When doctors follow the rules, are they violating the Hippocratic Oath?

- I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I went to my doctor a few weeks ago for the first time in months. During the course of conversation about my health and how I was doing, etc., we stumbled onto the question of why I hadn’t been in for a visit in so long. I told him that in the wake of my separation from my wife I had lost my insurance coverage (I was on her work plan) and had been unable to get insurance as a result of my pre-existing condition. I don’t remember exactly what he said to prompt this response, but I distinctly remember saying this:

As soon as you typed the word “diabetes” into the system, you made me uncoverable.

He sort of looked away and didn’t reply, and I honestly have no idea what impact, if any, my words left on him. But he’s a good physician and I know from experience that he’s not a guy who’s in it just for the money. There’s plenty of evidence suggesting that he’s thoughtful, reflective, open-minded, empathetic and genuinely concerned about his patients. Very Boulder, if you will. So part of me imagines that my words landed like a whip, that he was forced to confront his role in the perpetuation of the most costly and corrupt health care system in the developed world. Or maybe he was just thinking about what else he needed to ask me since he hadn’t seen me in so long. Who knows?

Just for fun, pick up the phone. Call any health insurance provider – Blue Cross Blue Shield, Kaiser, United, Wellpoint, Cigna, Aetna, any of them will do. Tell whoever answers that you’d like to buy individual coverage. They’ll be polite and helpful and will initiate a pre-screening process. You’ll be asked some basics about yourself, and then they’ll get to a question that will go something like this:

Do you have or have you ever been diagnosed with any of the following conditions? [Proceeds to read laundry list, which will include things like HIV and diabetes.]

Answer yes to any of these items.

Thank you, sir. I’m sorry, but we’re unable to offer you coverage at this time. Thank you for calling and have a nice day.

[Click.]

If you feel like maybe you just called the wrong provider, try the same thing with another one. And another, and another. Go ahead, I’ll wait.

This is why I said what I did to my GP. The instant he checked the diabetes box in the medical records system, he assured that no insurance company would touch me at any price.

As a result of the “Obamacare” law, it’s now a tad better. I have been able to secure coverage under the new pre-existing care program, and I’m grateful. That said, it’s not exactly a Cadillac plan, and it’s a sad comment on the state of our system that I should be so happy over so very little.

I pay outrageous monthly premiums and until I hit my really high deductible I’m paying through the nose for every office visit, every test, every drug. Some recent blood work – fairly basic diabetes check-up stuff – is costing me over $800 and my last round of testing supplies ran me more than $50 after the plan knocked off a generous $5. But at least now if I get a sinus infection it won’t bankrupt me.

I’ve been thinking about this a lot, and the headline above probably tells you that I think American physicians are facing an ugly medical ethics problem – likely one that they haven’t even considered. My GP was required to diagnose my illness. In order to prescribe treatment, he was required to enter the diagnosis into the practice’s medical records system. He was, by legal  and common sense reckoning, doing the right thing. But he was also, to employ the language of the Hippocratic Oath, doing harm to his patient.

Yes, he was then able to prescribe Metformin and a couple of other peripheral treatments. He was able to refer me to the practice’s nutritionist. But he placed me in the direct path of disaster should I lose my insurance (as I eventually did). In my case, the result was several months of praying I didn’t get sick, followed by the arrival of a program that will insulate me from utter catastrophe, but at a steep price.

Fine. I can live with it. But I find myself thinking about people who reside further down the economic food chain. The bills that hurt me would total many people. What if I had a family that depended on me – if I can’t get coverage for me, imagine the challenges of covering them.

How many sick people in America today do not seek or receive the medical attention they desperately need because their doctor followed the rules, thereby consigning them to a vast, unyielding “Do Not Cover” conspiracy on the part of our health care cartel? How many people have died?

I can’t answer that question, but I can tell you what it’s like living in terror that something, anything, will go wrong. Even when, as a result of three busy clients, I had almost too much work and plenty of money coming in, I was constantly aware that I could be wiped out overnight.

Do. No. Harm.

Rapid advances in the field of medical records technology are only going to make the problem worse. Granted, this technology can be tremendously beneficial. Imagine if you’re on vacation and are taken ill – the health care facility that you land in will have instant access to your complete medical history, and that may just save your life. However, it also means that you can’t call another insurance company and lie about having a pre-existing condition. No, you don’t want to have to lie, but would you if it meant being able to get critically important treatment for you or your family?

I talked to a close friend of mine who’s a physician. He graduated from one of the nation’s top med schools, then interned at an even better institution. He’s now a prominent expert at one of the country’s most prominent facilities. He says that there was very little treatment of medical ethics at all in med school, and certainly nobody ever talked about anything as sticky as the question I’m raising here. This leads me to suspect that it has never even occurred to many, if not most, physicians, that diagnosing a disease on that pre-existing conditions list might represent an ethical problem.

I can’t advise America’s physicians on a course of action here. I believe the issue is real, but I also understand how incredibly complex it is. What was my GP supposed to do? Not enter diabetes in the system? If he didn’t, how would he go about explaining the Metformin prescription? As far as I know, the drug isn’t used for anything other than diabetes and I feel certain that at some point the carrier would notice the discrepancy. Might he lose his license?

But I also know how powerful a political force the medical community represents. We can imagine that there are doctors who are bloodless mercenaries all we like, but my guess is that a vast majority of them care a great deal about the well-being of their patients. That certainly describes most of the docs I know.

So, for what it’s worth, I’m raising a question for our medical community. You swore to do no harm. But, by following the rules, are you actually hurting your patients, perhaps even hastening their deaths?

Please, think about it.

9 comments on “When doctors follow the rules, are they violating the Hippocratic Oath?

  1. You’d think that health insurance companies would get smart and, to avoid flak, devise simple, cost-effective protocols for dealing with quotidian diseases like diabetes. As for doctors, I’ve observed that many like to think that they’re above insurance issues and leave it to their staff. They just want to practice pure medicine. Others, such as chiropractors, are keenly aware of the issues involved and will work with you to ensure you pay as little as possible.

  2. As part of a study I ran, we asked practices for a list of patients that they treated for depression. The problem was, because of “insurance reasons”, many practices “code shifted” their patients so that their diagnosis would show up in the ICD-9 codes as “fatigue” or “anxiety”. From what I gathered, many insurance companies do not reimburse for depression treatment and so primary care practices “shift” them over to similar illnesses so that the patient can be treated and the practice can be reimbursed. This little bit of rule bending is beneficial to both the patient and practice, but I now wonder if they would have put their neck out if it was only for the patient’s benefit.

    This is a very good question you brought up, Sam. I’ll have to bring this up with the docs I work with and see what they think.

    • Russ: I think when all is said and done it’s hard enough to be an actual physician without having to be an MBA and an ethicist and an insurance bureaucrat. Many of them probably don’t think about these issues because they figure there’s nothing they can do, or they don’t feel qualified, or there are probably a bunch of other reasons. Hard to say.

      Brandon: Most people probably see TV shows that portray doctors gaming the system in ways similar to what you describe, and it probably happens in real life. I don’t know if there’d be any way to do it with a diabetes patient, though – like I say, I don’t think things like Metformin and insulin are used for anything else.

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  5. Samuel – I’m not aware of any other use for insulin, but a number of other diabetic drugs do have other uses. Metformin, for example, is used for both PCOS (Poly-cystic ovarian syndrome), and for insulin resistance. So a patient with non-insulin dependent diabetes might be able to get the needed treatments with a shift in diagnosis.

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