WILL QUALITY SURVIVE IN AMERICAN HEALTH CARE? A PHYSICIAN'S PERSPECTIVE So, what's wrong with President Clinton's proposed Health Security Act? After all, it guarantees universal coverage, which is portable and non cancelable. It denies exclusion for preexisting illnesses. Insurance premiums would be uniform for all patients in a community and would not be related to their past medical histories. These provisions are essential and should be non-negotiable. In addition, we believe it is essential that medical savings accounts should be included in any future health care system, in order to preserve our patients' right to high quality health care. The problem with the President's plan is that it sets up a giant bureaucracy which stands between the doctor and the patient, with rules of treatment dictated by the Government and the large corporations who will dominate the Health Alliances. And even if the plan is modified, most of the competing proposals before Congress stress managed care, an unproven commodity, which we believe will be seriously detrimental to the health of our patients. So what would we practicing physicians support in any future health care system? After all, we treat the patients and best understand their needs. Our requirements are simple. We must be allowed to continue to provide high quality care, and our patients should have the right to choose all of their physicians. We also request, as a consumer right, that Health Maintenance Organizations reveal to the public, in advance, how their physicians are paid. When H. M. O. physicians are rewarded for not referring to specialists or for not ordering expensive procedures, our patients have a right to know. Patients should also be informed about the capitation mechanism of compensation for H. M. O. physicians. As an example, under the President's scenario, dermatologists in Los Angeles will be paid at a rate of twenty five cents per month, for each patient, effectively eliminating all surgery, other than for skin cancer. This form of per capita or capitation payment to physicians, central to the President's package, punishes us physicians for quality and rewards us for providing sub-standard care. Why not have negotiated fee schedules for physicians, rewarding quality rather than volume? In a recent eighty eight million dollar judgment against Health Net, financial incentives for physicians and executives were exposed in a court of law. This is the first such case to be tried in the United States. Similar cases against H. M. O.s have previously been settled out of court. As part of earlier settlements, plaintiffs have agreed to gag rules, preventing them from discussing their cases in public. So what has created the health care financing crisis, which has led to the proliferation of Health Maintenance Organizations? The answer is that the combination of an aging society and advancing technology is literally breaking the bank. We have a health care system which is literally being overwhelmed by its own medical advances. The number of coronary bypass operations rose from 14,000 in 1970 to 165,000 in 1991. Each new breakthrough in biotechnology adds fuel to the fire, thereby increasing the costs of medical Today, research is commonly financed and promoted for the benefits of hospitals and teaching centers. It is not unusual to find research teams headed by hospital employees who are, at the same time, part owners of the company funding the research. What's the answer, then? Technology should be evaluated on the basis of need and value to society. Hospitals and other institutions should share resources, rather than buying unnecessary sophisticated equipment in order to compete with their neighbors, thereby increasing medical costs. Why is this important? If technology is not to be evaluated by need and by value, then the only other option is rationing of resources. When Dr. William Schwartz of Tufts University studied managed care between 1980 and 1990, he concluded that, "Given the rapid advances, in medical technology, the only way in which managed care can slow long-term rising costs will be to limit the availability of beneficial services." He pointed out that managed care companies could contain costs by “silent rationing", or the decision to use less costly but less effective intervention without the knowledge of the patient. Unfortunately, this technique is standard practice with many H. M. Os today. In addition, physicians are in fear of being terminated by H. M. O. plans if they publicly share their private concerns about the quality of care in the plans with whom they participate. In other words, the doctor is prevented from telling the patient that the best physician or best source of treatment is not an option in the patient's plan. Since it is almost certain that H. M. O.s will dominate under the President's plan, what's the alternative? To answer this question,. let's look at how our health care dollars are actually spent. Only 10% of the American public is responsible for over 70% of annual health care costs. 