At some point, he continues, clinicians are now starting to say, if patients like this one will go into hospice soon in the near future, "Why couldn't we move them into hospice quicker?"
He's also concerned that these clinicians—increasing numbers of whom are employed by hospitals—will take it a step further, encouraging hospice designation for patients for whom the question of hospice appropriateness is less clear.
"There may be someone who is very old, a 93-year-old man comes in with an MI (myocardial infarction). Should they go to the cath lab or not? They have no other medical problems. What should be the level of care? What is the expiration date on a person? Is it 90 or 80, or after one procedure or two?
"There are people in the [federal] administration who believe that the only way to really solve the high cost of healthcare is to ration care," Kupfer says. He doesn't think that's a good direction for national policy.
Kupfer, a practicing cardiologist, doesn't stop there with his concern.
"My question really is, are incentives constructed around physician behavior morally ethical? Should a physician get paid extra for what [he or she is] supposed to do in the first place, like prescribing beta blockers or ace inhibitors?
"And when you have incentives like this, and hospitals have financial interests in the incentives, what kinds of processes do they put into place to make sure they win the incentives. There's a balance between positive and negative effects."