"After all, what oath, promise, or pledge did we ever make, either as individuals, or as a profession, that obligates us to restrict care? We pledged, instead, to provide care."
--Jerome P. Kassirer, M.D.
The New England Journal of MedicineThere was a time in this country when patients trusted their doctors completely...trusted them with their lives...and listened to them and heeded their advice and friendly consultation. You could talk to your doctor in privacy behind closed doors and you felt entirely confident that what he or she recommended was 100% in your best interest.
There was also a time when doctors thought of little else but treating and caring for their patients, and doing everything in their power to offer their patients the best medical care known to science. They trained long and hard in medical school and took an oath to provide the best care possible to their Patients, regardless of cost, and make their own selfish interests secondary to their chosen vocation of healing and doctoring.
But something happened in the United States of America. A wedge was driven between patient and doctor. For one thing, our society became increasingly litigious. Doctors, fearing lawsuits, frivolous or otherwise, began practicing defensive medicine -- they became a little more detached and self-protective. And patients, having once perceived their doctors as friends, advocates, and teachers, began seeing dollar signs and spiraling healthcare costs. Were doctors practicing medicine to line their pockets? Were they in it for their patients or for those fancy European sports cars, exclusive country club memberships, and frequent vacations to various tropical paradises? Could anyone really tell?
Did "fee-for-service" medicine create a perverse or corrupting set of financial incentives for doctors? Why in heaven's name were they ordering so many diagnostic tests? Why were they using so much high tech equipment? And why were there so many coronary bypass operations, hysterectomies, and cesarean sections in this country, anyway? Had good, old-fashioned vaginal birth gone out of style?
To make a long story short, people started keeping close tabs on healthcare expenses. It was determined that spending close to a trillion dollars a year on healthcare was too much...that it was bankrupting the country, and that even with such immense expenditures, many Americans still weren't receiving the medical care they needed. (For example, infant mortality is higher in the U.S. than in other industrialized nations). People were falling through the cracks in the system, even with Medicare and Medicaid. The U.S. healthcare system was said to be broken and in dire need of repair. Enter the politicians. Healthcare became a political issue. Strike that. Political hot potato is more like it.
The Clinton Administration banked on comprehensive healthcare reform. But the issue was more complex and controversial than anyone expected. Americans, it turned out, had pervasive fears of big (and inefficient) government involvement in their healthcare, and throngs of well- heeled lobbyists roundly and soundly defeated healthcare reform in Washington, D.C. The hot potato was subsequently tossed back to the individual states. The health insurance companies, threatened with their own possible extinction under nationalized healthcare delivery and a government- run single- payor system, breathed a deep sigh of relief.
Now we're left with managed care. And managed care is marching forward in most markets throughout America largely unchallenged, largely backed by huge corporate entities with extensive financial resources, and consequently, largely unstoppable. Everyone seems to be buying into managed care, even before we know for sure if it's good or bad for individual patients or for the health of Americans, collectively considered. No one, except the very rich individual who can afford to pay for medical care out of pocket, is immune from this progression. Even senior citizens, who could long depend on Medicare for their healthcare in their aging years, are now being herded into large HMOs to contain costs.
Some say the relationship between patient and physician has been further compromised, further weakened, under managed care.
"The doctor-patient relationship, once considered the basis of therapy, has been subverted by technology, by the medical education system and, more dramatically, by the intrusive demands of managed care," said Elizabeth DeVita, associate editor of American Health magazine, in a recent article.
What is managed care? It's basically a system that attempts to control healthcare costs by carefully managing how, when, where, why and by whom care is provided. To call it "rationing" would be going too far. But its effect is to prevent needless or unnecessary utilization of healthcare services...to keep people away from doctors they don't need to see, and out of hospitals - - which, when compared to luxury hotels, are pretty expensive places to stay...even for one extra day.
The buzzword in medicine these days is "capitation." The word is reminiscent of a similar word which brings to mind the swift descent of a guillotine blade, followed by the sound of someone's head going "plop" into a bucket. Actually, capitation means doctors are paid one set fee per month for each patient. And if they can't manage their patients' medical care for this set fee, it's likely to be the doctors' heads winding up in the bucket.
"Under capitation at the provider level, the patient becomes a cost center rather than a customer," said Joseph C. Nichols, Jr., MD, president of the Washington State Orthopaedic Association. "There is a disincentive to provide care, and the sickest patients who need health care the most become pariahs of the system. The focus in this methodology becomes cost containment, and patient illness becomes a burden to cope with."
