Maintaining Plausible Deniability

Posted on January 7, 2009
Filed Under General Rationing Issues |

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Thanks to the Happy Hospitalist for pointing us to yet another fine example of covert healthcare rationing.

Happy directs us to the case of one Phillis Dewitt, a Peoria nurse manager who worked for Proctor Hospital until she was fired in 2005, allegedly because her husband’s hospital bills were becoming too expensive as he fought a losing battle with prostate cancer. According to Dewitt, her supervisor began to suggest, repeatedly, that it certainly appeared (didn’t it?) to be nearly hospice time for hubby, and, by the way, one must remember that the hospital itself is footing the high costs of his cancer therapy.

Dewitt was “taken aback” by the suggestion by her boss that she opt for hospice care, and replied that neither her husband nor her husband’s doctor were ready to give up trying to cure the disease. So Dewitt repeatedly refused to take the hint. Finally, the supervisor phoned Dewitt while she and her family were on vacation several hours away, insisting that she come in for a meeting on one of her vacation days. Apparently voices were raised during the ensuing discussion of this unusual request, and the next day Dewitt was fired. Dewitt sued for wrongful termination. (And her husband lived for another year, strongly suggesting that, indeed, he had not been ready for hospice care.)

An appellate court has now ruled that Dewitt’s suit against Proctor Hospital should go forward, pointing out that Dewitt’s supervisor seemed “very interested” in limiting the cost of her husband’s medical bills, and that the timing of her firing indeed suggests a relationship between her termination and the expensive cancer treatment.

Proctor Hospital strongly denies the allegations. Their spokesperson notes that other hospital employees have tallied high medical bills without being fired, and indeed the hospital has never fired anyone because of their medical expenses, and would never do so. Dewitt was fired, the hospital attorney says, “because [the supervisor] lost confidence in [Dewitt's] ability to carry out orders.” (Dewitt had never been alleged to have had any disciplinary problems prior to her firing, and the same supervisor had given her a perfect score on her annual performance evaluation two months earlier.)

It seems to DrRich that Proctor Hospital is, most likely, strictly correct. Of course they’re not firing people because of their medical expenses. Why, doing that would be illegal and unethical! They are not telling their supervisors to fire members of their staff who are chalking up those big medical bills. And they are not asking them to push those staff members into hospice care (or, soon, if trends hold, toward assisted suicide). To do any of those things would be more than merely callous; it would be the height of stupidity. For there are subtler ways to achieve the desired ends, ways that include plausible deniability.

To figure out what Proctor Hospital is really up to here, we should note that 1) the hospital was self-funded for employee’s medical expenses up to $250,000, and carried insurance only for charges above that amount; and 2) managers (such as Dewitt’s supervisor) were “notified” quarterly of any employee whose medical claims were above $25,000.

In a word, it appears to DrRich that Proctor Hospital was likely placing their supervisors into a classic “intentional untenable position.” To induce an intentional untenable position (DrRich’s term) is to knowingly and systematically place the subject into a situation where her only true recourse is to take an action that is officially forbidden, but unofficially hoped for. Here, DrRich surmises, supervisors were likely held responsible, in one way or another, for the medical expenses incurred by their staff. Notably, supervisors were fully and regularly informed as to what those expenses were, a practice that seems highly irregular and suspicious, and - if it were not meant to induce actions consistent with an  untenable position - inexplicable.  DrRich theorizes that supervisors at Proctor Hospital felt immense pressure to do something (anything, no matter how inappropriate) to limit those medical expenses. Which, DrRich submits, Dewitt’s supervisor apparently did.

The beauty of this methodology is that, because badgering people to put their spouses in hospice and firing them when they refuse is so clearly beyond the pale (and thus obviously cannot be official hospital policy), Proctor Hospital can plausibly deny causing this action, and can with good conscience hire indignant spokespersons to defend their immaculate hands.

While admittedly what DrRich has described here is conjecture, it is conjecture that seems quite persuasive. For one thing it fits the facts of the case, as publicly reported. But more than that, it fits the tried and true methods that have been used to covertly ration healthcare for decades.

After all, this is precisely what the health insurance companies, and the feds, have been doing for years now to get doctors to ration at the bedside.  That is, having gained control of the individual physician’s professional viability, they subtly (and not so subtly) create untenable situations to coerce doctors to stop spending so much money on all those dam*ed patients. And having done this, they can claim (summoning up every bit of the indignation displayed by Proctor’s attorneys) that they’re certainly not telling doctors how to practice medicine, and are not in any way directly making medical decisions for patients. Rather, they’re merely putting processes in place to encourage a certain amount of “efficiency” on the part of the doctors, and heaven forfend that their beneficent processes would ever do anything to induce detriment to any patients. Now, what those greedy doctors may do on their own volition, sad to say, is a different story.

So, really, there’s nothing new to see here, people. Move along, move along.

Comments

One Response to “Maintaining Plausible Deniability”

  1. Annie on January 7th, 2009 1:04 pm

    This is very common. Been there, had a constructive discharge and have also been fired in retaliation for patient and nurse advocacy. threats weren’t veiled in my case, and the blacklisting and defamation have been as effective as Sherwin-Williams “Cover the Earth” lead paint.

    It’s a result of nurses working as employees. That eliminates all non-clinical nurses from any sort of collective representation, and it pits nurses directly against each other, thereby weakening nurses’ work conditions and professional nursing practice.

    There is no more isolated and fully ostracised place than that of a nursing manager or director who falls below the chief nurse executive position. It’s the worst sort of limbo because no one supports you - not clinical nurses, not unions, not the NLRB and certainly not employers who then label and blacklist that nurse.

    Any nurse who is remotely forward thinking, independent and values practice autonomy and professionalism doesn’t last long. They are either run out, run over or flee.

    That’s why when there is a rare media story about nursing recruitment, it’s always about luring nurses with outrageous incentives which are not related to practice conditions and power/control over their practice. It’s bait and switch on a grand scale, and physicians would do well to look into the back rooms and alleys of it and then to collaborate with nurses to develop self-governed professional practice organizations and contract directly with patient care institutions to provide nursing and medical services. No one who is a professional should work as an employee. It creates a paradox of loyalty and ethics: to the employer or to the patient - and those should be just about mutually exclusive.

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