Grateful patient programs, in which doctors request donations from wealthy patients, have become increasingly popular in hospitals across the country. While some feel the program provides an important source of revenue to hospitals, critics claim the practice compromises the doctor-patient relationship. Yale Law student Julian Prokopetz LAW ’15 coauthored an article that appeared in the journal PLoS Medicine on Feb. 11, exploring how grateful patient programs fit into the national health care debate. Prokopetz talked with the News about the strengths and weakness of the program and what the practice signals about the American healthcare system.

Q. How did you get interested in grateful patient programs in hospitals?

A. I used to work in Brigham and Women’s Hospital [in Boston] in the clinical research center, and we’d been doing some work with the bioethics center talking about ideas for new papers. My co-author, Lisa Lehmann, mentioned that she had herself been contacted about fundraising and knew other doctors who had been contacted about fundraising. Different people felt different ways about it: Some doctors were very comfortable with it, others were not so comfortable with it. She was just surprised that more had not been written about it given how prominent it is.

Q. In the article you mentioned that certain “development policies” would fix the problem of ruining the doctor-patient relationship through fundraising. What policies in particular are you referring to? 

A. The law used to prevent certain types of activities that we thought were problematic. But now, it’s perfectly legal for development officers to screen patients, and identify wealthy ones and proactively notify their doctors and request that those doctors get involved in fundraising. The way the law changed is that now information on patients’ treating, condition and department of service is freely available for fundraising and development purposes without patient notification or consent. What we’re saying is that even though it’s legal for hospitals to use that information for fundraising purposes, that they should voluntarily adopt a policy of not doing so. They should seek patient consent before using that information for fundraising in order to preserve confidentiality and trust in the doctor-patient relationship, and to avoid undue strain on physicians to do things they’re not comfortable with.

Q. Do you think the fact that doctors are fundraising speaks to larger systemic issues with our health care system? 

A. We actually note in the article that while we focus on the American doctors and hospitals, similar things are going on in other countries like the UK. They have a single payer government system, but because the hospitals are privately owned and they are independent medical associations, they do their own fundraising. The issue of fundraising comes up anywhere you have private associations. I think the reason fundraising has intensified in recent years is that we have seen an emphasis on cost cutting on the medical reimbursement side of things. Government payers are paying less than they used to, and insurers are shrinking their networks. To help make up some of that gap, doctors have been doing more fundraising, particularly at academic medical institutions, where they do have both the research and training initiatives as well as providing basic care. They also tend to take a lot of very wealthy, very high profile patients.

Q. Do you think that fundraising programs should end, or would you rather see those reformed?

A. I think fundraising programs can be a great way for hospitals to raise revenues for things like academic research. I think also that many patients really do enjoy giving back to institutions, whether because they see them as important in the community or because they themselves have benefited from the care. We’re not saying that fundraising shouldn’t happen. Institutions should be very careful about the way they approach it. At the moment, programs are getting more and more aggressive, and there are a number of private consulting firms that offer to help make the programs more aggressive that offer wealth screening, software tools, the VIP concierge programs where donors get special services while they’re in the hospital, and they do special training programs with doctors where they teach the doctors how to ask for money.

Q. Do you think these programs implicitly encourage doctors to treat wealthy patients differently than poor patients?

A. The reality is that a lot if this is already happening. When Beyoncé had a baby, the hospital shut down an entire floor. When very important people are treated, the hospitals do offer special services. Whenever a known donor is there, someone flags it down and everyone makes sure to be extra nice. They sometimes feel conflicted as to how much they should be treading on the needs of other patients in order to keep these donors happy. One thing we’re concerned about potentially happening is less appropriate requests by these patients. If a wealthy donor starts requesting, say, prescription narcotics, you would hope that a physician would have the integrity to refuse these requests, but we have to be aware of psychological biases at play and the desire not to harm certain financial interests. In order to avoid putting doctors in that situation, we don’t want them to be actively soliciting donations in an affirmative, active way.

Q. Do you think this practice has any implication outside of the health care system?

A. I think this is part of a trend in most capitalist societies where money can buy greater access. Those who can afford to pay more for a certain service get a better version of that service. Sometimes that results in the service getting worse for those in the lowest tier because they’re the ones producing the least money for the operator of that service. We just want to make sure that we don’t make the individuals expected to donate feel uncomfortable, we don’t want to make their doctors feel uncomfortable, and we don’t want to end up with a system that focuses so much on the financially well off patients that it doesn’t give other patients the attention that they deserve.