"The potential for under-utilizing services is a real concern," continued Dr. Nichols. "Those who claim that the fee-for-service system causes physicians to inappropriately over-utilize must recognize the potential for those same physicians to inappropriately withhold services when they are given incentives to do just that under capitation."
Withholding services may become the "default position" under many evolving scenarios of managed care. In cases where a bad legal outcome isn't anticipated, withholding services
may be easier for doctors to do, considering how time-intensive and aggravating it is for them to argue with managed care companies. It's also true that doctors who fight managed care companies can be cut from their provider panels. This can hurt doctors' incomes, sometimes seriously enough to jeopardize their practices.
"...many physicians in a capitated system may not provide all the services they should, may not always be the patient's advocate, and may be reluctant to challenge the rules governing which services are appropriate," said Jerome P. Kassirer, M.D., writing in The New England Journal of Medicine.
One big problem is that, despite a veritable cornucopia of clinical guidelines available to practically every doctor, nurse, physician assistant and other physician "extenders" in the system today, no one really knows at this stage in the game what constitutes under-utilization or over-utilization. That missing bit of information is being worked out by hundreds, perhaps thousands of experts in a burgeoning industry called "outcomes research."
Researchers hope to amass data on what procedures or treatments really improve the lives of patients...by helping them to live longer, live more comfortably, or be happier or more content with the quality of the medical care they received. "Medical quality" is another one of those vague and fuzzy terms that the experts have yet to define satisfactorily. For in 1995, when we can track the cost of healthcare down to the fraction of each penny spent, we don't know what medical quality really means. In broad terms, it probably has something to do with whether you get better or not -- with whether you live or die. But many doctors are losing the ability to make that judgment call. What care is "appropriate" and covered, and what is not, is often defined in a seemingly arbitrary manner by managed care corporations and fashioned into hard-and-fast health insurance policy -- which is the insurance industry's equivalent of legal gobbledegook. Have you ever been able to read an explanation of covered benefits booklet given to you by a health insurance company and really understand it? Didn't think so. And guess what? There's probably a reason for that which works to the benefit of insurance companies -- not healthcare consumers.
By now, you've probably heard the terms "corporatization" of medicine or "market-driven" medicine. What this means is that healthcare, and the delivery thereof, becomes a commodity subject to the same laws of the marketplace as soda pop, breakfast cereal, used cars, toaster ovens, and personal computers, for that matter. Is cheaper always better? Are there principles nearer and dearer to us than just saving a buck? Has our emphasis on cutting costs resulted in cutting some very important corners?
"Health care is not toilet paper," said Barbara R. Reed, M.D., President of the Denver Medical Society, in an editorial published in the Denver Post. "As physicians we know that all too well, but we had better spark that realization in others."
She's right, of course. You can easily replace one roll or ten thousand rolls of toilet paper. But when you lose that special, trusting relationship between patient and physician, you've lost something truly irreplaceable, unique, and desirable -- yes, desirable.
The relationship between you and your family doctor, for example, is the cornerstone of your healthcare. Your family doctor knows you, knows your medical history, knows your lifestyle preferences, and knows and understands the context of your familial and other social relationships. There's value in that. Not just medical value, but something that transcends the measurable clinical benefit. "Continuity of Care" is the term used to describe an ongoing relationship with your doctor. It can be one of the single most valuable tools you have in the preservation and maintenance of your health. It's something you should insist on. And be willing to fight for.
But with marketplace medicine, what's happening is that health plans are competing with each other to deliver care at the lowest cost. This, in turn, is being driven by employers who want lower healthcare premiums. Corporations used to buy healthcare insurance for their employees as an added incentive for their employees to work for them...and stay with them. But, as healthcare costs increased, those healthcare premiums became an increasing liability to corporations trying to stay competitive. They became, in effect, a real drain on the bottom line.
Companies nowadays, many of which are operating in a lean and mean "downsized" mode to begin with, show little allegiance or loyalty to their employees...or to the companies from which they purchase their insurance. If they can save some money, offer a more favorable report to their shareholders or investors, they will do so. These are the ways of corporate business.
Yet each time a company changes its health plan, employees typically wind up with a new panel of "providers" -- the doctors participating in that particular managed care plan. In many cases, employees have to select a primary care physician who participates in their company's health plan. If they want to stay with the doctor they already use, they typically must pay more -- or pay out of pocket. I've heard doctors tell me that their patients leave them regularly just to save a few bucks under a new managed care plan.
