MDs Fear Managed Care Equals Lower-Quality Care

NEW YORK--Yogi Berra had the last word at a panel discussion onhealth-care reform sponsored by the Medical Society of the Stateof New York. Television talk show host Larry King moderated thediscussion and fielded the caustic remarks of doctors, pharmacists,and medical students who packed a Waldorf-Astoria ballroom todebate whether quality medical care can be maintained under health-carereform.

No one was optimistic. But what to do? Mr. King quoted the NewYork Yankee catcher: "When you come to a fork in the road,take it." This typically ambiguous Yogi-ism reflected theaudience's evident distress with health-care reform--all forksseem to lead to managed care.

The land-mine ahead that seemed to most worry those at the meetingis whether health maintenance organizations (HMOs) and other managedcare plans can provide quality care. "Will physicians bemaking the ultimate decisions about treatment or will that beleft to clerks who don't have any medical background," amedical student in the audience asked, to big applause.

"No HMO would ever consult anybody but a physician to makea medical decision," panelist Karen Ignagni, president ofGroup Health Association of America, a trade association of HMOs,reassured the student.

Speaking as the only representative of a managed care plan onthe panel, Ms. Ignagni noted that the various forms of managedcare may differ in how they operate, but that in HMOs, medicaldecisions are always made by physicians. She added that HMOs havea track record of providing quality service.

But not everybody was reassured. "May I tell you why I'mseriously contemplating leaving the practice of medicine,"said a physician in the audience with some 50 years in practice.He had received a letter from a managed care plan that began 'Dearparticipating provider.'

"You see? I used to be a physician; now I'm a participatingprovider," the physician said. "The letter goes on tosay that only one hospital will be allowed to do my patient'sheart operation. You choose a hospital because it has the lowestincidence of side effects, and they can change it without anydue process."

"You've got your hands around one of the most difficult issues,"Ms. Ignagni agreed.

"Now we have insured people who are dying because they can'tgo to the right doctors," the physician added.

No More Norman Rockwell

Michael Caldwell, MD, an internist and health commissioner ofDutchess County in upstate New York, was also in the audience,and he was no optimist either. "The Norman Rockwellian viewof the patient-physician relationship is eroding at a faster ratethan ever before. It's impossible for a young doctor to open aprivate practice. It's becoming increasingly difficult to joina group practice, so HMOs seem very appealing, just as they dofor those healthy Americans who are signing up with them in droves."

However, Dr. Caldwell believes patients are getting a raw deal."When they're well, an HMO is okay, but not when they reallyneed it. When the chips are down and you're in the hospital, yourchances of seeing your own doctor are remote. Is this what theAmerican people really want? I believe that fee-for-service internistsshould be the health-care coordinators, not the HMOs."

"Thus far, Charles, an angry audience," Mr. King musedto panelist, Charles Aswad, MD, executive vice president of theNew York State Medical Society.

"I think with cause," Dr. Aswad answered. "Becausehistorically, primary care physicians, pediatricians, family practitioners,have in fact been case managers for patients. They have steeredtheir patients through the maze of specialties that are availableto them. Patients have had the right to bypass the primary caresystem and go directly to the specialties they desire, and thatis a right that many people do not want to lose."

Health Care Musical Chairs?

But the fact is, Dr. Aswad pointed out, people who sign up withHMOs or orther managed care plans through their employer oftenfind that the company changes plans from year to year, meaningstarting over with new physicians. "That problem, the abilityto substitute one managed care system for another without muchinput from patient or physician, is one that is going to dog thiscountry until we figure out how those with chronic illness canstay with their preferred physicians," he said.

Larry King had a question for panelist Mark R. Chassin, MD, commissionerof the New York State Department of Health. "Dr. Chassin,a friend of mine has this joke. Money is not the only thing; healthis 3%. What is the balance between profit and quality in healthcare?"

"We do in fact have serious quality problems in medicine,and it's hard to divorce them from some of the finance issues,"Dr. Chassin said. He noted that our reimbursement systems do notreward excellence. Fee-for-service reimbursement encourages possibleoveruse. "That is a quality problem because everything wedo in medicine has risks, and overuse increases the likelihoodof harm," he said, adding that capitated reimbursement systemsmay create another kind of quality problem, underuse.

"Are you saying that the statement we always hear--that wehave the best health-care system in the world--is not true?"Mr. King asked. Dr. Chassin responded that although the UnitedStates has the capacity to provide the highest quality care inthe world, "we very often fail to do so."

How to evaluate the quality of care in HMOs and other managedcare plans is another pitfall ahead, warned panelist Trudy Lieberman,senior editor of Consumer Reports. "There are many groupsout there that purport to measure and rate quality, and many ofthese groups have been selling this information. Some of it isgood, and a lot of it is not. The real challenge will be for consumersand those who represent them to separate the wheat from the chaff."

Larry King recalled his own concerns when just before he was aboutto have a triple bypass, he looked up to notice that his surgeonwas missing a thumb. "Don't worry," the surgeon toldhim. "I had to learn to become ambidextrous. Because of it,I actually have the use of more fingers than most surgeons."And there may be a moral there for physicians worried about havingtheir hands tied by health-care reform.