Physician Boundary Crossing in the Face of Health Care System Failure

Abigail Zuger's November 11, 2013 NYT post on "When Healers Get Too Friendly"  (found here: http://well.blogs.nytimes.com/2013/11/11/doctors-boundaries-with-patients/) caught my eye — such a beautiful meditation on how, over many years of a physician-patient relationship, genuine friendship might actually take root between a doctor and a patient. How might this friendship be expressed? Through the gift of a relatively small sum of money (bus fare, a prescription co-pay, money for food).

Intrigued by the reporting of the chastisement of an experienced physician who, at 5:00PM on a Friday afternoon, punctuated a failed two hour insurance battle by giving a patient $30 of his own money to refill a prescription, I read on.  Dr. Gordon Schiff was later reprimanded for the act as violating the "professional-patient boundaries" of the Boston academic medical center he had recently joined.  You see, such acts of kindness were not common place but also not unheard of among the medical staff during his immediately prior 30 years of service at a Midwestern public hospital. You may read Gordon Schiff's "Crossing Boundaries — Violation or Obligation?" here: http://jama.jamanetwork.com/article.aspx?articleID=1741827. I know, I know, those of you who want to say "And that's one of the differences between the Midwest and the East Coast" have already crossed my mind.

But Gordon Schiff's anecdotal observation that physician practice and opinion is all over the place on the question of offering or giving small financial assistance to a patient is what really interests me. His account wonders (as do I) if practice environment (public hospitals often being the acute care provider of last resort in many communities) may play a role. I also wonder about the role of geography.  Would it be easier for a physician in a small community to refuse a request for money for food if the likelihood of encountering the requesting patient on the street later were exponentially higher?

And, finally, I wonder if physician opinion on what I will call out-of-provider-pocket assistance changes depending upon whether the request is for food (something we all need but not particularly the domain of the physician to provide, though good health is unobtainable without reasonably good food) or for coverage for the ailings of our byzantine health care system?  Was Dr. Schiff's gift to his patient an expression of faith in that patient's quest for good health or an expression of his despair in hoping to move our health care system toward one that does not penalize patients who have medical needs on Friday afternoons?

While all of this was on my mind, Katie Kraschel had a different take on the same Zuger NYT article.  In this posting ( http://blogs.law.harvard.edu/billofhealth/2013/11/14/limits-on-the-physician-as-a-good-samaritan/)on Harvard's Bill of Health Blog ("Limits on the Physician as a Good Samaritan") she discussed the restrictive role the Stark and Anti-Kickback laws can play in stifling creative thinking in health care delivery.

This also struck me as interesting. Neither the Zuger nor the Schiff articles referenced fraud and abuse laws as significant in the provider out-of-pocket to patient generosity calculus. Perhaps I am missing part of the story.

One popular theme in the health care finance literature is that fraud and abuse laws constrain provider innovation. And so they do.  This is because provider innovation too often runs in a troubling self-serving direction.

Here is a 2003 "Curbside Consultation" where all kinds of horribles are imagined as potentially flowing from provider out-of-pocket to patient generosity that is little focused on the legal implications of a small provider out-of-pocket to patient gift. (http://www.aafp.org/afp/2003/0401/p1629.html)  Though provider waiver of co-pays in government funded insurance have long been a subject of concern, Gordon Schiff wasn't waiving his practice's co-pay, he was paying forward the out-of-pocket cost of a patient prescription to be filled elsewhere, as I understand it. Is this all that different from a physician reserving and using a plentiful samples cabinet?

All of this merits more thought.  But you should know that there is far more anecdotal internet-available evidence of physicians and physician-office staff discussing how to extract co-pays from patients than in figuring out how to waive them within the constraints of the fraud and abuse laws. This is probably because waiver of co-pays for government funded insurance is rarely permitted, though documented indigency offers some relief. This, of course, does not preclude the courtesy "insurance only" services physicans are permitted to offer other physicians as a matter of professional courtesy, irregardless of fellow physician income.

And the courtesy owed a health-seeking adult in need of an immediate prescription at 5:00PM on a Friday afternoon? Better hope you have Gordon Schiff as your physician.

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