This is really sad. In cases of financial hardship, it's certainly understandable, but sad nonetheless. Wouldn't we be better off with a system where we are free to stay with the doctor we already have? If you have a doctor you like, who you believe is a good doctor and who has taken good care of you in times of need, doesn't it make sense to stick with that doctor?
Corporations should contract with health insurance plans which allow their employees to maintain their existing relationships with doctors, if they so choose, without penalizing them financially. Allowing employees to keep their doctors may result in healthier and happier employees, which can only improve their productivity and motivation...and the corporate bottom line.
What about the argument that managed care is a good thing because it saves money and prevents needless procedures, and that under the old fee-for-service system doctors really were making too much money anyway?
The real question is this: should health care be treated like a commodity, like an item to be bartered, bought, traded and sold?
Managed care in and of itself isn't the bad guy. HMOs, for example, emphasize preventive medicine and regular checkups for their patients to rule out disease or detect it early on when it's most highly treatable. They also do a terrific job educating their patients to help them minimize the risk of serious disease in the first place. Under traditional indemnity insurance, such preventive services may not be covered, since patients typically need a presenting complaint (or sickness) before insurance kicks in. In this context, managed care is unquestionably a good thing.
What's potentially hazardous to our health as healthcare consumers, however, is the underlying set of financial incentives inherent to certain forms of managed care. Serious gaps may exist between the care you need (and which your doctor deems medically advisable) and the care which managed care is willing to pay for. "Medical necessity" is a term that's open to interpretation, and managed care organizations have been known to use it as a weasel word when they don't want to pay or when they want to delay claims processing and payment. As an enlightened healthcare consumer, you need to ask yourself this: who should be deciding what is or is not medically necessary for you and your family...your doctor or a managed care clerk somewhere?
In the old fee-for-service system, physicians and hospitals made their money on the basis of the procedure, test, or treatment given -- and on the length of "inpatient" hospital stays. The sicker patients were, and the more surgeries and procedures patients needed, generally speaking, the more money the physicians and hospitals made. This was really a "sick care" system, because people profited from other people's bad health. The system was driven, in many cases, by physicians and hospitals, who were paid for their services by insurance companies or, in the case of Medicare or Medicaid, by the U.S. government.
Today, financial risks have shifted back onto the doctors and hospitals and other healthcare providers. Under global capitation, with doctors getting a set amount of money per patient per month to deliver care, the incentive scheme changes dramatically. Under this scenario, the more care that doctors provide and the sicker patients are, the less money they make. Thus, doctors have a financial incentive to have healthier patients to begin with, and to keep these patients healthy. (The insurance industry long ago turned "cherry picking," or selecting the healthiest patients with the lowest risks as health plan subscribers, into a near art form.) The danger is that doctors may now limit care in an effort to preserve a bigger piece of the capitation money pie for themselves. Some doctors receive bonuses at the end of the year based on their patients' utilization of medical services. The less care they provide, the bigger bonuses they get. Now, doesn't that just fry your goose -- the thought that your doctor will get more money at the end of the year because he or she limited care to you and your family? Does that make you trust your doctor more or less?
In most cases, simple human greed isn't the motivating factor. Fear is. Doctors may limit care because they're afraid that if they provide more care, or more expensive care, than their medical peers, they may be cut from managed care panels. Since managed care contracts often represent a sizable portion of total practice income to many physicians, doctors may be reluctant to "rock the boat." This is especially true in heavily managed care-penetrated urban areas, where competition for patients and managed care contracts can be intense. If you're a country doc out in a rural area, you have less to fear from managed care now, but the experts say this could change dramatically in the near future.
Some health system analysts fear that the unchecked expansion of managed care may alienate physicians, undermine patients' trust of physicians, and expand the population of patients without healthcare coverage.
"Physicians will be forced to choose between the best interests of their patients and their own economic survival," warns Dr. Kassirer.
How can this sort of economic climate in the medical profession help to engender trust between patient and physician? Patients expect doctors to advocate on their behalf, to look out for their best medical interests in times of sickness, vulnerability, and need. They need to be able to trust their doctors completely, and know that their medical care is in good hands. Doctors expect to step forward, to help and to heal. They aren't taught in medical school to withhold care that is medically necessary or advisable.
