What's On My Mind...

My 2¢ worth...

March 1, 1999

One of my plans for the future with this Web Site is to include commentary from time to time on the state of today's healthcare delivery system. The concept of Managed Care is basically a good one. It's stated aim is to provide the highest quality care for less money. The profit motives of the health insurance companies may take precedence. There sometimes seems to be more emphasis on "managed" than there is on "care". Realistically, I can't do what they won't pay for, even if I think my patient is not receiving the best possible care. An example: Some HMO's will not authorize payment for a more expensive mode of therapy unless a course of less expensive treatment has been prescribed, no matter if the physician believes from his own experience and knowledge of the patient that such treatment is unlikely to be effective in a particular case, and that delay in alternate, more expensive, treatment would be harmful. Many HMO's now have a formulary of "preferred" drugs and either will not pay for other drugs not on their formulary, or will require a higher copay from the patient. These drugs are usually, but not always, more expensive than the "preferred" drug.

The reason given for denials of payment is that the service was "not medically necessary", and the insurance company makes that decision. "Medical necessity" is determined by a complex set of rules and definitions that are not readily available to the practicing physician, and until recently, were not disclosed to the physician. Payment of hospital days is not uncommonly denied, or paid at a "skilled nursing care" level. The insurance company decides what constitutes "hospital level care", and their payment policies dictate when the patient must be discharged if payment is to be received. Sometimes payment is denied for days in the middle of the admission if a procedure is delayed, even if the attending physician felt the patient could not safely undergo the procedure earlier. It would seem to me to be more accurate for the company in many cases to simply state "that isn't covered", rather than automatically override physicians' judgments as to what is "medically necessary" in an individual case. Arbitrary decisions can sometimes be reversed by letter writing and by appealing to a Medical Director in the insurance company. Anyone who has tried to telephone an HMO for information can testify as to the time and frustration it often takes to resolve an issue. The doctors' incomes have already been decreased by reduced reimbursement from insurance companies and time spent away from patient care writing letters and making phone calls further degrades the doctor and his income.

HMO's do not pay the physician a fee for service. Reimbursement for most HMO patients is by capitation. That is, a monthly payment, ranging from $6 to $8 a month for younger patients, to $20 or more for MEDICARE patients. The HMO's that cover the indigent patient, or those who are disabled and unemployed pay even less. Incentive payments and bonus payments are added for various qualifications. These include whether the practice is open to new patients or not, whether the office has the capability of doing such things as ECG's, flexible fiberoptic sigmoidoscopy, or other procedures as part of the capitation payment. "Quality points" are given for proper patient management. This is an incentive in many cases to systematically do the preventive medicine procedures and therapies that SHOULD be done, and is a good thing. However, extra money will also result from the "efficiencies" previously described.

I can qualify for higher payments from the HMO by:
1) Having more patients in the practice on which capitation is paid. This means one has to see more patients. Since there are only so many hours in the working day, this must translate into spending less time per patient seen.
2) Becoming more "efficient".. that is seeing more patients per hour. I believe additional time is often needed for personal attention that allowed the "family doctor" to know the "whole you" better, as well as being more interested and more human. But this increase in time is not reimbursed adequately.
3) Decreasing the number of days my patients spend in the hospital, decreasing their numbers of visits to emergency rooms, and decreasing the number of referrals to I make to specialists. One way this can be accomplished is by giving the best care possible in the office. Catch 22 ... this requires more time and more frequent visits for very ill patients.
4) Merging the practice with a large organization, or expanding the practice to include numerous physicians can result in higher reimbursement by the HMO. Large groups are able to negotiate better payment levels than an individual physician.
5) Completing assigned Continuing Medical Education subjects. This is a good thing!
6) Keeping immunizations and doing regular routine health checks and cancer screening tests. This is also a good thing.

Extensive computerized records allow multiple comparisons to the average HMO doctor in one's specialty. I receive a regular "report card" reflecting my practice patterns. A percentage increase in capitation payments is given for improving these cost containment "efficiency" ratings.

None of these changes is intrinsically bad, and some are desirable. But the system is easily abused. While the insurance companies, especially the HMO organizations, tell me they don't make clinical decisions, the financial limitations they impose and the curtailing of hospital treatment force all doctors to accept the new standard of care imposed by their rules. Many caring, conscientious doctors find the present climate of practice a real dilemma between what they KNOW would be optimal and what insurance will cover. It can be very depressing. Having said these things, it is also true that there are abuses of the system by doctors, hospitals, laboratories, etc. that HMO's are successfully addressing. But a prime motivation is to reduce expenses and maximize profit.

Medical care provided by health insurance has to remain, overall, at least adequate in order to maintain membership. Changes in the way HMO's operate come slowly since the majority of their subscribers are healthy, and seldom have to deal with the changes that have occurred. I believe also that many people accept the change as "that's just the way it has to be", or aren't fully aware of how much medical delivery has changed in the past 20 years. Some changes come about because of regulatory laws passed curbing the health insurance industry by various states as well as the federal government. For doctors enduring the loss of authority, loss of prestige and respect, loss of autonomy and lower incomes, it would not seem unreasonable for the best and brightest of our next generation of potential medical school applicants to choose another field. In fact, there has been a significant decrease in the number ofapplicants to medical schools in the past two years. Polls of the students reveal that the reasons for avoiding the medical profession is the perception that physicians are controlled by the health insurance industry, and that other fields of study offer the potential for better financial rewards.

For additional information about what's going on in medical news, go to the Physician's News Digest on another page. On that page is an article on the problems in Texas with managed care. While the situation there seems worse than this area, Aetna U. S. HealthCare has insured members here also. Read the article Medical Care showdown in Texas..

But we can make some fun of the situation... here are a few cartoons to raise your consciousness and give you a laugh (maybe) at the same time. These are the work of the political cartoonist Mike Keefe whose work appears in the Denver Post. While these are copyright protected, permission is given by Mr. Keefe for their use in education, and this IS educational!

Page 18 

William H. McMicken, M.D.