Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, August 21, 1995 TAG: 9508210125
SECTION: NATL/INTL PAGE: A1 EDITION: METRO
SOURCE: MARTHA IRVINE ASSOCIATED PRESS
DATELINE: PORTLAND, ORE. LENGTH: Medium
Although diagnosed 15 years ago, Harrison never had seen a neurologist who specializes in the debilitating nerve and muscle disease.
She finally found one on a list provided by her insurer, a health maintenance organization, but then ran into a problem: Her primary care doctor wanted her to see his clinic's neurologist - one who did not specialize in MS.
She had to change primary care doctors before she got to see the specialist.
``I got tired of arguing,'' Harrison said. ``The bucks are always the bottom line.''
She and others contend the problem she faced is becoming more widespread as managed care overtakes the country.
Patients complain that primary care doctors limit referrals to specialists because that means parting with some of the money coming in from the HMOs. Many specialists agree.
The controversy is escalating in Portland, which leads the nation with 64 percent of its residents in HMOs.
In medical insurance jargon, the controversy centers on a term known as capitation.
It means an HMO gives a primary care doctor a lump of money each year to cover a patient's medical costs, including tests and specialists' fees. The sum depends on the kind of contract an employer negotiates.
Primary care doctors or their clinics are, in effect, ``gatekeepers'' who determine what care a patient gets. If the patient visits an HMO-approved specialist in another clinic, the primary care doctor has to share some of the money.
``The gatekeeper almost holds you captive because of the financial reward,'' said Kathy Weaver of the Oregon Health Action Campaign, a nonprofit patient rights group based in Salem.
Weaver, who has an inflammatory digestive disorder known as Crohn's disease, said primary care doctors have held her back. And she regularly hears from patients in similar circumstances.
``It's a serious problem,'' Weaver said.
At the crux of the debate is this question: Is it better to treat patients too much or too little?
Capitation also is causing a rift between primary care doctors and specialists.
Because primary care doctors receive the money up front, the system encourages them to hope patients do not come in, specialists say. And when patients do get sick or hurt, specialists contend, primary care doctors are reluctant to refer them.
``The incentive is to do less,'' said Dr. Richard Zimmerman, a senior partner at the Portland Orthopedic Clinic. ``I have seen neglected diagnoses that I haven't seen in 30 years.''
Primary care doctors, and some health care experts, argue that they have been given the tough job of balancing services and economics and are, for the most part, doing it well.
``The reason a lot of specialists have been bothered by it is because it clearly limits their control, and they're used to being in control,'' said Dr. Brenda Bruns, medical director at Metropolitan Clinic in Portland.
Bruns, an internist and former emergency room doctor, said having one doctor to oversee a patient's health care prevents duplication of medication and treatment. ``Without managed care, it's like too many cooks. The care is not organized,'' she said.
Dr. Alan Hillman agrees. He is a health economist and director of the Center for Health Policy at the University of Pennsylvania.
``It will always be the battle cry of physicians that managed care is ruining the quality of care,'' said Hillman, who attributes specialists' complaints to growing pains amid inevitable economic reform in health care.
Nationally, the only organization that seems to be keeping an eye on HMOs is the National Committee on Quality Assurance, an independent, nonprofit group in Washington that accredits HMOs.
Other than that, HMOs are trusted to police themselves, and are required to set up extensive grievance processes for patients.
Both sides in the HMO care controversy agree patients have a responsibility to learn more about their health care plans.
``Education is the only thing that gives you power,'' said Harrison, the nurse with MS.
by CNB