It is increasingly obvious that contemporary healthcare practice is less and less consonant with the traditional, mythologized vision of Hippocratic medicine that many people carry in their heads, and which some advocate is still the right model for the professions today. It is fashionable to bemoan the loss of this mindset and its attendant professional iconograpy (the kindly, white-haired patrician physician; late-night house calls; lifetime relationships between doctors and patients; etc.). At the same time, it is inescapable that financial pressures (among others) on healthcare practice have distorted every aspect of patient care without exception – from the patient/caregiver relationship to what treatments are offered and what treatment goals will be honored. This trend, along with other assaults on the Hippocratic model, forces healthcare into a new mold, and forces us to find new ways to solve problems for which simpler, traditional solutions are not adequate.

This may be a good or a bad thing. However, even those who reject the Hippocratic model – and I do – usually also reject an explicitly market-driven model of healthcare, arguing that health is a primary human good, and in many ways a social good, that should not be subject to market forces. So it is thought-provoking to see evidence that healthcare provision occurs in some ways in a “stealth open market”, in which unacknowledged market forces shape care delivery in ways that are denied by the providers who respond to those forces; it is equally provocative to see open advocacy for such practices. But these are issues we have to come to terms with.

The New York Times reports the not-exactly-shocking news that doctors alter their treatment recommendations in response to their own expectations of profit from them.

The way cancer doctors are paid may influence the choice of drugs they use in chemotherapy, a study published yesterday has concluded.

Payment methods do not seem to affect whether doctors favor chemotherapy over other treatments, the study’s authors said. But once they decide to use chemotherapy, the current payment system appears to prompt some doctors to use more expensive drugs, the study found.

“Providers who were more generously reimbursed,” the authors wrote, “prescribed more costly chemotherapy regimens to metastatic breast, colorectal and lung cancer patients.” The study, by researchers from the University of Michigan and Harvard University, is published in the current issue of the academic journal Health Affairs.

Unlike other physicians, a cancer doctor can profit from the sale of chemotherapy drugs in a practice known as the chemotherapy concession. These doctors are paid for the cost of the chemotherapy drugs given intravenously in their offices — even though they frequently purchase the drugs at lower prices than the amounts they are paid in insurance reimbursements.

One government study said that cancer doctors, or oncologists, were receiving discounts as high as 86 percent on some chemotherapy drugs. The doctors then pocketed the difference.

On the bright side, the study appears to suggest that doctors did not knowingly prescribe a less-effective mode of treatment in anticipation of gain, but on the other hand they do correlate their drug choices with their personal expected income. (Defenders, of course, say it’s a coincidence.) If it matters which drug you use, then drug choices are not correlated with efficacy but are correlated with profit, which would be disgraceful under the Hippocratic model of healthcare (unless the best drug for most patients just happens to be the one that pays that particular doctor the most, which seems unlikely).

Now, this just bolsters many, many similar studies over the years showing that doctors are influenced by drug company stipends, paid-for lecture attendance, gifts and trips, and all the other blandishments offered them. (The drug companies aren’t stupid. They provide these gifts and kickbacks because they work.) No one who has followed the issue should be surprised that this wholesale and above-board bribery redounds on patient care. It’s intended to, and it could hardly fail to. Even medical-school application rates fluctuate sharply with the average income for physicians compared to other educated fields. But at some point we have to admit to ourselves – and this study provides as good an excuse as we need – that doctors do not make patient-care decisions solely out of concern for the patient’s good, and often do so in strikingly self-interested ways.

With that fact finally admitted, we can decide what to do about it. David Leonhart, in the Times‘s business section (naturally), argues that we should embrace it as a policy tool.

Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the rate has not really changed since the 1930′s. “No improvement!” was how an article in the normally exclamation-free Journal of the American Medical Association summarized the situation. . . .

Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.

There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so. . . .

Dr. McClellan has set up small pay-for-performance programs in Medicare, and a few insurers are also experimenting. But it isn’t nearly a big enough push. We just are not using the power of incentives to save lives. For a politician looking to make the often-bloodless debate over health care come alive, this is a huge opportunity.

Leonhart’s assumptions about how medicine works are clear enough: “doctors . . . have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so“. He gives no sense that doctors might have – or that they might be expected, or morally required to have – a non-economic incentive to treat patients effectively, or that hospitals’ incentives are anything but economic. And as a practical matter, it’s looking more and more like he’s right.

I have suggested in other contexts that the old notion of professional obligation in the healthcare fields has been taking a beating, and in fact may be counterproductive in certain ways. Perhaps Leonhart is right that we ought to expect that caregivers’ incentives in professional practice simply are self-interested (which is not the same as saying we should throw all of healthcare open as a laissez-faire free market), and treat them accordingly. This would require modeling provider/patient relationships as economic transactions (something like Robert M. Veatch’s “contractual model”), rather than exercises of autonomous, fiduciary professional prerogative. It would also require ratcheting patient autonomy up even higher than currently, and eliminating the patriarchal aspects of healthcare almost entirely. (Doctors would then bear a relationship to their patients something like that of lawyers, in which the differential of knowledge and effective power remains, but the professional acts strictly on behalf of, and for purposes defined almost entirely by, the client.)

Would it be better to drop all this “noble profession” nonsense and just treat doctors as skilled contractors? Would our trust in doctors be diminished if the profession was understood to be just a reputable way to make a lot of money? Would it be diminished more than it is likely to be by finding out that doctors really do behave as if their profession was just a way to make money, while denying it (as the Michigan/Harvard study reveals)? If we decide we want to retain the Hippocratic-altruism ethos of the profession, can we do anything to restore it other than simply claim to be shocked, shocked to discover there’s self-interested behavior going on?