Under fee-for-service medicine, with its underlying financial incentives to do more to make more money, all medicine was not always necessarily in the best interest of patients. Medical tests and procedures, after all, can have side effects. They can leave a patient worse off than before because of complications or adverse outcomes. Sometimes, less care (instead of more care) is actually better for the patient. That having been said, it's also true that too little care, or care given too late, can be ill-advised and dangerous. Consumers need to know they are getting the care they actually need -- no more and no less. Their physicians are most qualified to find the right balance and make sure they are cared for properly.
Consumers who sign up with an HMO or otherwise trust their health and well-being to an insurance plan may expect that all care will be provided for them, under all circumstances. They must view the situation more realistically. For many healthcare consumers, particularly those whose health plans were selected by highly cost-conscious employers, the free-rolling and romping days of getting all of the care they want, and letting someone else pay for it, are over forever.
People should be more conscious of healthcare costs, and be more responsible for their own health by adopting healthier behaviors and reducing their personal health risks. Few would dispute that. The risk we face in market- driven healthcare, however, is that cost-containment will eclipse quality, and pleasing investors will take precedence over patients.
In the short term at least, managed care will continue to put increasing pressure on doctors and hospitals to keep costs down, driven by employers who are pushing managed care plans to offer greater value for each premium dollar spent. Corporations who are providing health insurance coverage for their employees are always looking for ways to cut costs and shore up the bottom line. The interests of employers in selecting a health plan are not necessarily the same as those of employees and their families.
Sometimes corporations, in their desire to save a few bucks, unknowingly push their employees into health plans that may or may not be in their employees' best interest. Having to switch doctors frequently is more than likely not in one's best interest, health wise.
Insurance companies and managed care firms have succeeded largely through sales and marketing efforts. They must sell themselves effectively to large employers to get the sizable, premium-generating contracts. They must also sell doctors, hospitals, and other healthcare providers on participating in their plans and offering their services at a reduced, or discounted, rate. Insurance companies make their money from limiting care to patients and by obtaining increasingly large discounts on services from doctors, hospitals, and other care givers. Insurance firms spare no effort to curtail the amount of money spent on patient care, and yet they have no qualms about huge profits and paying their executives outrageously high salaries.
"The nation's big for-profit health maintenance organizations had a banner year in 1994 by doing what they are set up to do: squeezing every penny possible out of the fees charged by doctors and hospitals," said Milt Freudenheim, writing in The New York Times. "But as they put pressure on health-care providers to cut costs, the HMOs were rewarding their chief executives with sizable pay packages. The cash and stock awards to the chiefs of the seven biggest for-profit HMOs averaged $7 million in 1994."
Many doctors are forced to participate in managed care plans, whether they believe in their underlying philosophy or not, simply to stay afloat financially. Some doctors regard it as a necessary evil; others regard it as a game. Managed care companies keep careful tabs on doctors, not only on their individual practices and care-utilization patterns, but also on whether or not doctors are "managed care friendly" -- that is , whether or not they are cooperative, easy to work with, and whether or not they speak favorably of managed care, especially in public.
I've heard accounts of doctors getting cut from managed care panels because they spoke out against managed care in newspaper editorials. This, if true, is not right. Doctors should have the right to say what they will about anything that stands to have such a far-reaching effect on patients, patient care, and healthcare delivery in this country. After all, doctors will be the ones giving the care, or most certainly spearheading the teams giving the care. In our democratic society, we have always had the opportunity to question, analyze, and speak out against something if we think it may not be right. If doctors want to question managed care in the newspapers or on the Internet, for that matter, that should be their right and privilege. It should also be the right of managed care organizations to voice their opinion, should they desire to do so.
Accordingly, The Medical Reporter will give equal time to physicians and managed care organizations to voice their opinions about some of the issues mentioned here. The Medical Reporter stands for patient advocacy, education, and support. We will be watching managed care organizations to make sure they are not violating the rights of healthcare consumers in any way. We will also be watching all other groups and organizations that play a role in the provision of healthcare today. And I can assure you of this: the various World Wide Web sites and healthcare media to which we are linked will be watching as well.
We believe it is time to bring back trust to the practice of medicine and to restore the sanctity of something long-cherished and truly invaluable: the patient-physician relationship.
For, in the final analysis, as Elizabeth DeVita so sagely pointed out, "Doctors and patients need each other to survive."
Mr. Cooper, a professional medical/healthcare writer/reporter, is Editor-in-Chief of Your Health Information Resource.Home | More Health Articles | Men | Women | Stress | Sexuality
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e-mail: jcooper@medreport.com