An alternative diagnosis

“He specified a full blood analysis, an X-ray of the stomach and bowel areas, a urinary analysis an ECG and an MRI. He then put him on an X2i drip, which is the strongest anti biotic treatment available and prescribed two milligrams of morphine for the pain.”

“It doesn’t mean anything to me.”

“The guy came in with stomach pains and yes, a high temperature and he put him on every test he could think of before the insurance company had a chance to intervene. He ensured an income of Forty-Five thousand dollars to the hospital from tests alone.”

“But he has to do tests, Ollie.”

“Not every test imaginable and not the most expensive. His wife was there when he was admitted. She gave details of a recent gall bladder surgery he had in the UK. She even telephoned the UK surgeon and arranged that his medical notes be faxed over to the hospital. It does not take a genius to work out that he was and is experiencing some residual effects from that surgery.”

“But the surgeon has to be sure. He can’t just start opening him up if he isn’t certain what he is looking for.”

“That’s what he would say. If the man dies while his doing his tests, he will point to the speed that he organized the tests and the fact that he specified them as urgent. He will not say that he maximized the hospital income and refrained from surgery because he was not able to make a definitive diagnosis. He will never say that he had insufficient data to get the go ahead from his insurance company.”

Olivia Stretton is sat in a window booth at her favorite diner and is seated opposite her close friend Jocelyn Peterson. Olivia is English and had been born and brought up in Norwich. By twenty-six, she had been promoted to Senior Staff Nurse at the main Norwich teaching hospital, which is where she met Al Stretton, one of the patients. Within twelve months they had been married and she had returned with him to the United States. After twelve months she herself had been hospitalized by the birth of Faith, the eldest of her three children.

Now, twenty-one years later, Al has traded her in for a younger, more nubile model and she has returned to nursing. Six months and three testing reviews later she has achieved Senior Shift Nurse in the Intensive Care unit of Seattle General. Her now grown-up kids find it difficult to come to terms with the fact that she has so quickly changed from housewife and mother to a difficult to contact, salary-earning professional.

The one cultural difference that Olivia finds difficult to understand, given her training and background, is the predilection of the American medical profession towards money. A patient’s insurance cover is the number one priority for anyone seeking admission to a hospital. Even those unfortunates who are admitted directly into intensive care need to have relatives who can provide their insurance details. Where no cover can be established, senior administrators frequently make a quick decision to transfer the person to St Magdalena, known locally as ‘Charity’. Even more difficult for her to understand is the way doctors and hospital administrators manipulate each situation, and therefore each patient, to obtain maximum return from the insurance companies. More bizarre in her view, is the way all the insurance companies attempt to limit their expenditure by influencing the treatment that individual payments receive. Colleagues humorously dismiss her open astonishment with such comments as; ‘Remember who pays your wages’ and ‘It’s a trade off!’ Their continued reassurances do little to remove my unease.

Olivia continues to browbeat her friend; “The major problem I have got is that this patient is a ‘Brit’ and I know what is likely to happen to him. I know what the insurance company will persuade the hospital to do.” Olivia still presses her concerns on the ears of her sympathetic friend.

“What do you mean?” Jocelyn asks

“I’ve seen it before. The insurance company knows that medical treatment is free in the UK and that if he is treated on the UK National Health there will be no charge to them for surgery and hospitalization. For that reason, they will suggest that we stabilize him on drugs. When that has been achieved, they will then pay to have him returned to the UK, where he will be treated in a National Health hospital. The attending physician will never admit it but, apart from the income to the hospital, the other reason for all the tests is to protect the hospital against any chance of litigation when they eventually agree to implement the insurance company’s suggestion. He will be in intensive care for a week, he’ll get pumped full of antibiotics and then he’ll get shipped back to the UK.”

Jocelyn frowns: “If what you say is true, why do the Surgeons concur? Surely they would want the income for doing the surgery.”

Olivia takes a deep breath and shakes her head; “To use their words, ‘it’s a tradeoff.’”

As they were talking, a figure appears at the end of their table. Olivia and Jocelyn look up expecting the waitress and are surprised to see to see a dark-skinned man with a beard looking down at them. They are even more surprised when he speaks with a distinct foreign accent: “I overheard your conversation and I wish to tell you that you are only examining half the picture.”

Olivia frowns and moves her face towards his; “Are you a doctor? What are we missing?” She whispers forcefully

“My name is Gupta Singh. May I sit down?” Olivia and Jocelyn look at one another, grimace and shrug their agreement back at the intruder. Jocelyn shuffles along to make room for him. Once sat down and confronted by a fierce stare from both women, Gupta Singh gave them the benefit of his wisdom and experience: “You are forgetting the effect of professional indemnity insurance that the doctors have to pay.”

Olivia abruptly moves her face towards him. “What do you mean? she hisses

“Doctors have become prime targets for claims from dissatisfied and often predatory clients. Because of this, their insurance premium has increased, so that a surgeon is now paying considerably more than a million dollars in up front premium.”  

“How does that affect the situation?” Olivia pressed. Gupta Singh smiled at her; “They are careful to do every test possible to do a full diagnosis and thus to reduce their liability. They follow this with the most comprehensive treatment – all of this to eliminate the possibility of a claim against them.”

Olivia answers slowly and softly as his explanation sinks in; “But the insurance companies are complicit in the over testing and treatment.”

Gupta Singh nods at her; “It is a risk equation” he tells her. “Pay out more up front in order to reduce claims and pay outs at the end.”