Sunday, November 01, 2009

Out of line

Depending on your point of view, competition is either the strong point or the underside of Boston's spectacular collection of hospitals and physicians. It does produce an exceptional desire to succeed, to deliver the highest levels of clinical care. But it also has the potential to be rather juvenile and wasteful of resources. But here is an unusual case where it got downright ugly and out of line.

The story is documented yesterday in a Boston Globe article written by Liz Kowalczyk. The case involves a request for a restraining order against their former hospital physician organization by two doctors who chose to join another hospital's network. Why would they need a restraining order? I have seen the court complaint. Here is a representative part:

Defendant Caritas Christi Physician Network, Inc. ... has failed and refused to send a timely notice to patients presently under the Plaintiffs’ care with respect to the change in affiliation and Plaintiffs’ new contact information. Notwithstanding this failure, Defendants have further refused to agree to remedy the situation by permitting the Plaintiffs to maintain temporary custody of their active patient files until such time as patients have been fully informed of the change and given the opportunity to continue care with Plaintiffs. Without regard to the needs of Plaintiffs’ aged and chronically ill patient population, Defendants propose to remove forthwith ... all active patient files, with the exception of those patients who have a scheduled appointment with Plaintiffs in the next two weeks. Defendants also have failed and refused to agree to ensure that Plaintiffs’ new contact information will be provided to everyone who calls that number, notwithstanding that Defendant is keeping the phone number Plaintiffs have had for over thirty years.

The judge granted the restraining order. The legal standard for a restraining order is that the moving party has "a likelihood of success on the merits of its claim and, without the requested injunction, risks suffering irreparable harm." I'll leave you to read the story, but I want to respectfully disagree with Liz's characterization in one part of it.

She notes, "The disagreement highlights the intense competition among hospitals in the Boston area to hire and retain established physicians, especially primary care physicians." Not so! This is something altogether different.

This is out and out cruelty to patients by attempting to restrict their doctors' access to them and their medical records. I can't recall any other hospital system behaving in this manner when a doctor chooses to join another network, no matter how competitive the environment.


Manu Varma said...

It's happened before...

Anonymous said...

Wow. This raises questions not only for the present, but for the future.
The commenter dickey151 seemed to know the most about the rules in this situation, if his/her comment is accurate. However, at the very least both parties should have copies of the records. What if one of the involved Dr's patients had an emergency in the middle of the night while all this was going on, and he/she had no access to his own records? That's a recipe for losing your license in my state. Also, where I live, medical records must be retained by the physician for 7 years, so my retired husband has had them in our basement.
But in the future, if Drs. and hospitals, etc. are married together in some sort of "accountable care organization", what will happen should the Dr. choose to make a move? This is clearly something to be accounted for.
Finally, the voice message:

“You have fired the first shot,’’ Dr. Timothy J. Crowley said in the voicemail. “And trust me, you don’t want to go to war with me. I’ll take everything you got and everything you love and kill it.’’

just speaks to the competitive corporate mentality, a la Wall Street, that has taken over medicine/health care. This is why many people are suspicious of free-market, for-profit medicine.
It wouldn't be so bad if it might not literally kill you.....


Mark B said...

Cruelty to patients? The doctors didn't change hospital affiliation because they cared about their patients - they changed because they didn't get a raise. So now, at best, many patients will have to travel further to see their doctors.

Anonymous said...

Mark B;

You raise an interesting point which touches on fee for service vs. salary. I happen to favor salaried practice (with modifications, but that's not my point here). However, in any salaried situation, the one giving the salary has more power than the one receiving the salary. So if the salary-grantor doesn't give a salary satisfactory to the salary-receiver, what are his options? In most jobs, it is to leave. So should salaried doctors remain in their jobs at the same or lower salaries forever, just to care for their patients? Any salary-grantor would very quickly take advantage of that situation.
This is why I believe in shared power in a salaried situation.
Caveat: I do not live near Boston and have no idea how medical reimbursement works in the hospitals there.

nonlocal MD

Anonymous said...

Mark B, I didn't read the doctors are changing their physical offices, just their hospital affiliation so the patients won't be traveling any further. If they didn't care about their patients, doubt they'd spend the time and money to protect their patients' rights by hiring lawyers to have access to their medical records. What kind of health system would freeze out a physician from being able to provide consistent care to their patients? This isn't care giving. This is Caritas' greed and anger over losing a couple of physicians and caring more about that than the patients they serve. Not the mission of health care and sure not the mission of the Church. Very sad indeed.

