Money and Medicine

I am a strong believer that how much money you have shouldn't influence the care you get, at least in my specialties. If you are getting anesthesia for a surgery or you are admitted to the intensive care unit, I believe incredibly strongly that who you are, what you do, and what you have shouldn't matter. My anesthetic or ICU decision making should be the same whether someone is homeless or if they are a start-up executive.

There are some domains in medicine where this is not the case. Elective plastic surgery, concierge medicine, and reproductive endocrinology (IVF) tend to be medicine-for-the-rich. Perhaps these fringes are acceptable, but for the most part, medicine should be blind to money.

As an ICU fellow, I handle transfer requests from other hospitals. When I talk to physicians about whether their patient should be transferred to us, the most important question is one of medical need. Will Stanford be able to provide care that another hospital cannot? Sometimes, small community hospitals don't have services like interventional radiology or thoracic surgery. Larger hospitals may not have ECMO or continuous renal replacement capabilities. Even if another hospital could technically take care of a patient, we might transfer them if their condition is exceptionally complex or if the patient is "ours"; that is, if she sees our oncologist or liver specialist. Finally, we may consider taking a patient because of a family request, whether to be at a big academic center or to be closer to home. This last reason for transfer is the weakest one; depending on how many free beds we have, the insurance status, and other factors, we may decline a "family request."

Recently, we had a family request to move a patient to our intensive care unit. The patient had been admitted to the ICU for bleeding into her lungs, and he was isolated for concern for tuberculosis. The physician on the other end felt comfortable with the medical complexity and felt that his facility could handle all their medical needs. The patient was not a patient any of our physicians had seen in the past. Thus, this was a pure family request. As we had only one free bed in the ICU (which could potentially be an isolation bed), I declined the request; I had to triage resources. In addition, the patient's insurer was unwilling to pay for this transfer since there was no medical need. The outside physician agreed with my assessment and we went on our merry way.

Several hours later, I hear from our transfer center that the patient's family again wanted him over at our hospital. They'd even agreed to be self-pay and opened up a credit line of several hundred thousand dollars for this purpose. In reassessing the situation, I kept my ground; I only had one free bed, and it needed to be reserved for a code or an ED admission. The transfer center agreed and let the other hospital know. A few hours after that, I heard that the family was contacting progressively higher administrators, even up to the chief medical officer of the hospital. Evidently, the family was incredibly wealthy and felt that their money should buy them the care they wanted.

When things get above my pay grade, I don't fret about them. I do what I think is medically and ethically right, and I let everything else play out as it will. But this incident bothered me because I really believe medicine should be blind to money.