When Medical Thrillers Mirror Healthcare Injustices

By Dr. Nick van Terheyden aka Dr. Nick
LinkedIn: Nick van Terheyden, MD
X: @drnic1
Host of Dr. Nick: The Incrementalist#TheIncrementalist

One of Michael Crichton’s early successes was the movie “Coma” which came out in 1978. A movie based on the book of the same name by Robin Cook, MD. The book was his first break-out hit featuring corporate malfeasance and greed taken to extremes in a hospital to create a ready supply of donor organs. Michael Douglas starred in the movie.

Robin Cook went on to write 40 more books and is still writing today with his two most recent novels Manner of Death and Viral which came out in 2021.

For doctors and other clinicians who work in healthcare, these novels are a little like catnip – well at least they were for me. So much so that on our extended 4-week honeymoon (imagine trying to take that kind of a break today!) we both plowed through Robin Cook books at a real clip as we traveled around the Far East. When work and home life resumed we both found ourselves with less time and had run out of new books by then and we found ourselves doing less reading.

Fast forward a few years and I found myself searching for some light reading beyond the steady stream of non-fiction books I had been marching through. As I looked around I noticed a few novels from Robin Cook with titles I did not recognize and discovered I had a treasure trove of reading to work my way through. While not essential there are some recurring characters across some of his novels and he even has a whole separate series focusing on a couple of characters that I have yet to even start.

His latest medical thriller “Viral” was written in the context of the Pandemic and included a nod to the Pandemic protections and impact but instead focused not on the SARS-CoV-2 virus but rather Eastern Equine Encephalitis (EEE) – a mosquito-borne viral infection that although rare is potentially on the rise thanks to changing climate and increasing incidence of Mosquitos across populated areas outside of the more traditional tropical areas of the past.

No spoilers here but suffice it to say a worthy read and a stand out because in this case, we find even the medical thriller novelists have found extensive opportunities for suspense, intrigue, and misbehavior in our healthcare system, not from the medical personnel but rather the system itself and more importantly the insurance payor industry complex.

I personally have been caught up in misbehavior by these groups as seen in “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them” which was followed by “Congress Questions Cigna’s Large-Scale Denial of Insurance Claims” as Rep. Cathy McMorris Rodgers who chairs the committee launched an investigation into this practice and this is now the subject of a class action lawsuit.

If you have not found yourself on the receiving end of this, all I would add to that is “yet”.

Profit vs. Patients

Our healthcare system is a Capitalist based system of profit. For any company listed on the stock exchange then your guiding star is profit to be returned to the shareholders. It is hard for me to understand how this position can be reconciled with patient care. Your care costs money and anything that can reduce that cost is fair game for optimization and focus. Improving efficiency would allow for a decrease in the cost of the care, but so too would decreasing the amount of care.

So it is with no surprise that yet another investigative report uncovers yet another example of misbehavior denying care and payment. This time by STAT: “UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients’ rehab care”. The pressure of markets, and the demand for positive financial performance overwhelms the notion of caring and as detailed in the report even pressured employees who tried to push back by threatening to discipline or fire them if failed to hit a 1% variation target even when Medicare coverage rules warranted more days of service. Imagine working in that environment, needing the job, needing the benefits, and specifically the healthcare coverage that is linked to being employed. Would you be brave enough to stand up and say you were not willing to follow the mandated procedures? This is further amplified by incentive programs for employees from the bottom to the top of the organization who are incentivized to improve the bottom line. If your bonus is dependent on those metrics your behavior is aligned the same way.

As noted by the authors – this particular piece of technology was originally developed by NaviHealth and intended for the technology to help patients attain their target for rehabilitation but when UnitedHealth group acquired the technology they turned it into a punitive tool to reduce costs by reducing the amount of care given. As in the earlier case of the PxDx algorithm, this one fast-tracked to a class action lawsuit in short order.

How many more examples are necessary before we realize that this will not stop without a fundamental change in systems that are focused on profit above patients?

Without change the cycle continues, patients suffer and die without appropriate care being delivered and lawyers sue.

Prescriptions for Change

Without a fundamental change in the system, it is hard to imagine anything other than legislation and oversight of behavior. The better option is to create a system that incents the care of patients over profit. But that takes a complete shift in attitude for a country that believes the very foundation of success and efficiency demands a capitalistic approach to everything.

My personal view – we have tried that approach and have not succeeded. It is time to accept it does not work in every circumstance or industry and completely rethink the incentives and systems. But given the dysfunctional legislative system, we have mired in personal binary style thinking it appears to be an impossible task. Can we not all agree what we have is not working and needs fixing? Does anyone think the system we have is working and more importantly do they think they are getting value for money?

Some might argue that a profit-driven system incentivizes innovation and efficiency in healthcare. If so what are the efficiencies that we are benefiting from? Are these efficiencies benefitting everyone or are they just for those that are lucky enough to have resources to pay for healthcare?

I’m open to any suggestions – are you?

This article was originally published on the Dr. Nick – The Incrementalist blog and is republished here with permission.