A Case of Malpractice
The Great White Lie: How America's Hospitals Betray Our Trust and Endanger Our Lives, by Walt Bogdanich, New York: Simon & Schuster, 320 pages, $23.00
America's hospitals swallow more than $200 billion in federal and private funds each year through a convoluted and constantly evolving payment system. They serve as workshops for competing, hard-to-manage groups of professionals and come under the purview of a complex, multitiered system of regulation. Bureaucratic and professional power struggles are common. In their day-to-day functioning, life-and-death crises—some successfully resolvable and some not—are literally routine.
Enormous problems plague our health-care system. It should come as no great shock that there's some muck there to be raked. Journalist Walt Bogdanich applies himself to the task in his new book, The Great White Lie: How America's Hospitals Betray Our Trust and Endanger Our Lives.
Bogdanich focuses on two problems. Hospitals misbehave, sometimes with catastrophic consequences for their patients. But consumers don't have the kind of information that would enable them to pick their way through the healthcare minefield and avoid such abuse. Address the latter problem and the former might be solved as well, as informed consumers drive negligent providers out of business. But driven to indignation by the dirt he has found, Bogdanich flames out before making much of a contribution to cleaning it up.
What is "the great white lie"? It's "a myth holding that hospitals and doctors are equally good and deserving of our complete, unquestioning trust." This is, of course, a straw man: When was the last time you chose a doctor or a hospital by tossing a dart at the phone book? But by the same token, how often have you found reliable information about healthcare services so difficult to obtain that a decision seemed little better than random in the end?
For our edification, Bogdanich offers a litany of medical misdeeds. After teasing us with the murder of a young physician resulting from inadequate security at chaotic Bellevue Hospital in New York, he moves on to a main course consisting of three parts.
"Cutting Corners, Plugging Holes" deals primarily with sloppy personnel practices. Three chapters examine hospital responses to the nursing shortage, particularly their reliance on temporary nurses, with a focus on one especially slimy temp agency in Florida. Another chapter details the catastrophic consequences of slipshod pharmacy management at a major hospital in North Carolina. As a loose end, Bogdanich throws in a chapter on the shuttling of helpless elderly patients between hospitals and nursing homes because of financial pressures.
"The New Ethics" emphasizes the financial side. Three chapters uncover systemic flaws in the implementation of the diagnosis-related-group–based prospective payment system adopted by Medicare in the early 1980s. Another chapter describes a California hospital's fraudulent manipulation of the DRG case-coding system to maximize Medicare reimbursements. Two final chapters tell of bribes and kickbacks paid to physicians for patient referrals by for-profit chain hospitals in Louisiana and Texas.
"Absent Watchdogs" tells of dereliction of duty by regulatory agencies. Two chapters describe ludicrously substandard hospitals in Ohio, New York, and Pennsylvania, allowed to remain open through the negligence, or worse, of state and national licensing boards. One chapter reports lax clinical laboratory oversight at hospitals in Virginia and Illinois. Another touches base with some of Bogdanich's colleagues in journalism, contrasting kid-glove treatment of a local hospital by the Topeka daily with gutsy work by a small-town newspaper publisher in Ohio. A closing chapter follows an epidemiologist as he unravels serial murders by a nurse in a Maryland intensive-care unit.
The stories are depressing enough—indeed, those in which people die because of negligence or greed are downright horrifying. They're briskly told, full of color—and as the catalog above suggests, anecdotal to a fault. Egregious Examples of Hospital Fraud and Mismanagement That I Investigated in Recent Years would be a more apt title for this volume.
As an evaluation of the impact of flaws in the health-care system on the patient, The Great White Lie is inadequate. Bogdanich sees his cases as "not mere freak accidents or anomalies," but rather indications that the system is rotten. Yet he never assembles the reports into a coherent picture indicating how representative these cases are of hospital practice as a whole.
Worse, he ignores a less sensational kind of patient abuse that may be considerably more important. One of the salutary effects of the increase in the costs of health care has been a new demand for research on health-care quality, on the reasonable grounds that inappropriate or incompetent health care is likely to be wasteful as well as dangerous.
Some of the findings of this research have been as staggering in their own way as anything reported by Bogdanich. It seems likely, for example, that far more people have been harmed—many grievously—by well-intentioned but unnecessary surgery than by any of the practices reported in this book.
Bogdanich's treatment of fiscal and management issues is equally weak. The Great White Lie implicitly attributes hospital fraud and mismanagement to Reagan-era regulatory decadence but provides neither the historical evidence to judge such an assertion nor any plausible scenario for reclaiming the presumed virtues of an earlier time. And the focus on criminal behavior obscures the deeper, structural causes of the health-care cost problem.
Finally, and perhaps most disappointing given the author's stated concerns, as a consumer guide the book falls short as well. Even assuming that the existence of these abuses is news to the reader, Bogdanich offers little useful advice as to what the reader can do to protect himself.
The emphasis on the consumer's perspective could have provided an effective organizing principle for this book. The fact is that accountability to the patient has never been a criterion of major importance in the health-care system. To the contrary, the fundamental reforms that created the system as we know it today had the effect of insulating it ever more completely from the most basic kind of scrutiny by its supposed beneficiaries. This historical reality isn't irrelevant to our present predicament. Bogdanich seems to understand this, so it's a pity he didn't apply his evident talent as a reporter to the bigger picture.
While muckraking isn't without its value, when public policy on complex matters is at stake it can be a double-edged sword. Righteous indignation gave us a Food and Drug Administration that throttles innovation in order to avoid headline-grabbing horror stories, while depriving countless hidden victims of the benefits of potentially effective drugs—and of the personal choice of what risks to assume in the pursuit of health.
The present cry for systemic health-care reform carries both opportunities and risks. The cost problem is overwhelming. In many quarters, the desperation to find something—anything—that will put a lid on costs is almost palpable. The path to a genuine consumer-centered market discipline is perilous and uncertain. In this particular crowded theater the temptation to yell "fire" is both great and misguided.
Oren Grad, an M.D. with a Ph.D. in health policy and management, is a visiting scholar at the MIT Center for International Studies.