Anonymous said...

So, if a physician left BIDMC, you would expect him/her to be able to remove all of the patient records to bring to the new practice location? I think it is more likely that each patient would request a copy of the record to be sent on an individual basis (as is the expectation with this move). These patients all have access to their information, but as you know, for many reasons, the actual files belong to Caritas.

Anonymous said...

Sorry, anon 1024 (are you from Caritas?)- you can't separate a doc from his records, for ethical, patient care and legal reasons - even if the patient does not come with him. (There are many reasons for this but I won't go into them here). And expecting each patient to do it individually is merely setting up roadblocks for patients desiring to switch, much less multiplying opportunity for error.
The only fair and, more important, patient-centered and legal way to do this is to have 2 copies of each record; one goes with the doc and one stays with Caritas. If there were a true EMR, now, this could happen at the push of a button, couldn't it.
As I said before, I live nowhere near Boston and have no dog in this fight. But I am finding this whole thing, and the UPMC link another commenter attached - thoroughly disgusting. At least the federal gov't is merely inefficient - not out to actively nail the patient like corporate actors.

nonlocal MD

Anonymous said...

ps; perhaps "no dog in this fight" was an unfortunate choice of words (I own a pet dog). How about "no ax to grind." (Paul, you can just substitute this in my original comment if you like)


Brenda RN said...

A couple of years ago, I called my physician's office for an appt. I was told he was no longer in that practice. When I asked where he had gone, I was told they would not give out the information, because that would be "soliciting patients." I tried in vain to find where he had gone, and in the end, had to find a new physician. A patient is not the property of a medical practice. For the practice to act that way is, in my opinion, unethical. Patients should be notified that the physician is leaving, and told where he or she is going. If the patient chooses to move with the doctor and gather her own medical records, so be it. She can also just stay with the practice. But it is the PATIENT'S decision.

I agree with nonlocal MD that profit-driven healthcare is the problem. We are people, not profit sources.

Alyn Ford said...

Disclosure – I work for StatCom, a software technology company, and have worked for most of the large medical technology providers in the world.

I am fascinated by this particular exchange as there are several interesting dynamics… The question of who, if anyone, owns the patient… The question of how patient records are best manifested (paper or electronically)… The question of why an establishment would choose what, on many fronts, seems to be an unreasonable stance. I won’t comment on the first two questions as I believe the majority of clinicians would answer the question consistently the same way. The third question, though, is fascinating to me. I can only surmise the behavior to be that of an organism fighting for its survival or maintenance of the status quo. You could argue that the rapid rise in our standard of living over the past 40 years has enabled us to spend more on healthcare than any other nation in the world… and that the expense we have been willing to make has resulted in us employing or attracting most of the best talent in the world. We have also driven profit in the commercial sector that has been reinvested and has then resulted in technology and pharmaceutical innovation that has lead the healthcare world market. The net result for Americans has been a healthcare system many people of the world yearn to be part of. People with the financial means have been using the US system for many years now… not because it is cheaper… because it is the best in the world.

When patients move, or reimbursements are reduced, the welfare of healthcare workers is affected… and collectively, people will fight to sustain that which they have become accustomed to. I would bet there are substantial amounts being paid right now to lobbyists to attempt to sustain interested groups’ standard of living… and many other seemingly unreasonable actions on the part of organizations and groups.

I would argue that in order to sustain our leadership position in healthcare as a nation, or slow what appears to be the commoditization of our healthcare system, the answer lies not in iterative improvement in clinical processes or the next blockbuster drug and not in the assumption our demands for care are unreasonable or maliciously prescribed (see Jim Rosenblum’s blog “The absence of market capitalism broke healthcare”). I think we need to become the leaders in the efficiency of our delivery system. Let’s give clinicians and healthcare organizations the breathing room they need to continue to provide innovative, high quality clinical care by getting dramatically better “mileage” out of the operations of healthcare. Those organizations that “lead the pack” will not worry about the movement of patients out of their domain but rather the increase in demand for their services.

Anonymous said...

I am not local to Boston but in our market I have seen both health systems and physicians do this. As the previous poster noted I have seen physician practices stonewall patients when one of the MDs left the practice (or even send letters to patients disparagin the MD that left)and I have seen health systems force physicians to leave a community or make a patient jump through hoops to get their record. Unfortunately, selfishness, greed and meanspiritedness is not confined to one spectrum of the healthcare world. Wish it were not that way but it is.