Two years ago, the University of Washington School of Medicine paid the government $62 million to settle a Medicare billing
dispute. In addition to its legal expenses, the medical school paid more than $750,000 for a high-powered, outside committee
to review what happened and write up a report.
Obviously, the medical school learned an expensive lesson. But will the lesson help improve patient care?
We doubt it.
The title of the 111-page report summarizes the emphasis: "Achieving Excellence in Compliance." The document uses the word
"compliance" 620 times, and recommends a new objective for the school: achieving "a culture of compliance" in addition to the
more traditional medical school goals of research, teaching and patient care.
To implement the recommendations of the report, the school is spending money for more lawyers, more layers of staffing,
re-educating physicians and more oversight of who bills for what and how.
Unfortunately, the process is eerily like that for many businesses where the Sarbanes-Oxley law has resulted in complicated,
expensive and difficult-to-comply-with rules.
Once upon a time, an organization could be successful by ethically providing goods and services to customers and clients. The
ethical guidelines for this behavior were ultimately based on underlying and universal moral rules, such as those prohibiting
stealing or cheating. Understandable and enforceable laws and contracts often reflected those ethics.
Over time, many lost sight of the underlying moral code but still followed the ethical codes set up by business or professional
organizations.
More recently, complicated laws governing business and professional behavior are causing increased emphasis on compliance
to the often arbitrary rules, sometimes leaving common sense and ethics behind. Judges agreeing with new ideas put forth by
trial lawyers or government prosecutors often defeat rather than fulfill justice.
Many enterprises, probably now including the UW medical school, visualize these exceedingly complicated rules as an
impenetrable briar patch. It's easy to understand why they now concentrate their compliance resources in the areas targeted by
government enforcers. Because it's impossible to consistently comply with all the myriad rules, the goal becomes damage
control; the modus operandi becomes risk management.
Instead of being a uniform and solidifying bedrock underpinning civilization, law enforcement has become an unmarked
minefield destroying lives and enterprises almost willy-nilly.
In medicine, Congress is now considering "pay for performance" and "best practices" incentives that would reward doctors for
following government guidelines (i.e., rules) on how to treat patients with particular conditions or diseases.
One difficulty with this government micromanagement is that the scientific studies used to establish the "best practice" rules
typically include patients with a given condition, such as congestive heart failure and a narrow range of possibly complicating
factors. Researchers do not further analyze patients with a significant complicating factor because it would take too many such
patients to generate a statistically significant result. For these patients, there's no "best practice" science to unerringly guide the
doctor in treatment.
For example, a patient with heart failure might have a past history of a previous stroke and also come down with pneumonia on
top of the heart failure. It would be rare for an up-to-date scientific study to account for even this relatively simple set of
complicating factors.
And, medical advances quickly outdate these studies.
In addition, research funds for promising but politically-incorrect treatment methods, such as chelation therapy and hyperbaric
oxygen therapy, is cut off by the medical-political complex controlling almost all research grants.
Most people want doctors with experience in treating their condition rather than a technician treating them based on a printout
from the best-practices computer.
There's a huge disconnect between the goals of compliance and excellent patient care. "Compliance" implies there's something
to comply with, such as government billing and practice rules. But successful patient care often depends on creative insight. The
practice of medicine is as much an art as a science.
If it were only science and technique, we'd have high-school-graduate best-practices technicians following computer printouts
rather than medical doctors taking care of patients. Why waste all that time and money for college plus five to ten years of
medical training?
We agree that doctors should be moral, honest and ethical. But "compliant" as a primary motivation? Ethical should cover that
base.
The more energy and costs expended on compliance, the less is left over for patient care. The alternative is for increased costs
of medical care, without any added patient benefit. Ironically, although the government insists that Medicare recipients get first
class medical care at the same time it clamps down on medical costs, the result of more compliance efforts will be decreased
access and higher costs.
If the University of Washington succeeds in "achieving excellence in compliance," it may avoid further government penalties, but
patients will ultimately pay the price, both in the quality of care and dollars.
Editor's Note:: Robert J. Cihak wrote this week's column
