ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Tuesday, March 12, 1996 TAG: 9603120064
SECTION: EDITORIAL PAGE: A-5 EDITION: METRO
SOURCE: PHILIP T. SHINER, M.D.
THE CURRENT health-care environment is rapidly changing. Forces driven by the need to control cost and to provide medical care to the uninsured have become dominant.
So far, the changes have been directed at cost control with little progress in helping the uninsured. In fact, health care for the insured is being restricted by managed-care plans, most of which inhibit the patient's choice of physician and hospital. On June 23, 1995, John Burry, Jr., chairman of Blue Cross & Blue Shield of Ohio, made the following observation in The Roanoke Times: "We need to ... create an integrated hospital system where all the components of health care - doctors, hospital and insurers - work together to provide the best medicine at the best price."
Burry's comment illustrates a major problem in health-care reform: No mention is made of the patient. It should concern patients that they have not, nor will they be, participants in the debate over their health care. It also raises an ethical question for doctors.
Patients should be worried about their exclusion from the debate. As those who will receive medical care, they are entitled to make choices about how it is delivered, about who will be their doctor, about to which hospital they will be admitted.
Additionally, patients need to understand the effect managed care will have on the doctor-patient relationship.
As physicians, we must pay attention to the same issues. In the view of managed-care plans, patients are no longer considered those in need, but "covered lives," "clients" or "consumers of health-care resources." They have become pawns, played by business in the quest for profit.
We are not really talking about "managed care," but rather "managed cost" and controlled care". Such an attitude leaves little place for "care."
Managed-care plans dictate how patients will be tended, or extract a large financial price from the patient: Choose to do it the way The Plan says, or become partially "self-insured." That means the patient must pay a significant portion of the bill out of pocket if a physician or hospital outside of The Plan delivers the care.
Physicians outside The Plan are reimbursed, if at all, at a lower rate than participating physicians. The same service may be provided, but the difference in reimbursement is made up by the patients, a financial penalty of choosing their own doctor or hospital.
Not all physicians are members of managed-care plans. They may not be allowed to join. They may choose not to join for financial or ethical reasons. Patients are then in the position of giving up their right to choose, or be financially penalized for making a choice outside The Plan.
And no one should assume The Plan will choose a local physician or facility for care. If a cheaper alternative is found outside the area, patients may be required to go there for medical care. All these decisions are made by The Plan, not by the patient, not by their doctor.
Managed-care plans, especially HMOs, reduce health-care expenses by creating financial incentives for providers to avoid delivering care. This raises grave ethical issues for physicians and should cause alarm in the patients.
In a "capitated" system each patient ("consumer") selects a "plan physician" who is paid a fixed amount each year to provide that person's care. The doctor gets paid the same whether he ever sees the patient or attends to his or her care through a terminal illness, seeing the patient countless times.
Often, a "withhold" is applied by the HMO whereby a percentage of the doctor's payment is withheld until year's end. If The Plan believes that the doctor has "ordered too many tests," "made too many referrals to specialists" or "kept the patient in the hospital too long," then The Plan may decide to keep the physicians's withhold.
Conversely, if the doctor used fewer dollars than he had been allocated for the patient's care, then he will receive the money, a bonus for not delivering care. These incentives to the doctor to control costs are directed at limiting or denying care.
The real goal of many HMOs is to place doctors at risk. That is, if the HMO profits, so does the doctor; if the Plan loses money, so does the physician.
This raises the key ethical issue: Who does the doctor serve? The HMO or the patient? It is difficult to imagine a more inherent conflict of interest. Traditional medicine requires the doctor to serve only the patient. HMOs want to change that: Physicians will serve the bottom line of the insurance company.
In order to control access of patients to their physician, many HMO plans utilize a "gatekeeper." All care the patient receives must be given or approved by the "gatekeeper," usually a primary-care physician. All visits to another doctor, and the tests or treatments that are ordered and all hospitalizations, must be approved by this watchdog of medical care.
The gatekeeper ignores the recommendation of the HMO at financial peril. If the "gate is opened too widely," he will be financially penalized, or may even be dropped as a member of the HMO. Put another way, he may lose his job because he did what he believed best for the patient, not what was best for the HMO. How's that for an ethical dilemma?
In a recent Roanoke Times commentary, Dr. James Holman proposed "Four Reasons to Like Managed Care." This article mentions a number of areas previously addressed as reasons to like managed care rather than reasons to be concerned about it. Holman extols managed care as the "best known method for limiting and allocating health-care resources." In fact, it is a method to ration and control access to health care.
In managed care, Dr. Holman says, "providers are responsible for each person enrolled but also collectively responsible for all enrollees. ... Population responsibility is imperative in managed care."
This attitude should really worry patients. It not only is socialistic, but is counter to the traditional role of the doctor as the patient's advocate, a real assault on the doctor-patient relationship. Holman does not share the ethical concerns when doctors are placed in a capitated system or placed "at risk", even though he admits that "doctors ... respond to financial incentives."
"They will likely be ethical under the new incentives," he states. Doctors will behave ethically in an ethical environment. But since managed care is not an ethical environment, one should not expect it to result in ethical behavior.
Managed care does not preserve patient choice to people whose health is at risk, as Holman maintains. To the contrary, restriction of patient choice is considered essential to managed care. Managed care consolidates power in large organizations, as hospitals band together and doctors are driven to form larger groups or sell out to large corporations in order to improve their negotiating strength with managed-care companies.
Patients are only pawns to be controlled and sold in the marketplace. Most people feel they have little choice but to accept the plan or plans offered by their employer. The patient is powerless in a managed-care system controlled by the bottom-line interest of business, insurance companies and large health-care organizations.
Managed care is bad medicine. There must be a better way to deliver health care, one that does not restrict patients rights and require physicians to practice in an unethical environment.
Managed care will destroy the doctor-patient relationship. It does not address the problem of the uninsured. It requires doctors to "ration" care, a position that will malign patient trust.
We need to devise a system where the patient makes decisions about personal health care. We, the people, need to control our health care and its cost, just as we control other portions of our economy. Patients, after all, really are paying for health care either through their insurance premiums, in out-of-pocket payments, via taxes or as an employee benefit in lieu of salary.
Putting the patient in charge of health costs can save the doctor-patient relationship. The challenge is how to develop such a system of care. For it to happen, the leadership must come from the patients. They must act now, as the hour is late.
Philip T. Shiner, M.D. has been a practicing physician in the Roanoke Valley for more than 20 years.
LENGTH: Long : 143 lines ILLUSTRATION: GRAPHIC: BARBARA CUMMINGS/L.A. Times Syndicateby CNB