5% of the public accounts for over 50% of the total. Our health care dollars, then, are spent primarily on advanced technology used on those patients with serious or catastrophic illnesses. We believe that this is appropriate utilization of medical resources. Everyone wants the best that American medicine has to offer, but how are we going to pay for it? The major stumbling block is that we, as a nation, are over-insured for minor illnesses. This situation will be magnified by the President's proposal, which sets insurance deductible payments at $100 or $250 for all. This type of Insurance coverage is both wasteful and counter-productive. 90 % of insurance claims are for amounts under $1500. This is the ultimate in administrative waste. With 200 new bureaucrats in each new "Alliance", we'll have a whole new definition of waste. Patients should be allowed to choose high deductible health insurance policies, with direct access to any physicians of their choice. These policies should be combined with medical savings accounts, funded by the savings from reduced insurance premiums. These Medi-Save accounts could be used to pay minor medical bills not covered by the insurance plan or to purchase long-term care insurance. Moneys remaining would accumulate tax-free, but could be used at any time to fund any medical need. The end result would be that patients and their physicians would make decisions on minor medical problems, since it would no longer be the insurance companies' money. The President has long maintained that the cause of medical inflation is massive waste in the system. Current research has shown that elimination of waste will only decrease medical costs by one and one half percent a year. Medical savings accounts, on the other hand, would be a valuable tool in insuring proper utilization of medical resources. We believe that Medi-Save accounts must be included in any health care financing proposal. One size doesn't necessarily fit all. If our patients want to choose high quality health care, why shouldn't they have that right? HMO Physicians' Shared Risk Pools Are Dangerous By Ronald Bronow On November 5, 1992, the CBS-TV program Street Stories accurazały portrayed two horror stories created by a physician payment system used in most for-profit health maintenance organizations (HMOs), the so-called sharpd risk pools. In the most shocking story, a woman, through self-examination, found a lump in her breast. She went to her HMO physician and was told “it was only a cyst." When the patient requested a mammogram, she was told that it was not necessary. In spite of objections by the patient and her husband, the doctor remained firm in his refusal to order the test. Five months elapsed. during which time the patient noticed another lump. At this point, the doctor finally relented, and a mammogram was ordered. As the mammogram was highly suspicious, a biopsy was done. Unfortunately, the clinical diagnosis of breast cancer was confirmed. On subsequent surgery the pa tient was noted to have regional metastasis to five auxiliary lymph nodes. Subsequently, the cancer metastasized to the liver and to the bones. Unhappy with the therapeutic options offered by her HMO, the patient went to a large medical center, specializing in cancer therapy. She was advised to have an immediate bone marrow transplantation, this being the only hope to save her life. Her HMO refused to authorize the procedure. Her family then proceeded in insulшic a lawsuit against the HMO. At this point, the HMO relented and authorized the procedure, twenty-four hours before the scheduled operanon. The patient did well after the procedure, and so far there has been no evidence of recurrence of the cancer. Risk Pool Mechanism Why did this happen? The HMO spin doctors will tell you that this story is anecdotal, only an aberration. However, the truth is that this is not all that uncommon. Such horror stories are a direct result of the HMO shared risk Dr. Ronald Bronow, M.D., prezdent of Phycians Who Casa, in a jeonatologist in private practice in Los Angeles. Physcians Who Care is a national organzauan of pavate praence physicians bauni in San Antonio, Texas. Dr. Bronow is the major nither of "Tas Physicians Who Care Plan-Preserving Quality and Equitability in American Medicine,” printed in a spocasi issue of the May 15. 