The following is dramatic testimony given by Linda Peeno, M.D. before the House of Representatives Subcommittee on Health and the Environment in May of 1996. Dr. Peeno is a former medical reviewer and medical director for three managed care organizations. Currently, she works in the field of medical and health care ethics. Because of the powerful nature of her testimony, it is reprinted here.
I wish to begin by making a public confession: In the spring of 1987, as a physician, I caused the death of a man.
No person or group has held me accountable for this - for this was a half million dollar savings to my employer. In fact, this act secured my reputation as a "good" company doctor and insured my advancement in the health care industry - in little more than a year, I went from making a few hundred dollars a week to an annual six-figure income.
In all my work, I had one primary duty: to use my medical expertise for the financial benefit of the organization. According to the managed care industry, it is not an ethical issue to sacrifice a human being for a "savings." I was told repeatedly that I was not denying care, I was only denying payment.
I am not an ethicist whose opinions have come just from books. For me, the ethical issues were born in the trenches, fed by the pain I know I have caused. If I am an expert, it is in how managed care maims and kills patients. I am here today to tell you about the dirty work of managed care.
Let me explain some of the ways I was a "good" doctor:
I was regularly consulted by marketing on ways to change benefits, especially for things that were expensive, such as mental health benefits. Sometimes we just manipulated the language in order to be able to have a loophole for a later denial. For example, in one plan, we made our language for "experimental" procedures so vague that I was often able to use it to deny expensive, subspecialists required out of network.
I turned pre-existing exclusion into a game, as I tried to connect almost any medical complaint or visit into a reason to deny payment for some requested surgery or service based on "pre-existing" conditions; I commonly used this to deny gynecologic surgery.
I frequently used my medical knowledge to assist in making decisions about which groups and individuals we would cover or more accurately, not cover. In one plan, the marketing representatives (who often had "inside" information about a group's medical history), and I, with my medical knowledge, cultivated "cherry picking" to a fine art.
I was only as "good" as the doctors in my network, for it was their numbers that I needed to prove I was doing my job. That means that I did whatever it took to "control" them - intimidation, hassling, humiliation - I have done it all. I have used inaccurate data to create reports to get doctors to make their "numbers" better, i.e., lower their usage. I have used "economic credentialing" to select the least expensive physicians, rarely correlating these figures with corresponding assessments about clinical practice. I have helped design contract provisions to ensure our payment and monitoring schemes got the results we wanted at the plan. I have threatened deselection to those who were especially "difficult" or costly.
There is one last activity, though, which deserves a special place in this list. This is what I call the "smart bomb" of cost-containment "medical necessity" denials.
Let me take you to the heart of managed care. Even if a plan denies using all of the above to control members and physicians, it is impossible to deny their use of the practice vital to managed care: Making medical decisions about access, availability, and use. Even when a medical criterion is used, it is rarely developed through traditional clinical processes, and it is never standardized across the field.. The criterion is never available for prior review by physicians or members. So, even if a plan has a clear benefit package, a few perks like free eye exams, screening tests for cancer, or other marketing ploys, the member's physician will NEVER be the final authority on what his or her patient will get. This might go unnoticed with the simple needs - the yearly visit, the flu, and the simple surgery - but when something unexpected and expensive happens, e.g. trauma out of network,; a major medical or surgical condition; cancer; conditions needing extensive services, like rehabilitation or technology; something experimental or rare- then, like a bucolic pasture turned battlefield, the land mines start exploding everywhere.
Somewhere in every coverage booklet for every managed care plan is a claim that establishes the plan as the final authority for determination of medical necessity. What that means is that there is some physician making that decision - someone like me who:
What kind of system have we created when a physician can receive lucrative income for adding to the suffering of patients? I became a physician to care for, not bring harm to, my patients. Since leaving my last job, I live with the pain of what I have done. I am haunted by the thousands of pieces of paper on which I have written that deadly word: DENIED.
Those papers - Including at least one death sentence that I know about - are the evidence that managed care is inherently unethical.
Linda Peeno, M.D. - (Testimony before the House of Representatives Subcommittee on Health and the Environment.)