When “Do No Harm” Competes with the Bottom Line

March 27, 2017

Hippocrates is often credited as being the first to use some form of the famous quote “First, Do No Harm” which dates back to the late Fifth Century.  This quote was the precursor to today’s modern Hippocratic Oath and was obviously written when physicians weren’t influenced by government reimbursements. With the recent news that the Mayo Clinic plans to prioritize patients based on their ability to pay, the elephant in the room is finally being talked about, out loud, and in front of the world.

However, not long after the Minneapolis Star Tribune reported the Mayo story, CEO Dr. John Noseworthy issued a press release to clarify his earlier statements in an effort to correct the record after Minnesota regulators said they are looking into potential legal violations based on his comments, according to STAT News.[1] In his statement, Noseworthy said: “Patient medical need will always be the primary factor in determining and setting an appointment. In an internal discussion I used the word ‘prioritized’ and I regret this has caused concerns that Mayo Clinic will not serve patients with government insurance. Nothing could be further from the truth. In fact, about half of the total services we provide are for patients who have government insurance, and we’re committed to serving those patients.”[2]

Our healthcare system is based on the fundamental belief that, centuries after the Hippocratic Oath was written, physicians still strive to “do no harm.” But are people who rely on Medicaid and Medicare receiving the same treatment as people with commercial insurance? Maybe not. And, while we may decry inequities, can we really expect private healthcare providers to continue to run their practices on charity or limited reimbursements?

While Mayo Clinic’s CEO made news with his honesty, he simply verbalized what most people assumed, or at least suspected was true all along in healthcare. It is often said, you have to pay to play. And the Mayo revelation may not be the first time for discrepancies in care based on ability to pay.

Medicaid Cancer Patients Receive Subpar Care

This past December, Modern Healthcare reported that “Cancer patients with Medicaid coverage receive poorer quality and less healthcare than those with employer-sponsored, Medicare or other private insurance.”[3] The article cites a study published by Dr. Michael Halpern in August 2016 with findings that breast cancer patients who lived in states with higher Medicaid reimbursement rates received surgery sooner. In his paper, Halpern says: “The study included 7,542 Medicaid beneficiaries with breast cancer: 3,272 received breast conserving surgery (BCS), 2,156 outpatient mastectomies, and 2,115 inpatient mastectomies. Higher Medicaid reimbursements for BCS were associated with decreased time from diagnosis to surgery.”[4]

Mayo Preference Called “Disappointing”

Once the Mayo news hit, reporter Elizabeth Warren quoted Arthur Caplan, head of bioethics division at New York University Langone Medical Center in an article for Modern Healthcare: “A cornerstone of our ethical thinking is you get the same care whether you’re rich or you’re poor, and we don’t triage by the size of your wallet.”[5]

That’s a nice sentiment and one we want to believe. Yet, discrimination against patients is only illegal in a hospital’s emergency room. And Mayo is still planning to accept Medicare and Medicaid, while some physicians already choose not to accept patients who rely on those plans.

Hospitals Declaring Bankruptcy

Whatever we think about Mayo’s decision, hospital systems are faltering financially. Ten US hospitals and health systems filed for bankruptcy in 2016.[6] Five more systems have declared bankruptcy in the first quarter of 2017.[7] Public outcry against discrimination in healthcare based on economics might be loud, but who among us is willing to work for free? It’s easy to point fingers at healthcare executives and politicians. The fact is our economy has forced this issue on providers, and blaming any one entity or group doesn’t solve the problem.

With last weeks failed effort to pass the ACHA in the House, no one knows exactly what the future looks like for the ACA.  It may be that Medicaid funds will be doled out to the states, so those patients will fare better or worse depending upon where they live. Straddling the line between caring for patients regardless of ability to pay and staying afloat to even provide care is a difficult balancing act. Only time will tell which systems can manage one or both.


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[1] Casey Ross, “Mayo Clinic CEO walks back comments on prioritizing privately insured patients,” STAT News, Mar. 17, 2017, https://www.statnews.com/2017/03/17/mayo-insurance-medicare-medicaid/?_hsenc=p2ANqtz-9ySrM1vWUFm86n6Q3xgHcXXmX9plQPMqDxAuG5ysal1RGYyOP8cTFR4jynl8Cp34KLKDX1v9nJr8P4zEHR3bD7tPPzTQ&_hsmi=47963441

[2] Ibid.

[3] Virgil Dickson, “Medicaid cancer patients receive subpar care,” Modern Healthcare, Dec. 7, 2016, http://www.modernhealthcare.com/article/20161207/NEWS/161209931

[4] Michael Halpern, “Effects of state-level medicaid policies and patient characteristics on time to breast cancer surgery among medicaid beneficiaries,” National Center for Biotechnology Information, Aug. 2016,  https://www.ncbi.nlm.nih.gov/pubmed/27422241

[5] Elizabeth Warren, “Cherry-picking patients? Mayo Clinic aims to ‘prioritize’ privately insured,” Modern Healthcare, Mar. 15, 2017, http://www.modernhealthcare.com/article/20170315/NEWS/170319942

[6] Ayla Ellison, 10 Hospital Bankruptcies in 2016, Becker Hospital Review, Dec. 13, 2016, http://www.beckershospitalreview.com/finance/10-hospital-bankruptcies-in-2016-decmeber13.html

[7]Ayla Ellison, 5 hospital bankruptcies, closures so far in 2017, Becker Hospital Review, Mar. 6, 2016,