Doctored (24 page)

He said that doctors wanted everything done in their offices so they didn't have to worry about their patients' venturing out and being snatched up by another physician. Moreover, the imaging companies were paying them a couple of thousand dollars a month in rent. “But it isn't free money for them,” Faisal said. “They have to give us patients to do echos on,” which would then be reimbursed to the company by insurers. And what was in it for the patients? I asked. He replied: “Patients don't want to do a lot of driving. If you see a 7-Eleven and a Shell station, which one will you prefer?” He paused for a moment and then answered his own question. “The Shell station—because it has gas and coffee. The 7-Eleven only has coffee.”

He told me that some of his competitors were outsourcing test interpretations to India, receiving reports that were generated by a machine, not a physician.

“Is that legal?” I asked, dumbfounded.

He laughed. “The market is so bad since the Russians came in. They go to school for echo; then they buy a machine and start doing tests. A doctor I know was working with one of these companies. I asked him to send me a male and a female report. They were exactly the same: same measurements, same conclusion, everything. It was all made up. Only the name was different. See, we are professionals, Dr. Jauhar. Not like those other guys.”

By the time I was finished that Saturday afternoon, I had made up my mind I was going to quit. I was seeing so many patients, reading so many unnecessary tests—and Chaudhry was keeping most of the revenue anyway. Working with Chaudhry, I'd decided, was like allowing your eyes to close momentarily while driving late at night. You know it isn't a good idea. You know your judgment is impaired. But you think you can control it.

I popped my head into the treadmill room to say goodbye to Malik. He must have seen something in my expression because he put away his reports and asked me to sit down. I didn't want to talk, but I sat down anyway.

“Look, I can see you're unhappy,” he said as I fidgeted like a student at the headmaster's office. “When you leave fellowship, you have this idealistic notion of the way things should be. All this running around burns you out, but it pays off in the end.”

I nodded impassively.

“Amir is a businessman, you understand,” Malik went on. “That's the way you have to be if you want to survive today. In my neighborhood I see electricians and plumbers. Time was, those guys couldn't afford to live in a doctor's neighborhood, but now they're making more money and doctors are making less. The status has changed.”

Eva came in to tell me that my car was blocking the driveway. Always the last to arrive, I was usually the first to leave, too. I told her I'd be right out.

“Most doctors want to help people,” Malik said. “But to make money for the ex-wife or the fancy house, they are starting to do stupid things. I know doctors who are doing treadmill tests on patients with emphysema who cannot exercise. Their heart rate doesn't budge, but they inject them with the isotope anyway. They know it's useless, but they don't want to lose the revenue.”

“It's fraud,” I said, unable to hide my disgust.

“It is,” he said calmly. “Deep down they know it's wrong, which is why they are so depressed.”

It occurred to me that this assessment might also apply to me. I had been practicing a sort of ethics of double effect. The double-effect principle, as I had learned at the hospital ethics committee a couple of years back, states that actions in pursuit of a good end are acceptable even if they result in a negative outcome, as long as the negative outcome is unintended and not a direct consequence of the good one.

In my case, I had been trying to meet the expenses of my family. I was putting in the extra hours so that my son could go to an independent school, not the overcrowded local one. The waste, the overtesting, were unintended, a function of circumstance. I didn't want to participate in this deception, but at the time it seemed the only way I could remain in my apartment, pay down my debt, and give my family what I thought they deserved. Of course, good intentions didn't exonerate me. Even beyond the wasted money, what about the false positives, the radiation exposure, the downstream invasive procedures? Even if I wasn't primarily responsible, even if I was just the guy following up on tests that other doctors had ordered, the consequences were the same. I used to despise the unethical behavior of doctors in private practice, but in reality I was no better than they were.

“I often wonder, Why am I doing this?” Malik said, as though reading my mind.

“Why
are
you doing this?” I asked.

“Because, like you, I have to pay my bills. But one place was so bad I had to quit. They were doing stress tests on healthy eighteen-year-olds who could run fifteen minutes on the treadmill without even breaking a sweat.” He shook his head, as if to banish an uncomfortable thought. “You think New York is the worst? No, Dr. Jauhar, this kind of stuff goes on everywhere. West Coast, New Jersey—it's just the degree.”

I slung my bag over my shoulder and got up. “Just try to be accommodating,” he said gently, reaching out to stop me. “In the beginning, when I go to a new place, I go the extra step. Then they become dependent on you, and you can do what you want. But if you show that you don't want to do this, Chaudhry is just going to get someone else. There is only a finite amount of work, but an infinite number of doctors who are prepared to do it.”

I nodded and moved to leave.

“You are very principled,” he said. “But in the end, what does it get you if you go home and have a headache?” He gave a small laugh. “Anyway, make your decision and let me know. And maybe I'll see you next Saturday.”

Outside, the sun was blazing, though the temperature wasn't much above freezing. I backed out of the driveway. The neighborhood was teeming with ethnic life. I drove past farmacias, halal butchers, and ninety-nine-cent taco stands. Steam rose from gutters. The whirring of the treadmill—dum-dum, dum-dum—kept reverberating through my head.

In the car I called Rajiv. If I'd expected any sympathy from him, that hope was quickly dashed.

“You don't understand!” I said as the conversation got heated. “You're his best friend. You don't have a business relationship.”

“He created his empire,” Rajiv snapped. “What incentive does he have to pay you more money?”

“How much do you suppose he makes on any given—”

“That is none of your concern! He is giving you an opportunity.”

“Fine, but suppose he makes seven hundred dollars—”

“You are such an asshole! It's like Dad all over again!” he bellowed, referring to my father's lifelong discord with colleagues. “I want to pull my hair out when I talk to you, because you just don't get it. Or you don't want to get it.”

“Calm down,” I said. “I'm not saying—”

“What are you going to do if you can't find other work? They're going to foreclose on your apartment!”

“Okay, stop.”

“Like Dad, you're going to screw this up and then try to fix it afterward. God, I wish I had never helped you. He is twenty percent of my cath volume! You're going to screw up my relationship with him, too!”

“It's not like that,” I said weakly.

“He calls me and tells me you are late to the office. Why can't you get there on time? He is trying to run a business!”

“Listen—”

“Why don't you understand, Sandeep? You need him! He is helping you in your time of need. A year ago you were crying in my backyard. Now you're showing an attitude?”

“Stop. Just listen—”

“No, I am sick of you! You've got a good thing going, and you still don't know how to be happy. Like Dad says, you love blowing on cold milk.”

“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.