Doctors Feel Pressure to Keep Their Hospitals Financially Healthy : Medicine: Some say they pay a heavy price for putting patients before the bottom line. They charge administrators with career-threatening tactics.

When six people were hurt in a car wreck a few years ago, the surgeon on duty at nearby Parkland Medical Center knew his small emergency room would be overwhelmed by all the cuts and broken bones.

So Dr. Paul Harper made a quick decision: Ambulances should carry the victims to three other hospitals besides Parkland. Spreading the carnage around meant the injured would get help more quickly. The doctor felt it was best for the patients.

But in this case, what was best for the patients was not necessarily best for the hospital. Parkland lost business.

“I caught it for that,” Harper recalled. “The patients were supposed to come to Parkland, even though (it) couldn’t handle them. The head nurse told me the administration was mad and I shouldn’t do that again.”

Such vignettes are common. Hospitals need patients. Doctors who send them away for any reason, even for better care, risk rebuke: A gentle scolding, perhaps. A quiet lecture about hospital economics. Or worse.

In Harper’s case, what came next was much worse. His career is in ruins. Once he performed 350 operations a year, making him the hospital’s busiest surgeon. Now, he performs a dozen.

Harper has filed a lawsuit claiming the hospital engineered a slander campaign that destroyed his reputation and made doctors afraid to send him patients. Richard V. Wiebusch, the hospital’s attorney, counters that Harper is in trouble because he is an incompetent doctor, not because he is a financial liability.

Such open warfare between doctors and hospitals still is unusual, but the rules of conduct are changing. Many fear that blunt coercion is becoming more customary as more hospitals press doctors to practice a style of medicine that puts the health of the institution first.

Usually, hospitals try to keep doctors in line through more subtle means: Nurses, who lose their jobs when hospital beds stand empty, cajole doctors to admit more patients. Many hospitals post the names of those who fail to discharge elderly, low-paying Medicare patients quickly enough. Physicians who don’t get the message may suddenly stop receiving referrals from the emergency room, an important source of new patients.

But gentle persuasion can turn harsh. Some doctors complain that they have been dogged by crudely planted rumors of incompetence, that hospital administrators have ordered other doctors to stop sending them patients or that their tiniest medical misjudgments are scrutinized by hospital review committees.

The worst of these abuses do happen, said Dr. Howard L. Lang of Kentfield, Calif., chairman of the American Medical Assn.’s Hospital Medical Staff Section.

“It’s not a daily occurrence,” he said, “but it is occurring enough that it is not rare. We are not talking about a few whining malcontents. There are real problems out there.”

In general, hospitals want their doctors to bring in lots of patients. They want them to order plenty of X-rays and tests when the sick are covered by generous private insurance plans. And they want them to do just the opposite when Medicare picks up the tab.

Hospitals lose money when the elderly ill linger too long. Medicare categorizes virtually all old people into DRGs, or diagnosis-related groups. The DRG classification for a particular illness pays a single flat fee for all patients, no matter how sick they are or how long they stay in the hospital.

“DRGs encourage the hospitals to keep their costs down, and yet the physician controls what the hospital bill will be,” said Dr. E. Haavi Morreim of the University of Tennessee. “The hospitals have had to do something to bring the physicians under the same incentive. Many hospital administrators have felt the necessity for some sort of system of carrots and sticks, either formal or informal.”

Perhaps the most feared and effective of these sticks is peer review. This process is the main way doctors watch over the competence of their hospital colleagues.

Critics complain the system is sometimes perverted into a way of punishing those who are economic threats to the hospital or to other doctors. At its most extreme, doctors lose the right to admit patients or to perform specific tests, procedures and operations.

“There is overwhelming economic motive to eliminate doctors who cost the hospital money,” said Dr. Verner S. Waite of Downey. “Doctors who complain about unethical billing practices, unnecessary tests, using items the hospital can charge for that are not necessary, are all at great risk of a peer review.”

Waite has formed an organization to fight abuses of peer review. He and many others believe that instead of weeding out bad doctors, the system sometimes may protect dangerous hacks who are financially and politically powerful because they admit lots of patients.

“When they want to get you, they get you good. They blackball you,” said Dr. David M. Freedman. “They will take away privileges for nothing, when another doctor can murder someone and, because he’s in good standing, they don’t bother him.”

Freedman works with Harper at Parkland Medical Center, an 86-bed community hospital owned by Hospital Corporation of America, the nation’s largest for-profit hospital chain.

Freedman believes his own practice has suffered because he refused an order from a hospital administrator to stop referring patients to Harper for surgery. Harper claims many other doctors in this distant suburb of Boston also were warned not to send him patients, in large part because he went against the hospital’s financial interests.

Sometimes, a hospital can get rid of someone its considers a financial nuisance simply by giving another physician the sole right to perform that doctor’s medical specialty.

Ohio cardiologist Dr. Efraim Montesinos contended he was forced to move his busy heart surgery practice from Toledo Hospital because his patients often ran up bigger bills than were covered by Medicare’s flat-fee DRG system, which began in 1984.

Said Dr. Peter Overstreet, one of Montesinos’ supporters: “Before DRGs, he was a hero. Since DRGs, he is a villain. It’s the same guy.”

Montesinos said he cared for a large number of very sick patients. They often took longer than usual to get better, so the hospital lost money.

“I am in the service of my patients,” he said. “I am not in the service of the hospital or the insurance company. As long as I am a physician, I will do what I think is proper for the patient.”

Last year, the hospital decided to give an exclusive contract to a single heart surgery group. Montesinos, who could have bid for the job, believes the exclusive contract was a ploy “to get me out of the hospital.” He moved his practice to the nearby Medical College of Ohio.

Dr. John Gibbs, the hospital’s director of medical affairs, acknowledged finances played a role in the decision to change surgeons.