1991 Journal of the American Medical Associaton, Physicians Who Care may be contacted by aniling (1) (800) 545-9305. pool, a physician payment mechanism that strikes at the quality core of American medical care. So how does this system work? When a patient decides to join an HMO he or she is given a list of primary care doctors, known as “gatekeepcrs." The pacients must choose their personal physician from this list only. Each of the listed physicians is then given a monthly per capita payment for each parent assigned to him or her. The physician receives this payment each month whether or not he sees the patient during that month. This system is known as capization. The physician assumes the risk, that his expenses will not be greater than the payments from the HMOs. 105 A policy that makes For example, let's assume that the doctor gets $10 a month per patient. If he sees the patien: 10 times, it equals $1 per visit. If he doesn't see the patient at all, he still gets $10 for the th. But the story doesn't end there. The physician may receive only 57 or 58 of the entire $10 capamtion payment with the remainder put into a shared risk pool. What's left in this pool at the end of the year is divided between all the participating primary care doctors. The catch is that the physicians are notified that this pool will decrease if doctors order laboratory rests, x-rays or additional consultations. The physician, therefore, is given financial incen¤ves not to do his or her best and is no longer the advocate of the patient, but may become the panent's adversary.-/!)!! Risk Pools Lead to Malpractice, Frand A policy that makes physicians restrictive gaækeepers disrupts the trust that is so important to the doctor-patient relationship. The patient is already made vulnerable by disease and his own lack of medical expertise, so he is at increased risk for exploitation in a system of shared risk pools. The panent, assuming that he knows about the doctor's financial incentives, must always be wary that the physician might be avoiding a costly referral or expensive treatment because of personal financial considerations. This disruption of trust between doctor and pazient, to me, is too high a price to pay for cost savings. The saddest part is that the pazient, trusting his physician, may not be aware that he might need further tasting and consultations.) When financial incentives are provided to physicians to limit costs, the interests of patients and physicians become diametrically opposed. So how many patents actually know about physician financial incentives in for-profit HMOs? Unfortunately, very few. Why aren't the parents told in advance? The answer is simple. Wouldn't you think twice about joining a plan if you were told that your physician would be paid more for not referring you to a specialist or for not ordering laboratory tests? Of course you would. But the HMOs don't want you to have this information (or conveniently put it in small prat) because you might decide not to join the plan. Physicians Who Care will not compromise with a system that withholds such vital information from our parents. Patients have a right to know, before they join, about physician financial incentives from an HMO. Anything less than full and complete disclosure is noth. ing less than consumer fraud. So why is this happening? The answer is simple-corporate profit. Large corporations have convinced our government that they can get a handle on medical costs by doing away with "mnecessary medical care.” The corporations that own large, for-profit HMOs are, after all, businesses. In this sense, however, the product of the business is the patient, who has become a commodity. Medical care is rationed so that the corporation may show a prodle our patients had better get used to the fact that physicians were no longer in control of the American health care system. 167 I remember attending hospital staff meetings in Los Angeles in the mid-1980s, hearing corporate representatives pressure physicians into joining HMOs. They openly threatened that doctors would lose their practices mless they joined. We were advised that we could not compete with massive HMO adverusing campaigns and our patients would leave us. We were informed that managed care was the funre of American medicinc. We physicians would be powerless to change it, and we and Who Profits from Health Care Decisions? Now that's the real issue. Large corporations, in the name of cost containment, are amemping to wrest.control of the American health care system from physicians and their patients. Their battle cry is "Physician greed is the root cause of the American health care crisis." They argue that the rising costs of health care will be best controlled by plans that assign a restrictive gatekeeping role to the physician. They further maintain that in the fee-for-service system the physician has a financial inccntive to order unnecessary tests and treatments in order to generate profit Their cooclusion is that financial incentives for limiting service are necessary for cost control and that fee-for-service encourages cost escaiation. However, this explanation is too simplisac. First. in fee-for-service, the interests of the patients are generally the same as those of the physicians. Both pardes want the panent to get better as quickly as possible. Physicians who abuse the privilege of panent trust, by ordering HealthSpan now available on WESTLAW*! NEW DEVELOPMENT TIMESAVING unnecessary tests or procedures should be condemned. Physicians must insist on the establishment of scientific guidelines for medical care. Physicians who stray from these guidelines for personal profit simply should not be compensated. Physicians should be compensated for appropriate medical care. But