective procedures. While elective procedures like cataract removal and cardiac catheterization can often be medically necessary, there is a yawning gray zone in which these procedures get done for tenuous indications—as my former colleagues illustrated.
Researchers also noted a surge in the number of MRI machines purchased. Interestingly, most of these MRI machines were bought by nonradiologists. Radiologists own MRI machines because it is a necessary tool for their trade, but most nonradiologist doctors don’t need an MRI machine. And, unsurprisingly, the data revealed that most of the increase in MRI scans came from these non-radiologists. Even more illuminating was the type of MRI scans done: There was a marked increase in orders for MRIs of the back, whereas there was no change in MRI scans of the head and neck. (Imaging studies of the lower back for ordinary back pain are nearly always unnecessary and notoriously overused, whereas MRI scans for the head and neck tend to be used more appropriately.)
Analyses like these make it clear that medical care responds to money. This is not to say that all doctors are money-grubbing slime; on the contrary, most doctors are conscientious and genuinely try to do right by their patients. But medical decisions can be still swayed by money, even unconsciously, regardless of whether it’s from insurance companies or from industry.
Patients, though, would obviously prefer medical care be swayed only by our medical needs, not by market forces. So how do we address these enormous conflicts of interest in health care?
The pernicious effects of bribery by the drug and device companies require aggressive policing. Transparency of who is receiving this money, illuminated by the various databases, is an important first step but not always directly helpful to patients—especially if they are sick, or desperate, or lacking in internet or English-language skills. For the medical profession to retain a shred of its integrity, it has to flatly forbid for-profit companies from meddling in clinical care (in the same way that legitimate news organizations erect a barrier between the news department and the editorial department).
The conflict of interest raised by fee-for-service is trickier because of the fragmented nature of the American health care system. Bundling of payments is one possibility—for example, creating one fixed reimbursement rate for addressing back pain, whether a doctor prescribes ibuprofen or orders an MRI. But the most effective way would be to eliminate financial incentive altogether and have physicians be paid a salary rather than receive pay based on what procedures they order. My former colleagues’ income increased every time they ordered a stress test, whether it was necessary or not. Medical organizations like Kaiser Permanente that utilize the salary model deliver care that is recognized as both cost-efficient and high quality.
Switching to salary-based pay, though, still wouldn’t erase the most basic conflict of interest inherent to the American system of health care. That conflict of interest would be the fact that health care access is already tied to health insurance, and health insurers hold the purse strings that determine payment to doctors. Presence or absence or extent of health insurance is the most powerful influence on how doctors care for patients: Most patients can’t get to doctors at all if they don’t have insurance, and if they do have insurance, the more coverage they have, the more medical care they get. To address this conflict of interest, there is only one ethical option: universal health care.
Historically, universal health care has been a third-rail in medical policy discourse. The specter of socialized medicine is anathema for an America that prides itself in rugged individualism. However, the current political turmoil around health care may have offered an oddly salutary silver lining.
The lurching medical policy decisions of the Trump administration and Congress has allowed ordinary Americans to witness how the sausage of our health care system is made. The broader public has become viscerally aware that a for-profit system of health care means that when the chips finally fall, it is money and politics that matter more than patients. When maternity care, mental health care, and pre-existing conditions can be jettisoned for expediency’s sake, it’s clear that the patients’ best interests have fallen off the table.
Now that Americans have had a taste of medical fairness that the Affordable Care Act attempted—however imperfectly—to promote, they recoil from the specter of millions of people blithely axed off the heath insurance rolls in an effort to placate political or financial priorities. And they are painfully aware that in our country, getting cut from health insurance essentially means getting cut off from medical care.
The conflict of interest can’t get any more manifest than this. If we in the medical profession want the public to believe that our commitment to patients is our highest priority, then we need to take the lead in combating the forces that threaten this. We need to take a stand for our patients by rejecting industry money that sways medical decisions. We need to condemn the fee-for-service system that warps the priorities of medical care. And we need to forcefully advocate for a universal health care system that offers medical care on the basis of being human, not on the basis of being moneyed.
We don’t yet know where the Trump administration and the congressional leadership will finally end up with health care. Things may have quieted for the moment, but health care seems to be the zombie that keeps coming back to life in Washington. But the American public is now leaning toward the principles of a single-payer health care system, even if those exact words are not yet explicitly mouthed. The conflict of interest in our current system has become so palpable to the ordinary citizen that it’s going to be impossible to stuff the genie back into the bottle.
The system will only change when the American public insists on it. The fury expressed at town hall meetings this year suggests that the beast is stirring. But if the medical profession wants to retain its credibility as advocates for our patients, we need to be leading the charge.