is physician greed really the issue? Physicians Who Care has consistently opposed physicians over charging for services, as all physicians are blamed for the acts of this small minority. Yet, overall, physician earnings comprise 9 percent of total U.S. health care costs. If you cut all physicians' carmings down by one-third, the total share becomes 6 percent of health care expendimres. That's hardly enough to keep up with medical inflation or pay for 37 million people without health insurance. - On the other hand, when financial incentives are provided to physicians to limit costs, the interests of patients and physicians become diametrically opposed. The more the physician attempts to help the patient, the less the physician is compensated. That is an unfax burden for any physician to carry. Would you rather have one extra test to confirm the cause of your chest pain or one less test so the corporation may show a higher profit? The borom line is that HMOs should provide full disciosure to prospective patients on how their plans work. Does Gatekeeper System Work? I have discussed how any services that a patient receives under an HMO program have to be authorized by the primary care doctor, the "gatekeeper." Why should be patient have to ask for permission for anything regarding his or her health care? Not only showd patients have access to all accessary laboratory tests, they must have direct access to care, whether by generalists or specialists. The HMOs argue that specialists are too expensive and order unnecessary tests. An interesung study was done in my field, dermatology. This study evaluated the ability of primary care physicians to recognize the 20 most frequently encountered skin conditions seen by dermatologists. The overall performance of all 285 primary care physicians showed an accuracy score of 54 percent. Dermatology residents and practitioners consistently scored over 90 percent. This study's results mean that an HMO gatekeeper system may actually increase medical costs because of: (1) additional visits to the same physician because of failed therapy caused by misdiagnosis means added cost. (2) subsequent referral to a dermatologist to establish a correct diagnosis or resolve a poor outcome resulting from the initial misdiagnosis means even more cost; (3) additional diagnostic or laboratory procedures necessilated by lack of diagnostic expertise by the primary care physician means even more expense, (4) ineffective medications that were prescribed because of misdiagnosis, including unnecessary surgery or biopsies, adds even more cost; and (5) the monetary valus of lost time because of additional trips to the physician, the actual cost of travel, and the cost of time lost from work becausc of disability from inadequately treated diseases adds even more. This study poses a real question as to the vajuc of HMO restrictions to access for specialty care. Another example of a fundamental change in the doc. tor/patient relationship in a gatekeeper system is in the way physicians must refer parents for other consultations, second opinions or surgery. The physician is required to agree to send the patient to a consultant or surgeon on the HMO's "approved list." While in medical school. I made a commitment of personal ethics to my patients: to refer them to another physician or service only if I would have that physician treating me or a member of my family. But when I look over the list of paracipating doctors in many HMOs, I find that, in some arcas, physicians to whom I would be required to refer a patient do not meet my personal ethical and professional standards. Furthermore, although the physicians on the lists are changing constantly, I would not be allowed to refer a patent to a physician who no longer participates. HMO Contracts with Physicians The part of an HMO program that a patient will never see is the contract that the physician participating in that program is required to sign. That is because HMOs do not want their patients to know what types of limits and financial incentives are being given to their primary care physician and to others on the HMO's approved list. In many HMO contracts that physicians must sign is a secnon which forbids "the participating physician" from crincizing the HMO, its method of payments and disputes with the company over incorrect, slow or inadequate payments. Furthermore, the physician may not criticize the plan with regard to any of the other participaling physicians nor comment on the physicians or hospitals who are not participating in the plan. In other words, the doctor is prevented from telling his patient that the best physician or the best source for treatment is not a participant in the patient's plan and is therefore not an opuon for that patient. If the doctor is not allowed to tell the patient this, how is the patient supposed to know? After all, the patient trusts the doctor to do his best. Is this the future of American medicine? I, as one physician, will never sign a contract that requires me to deceive my patients. |