Volume VI, No. 2
Summer 1995

Insurers Demand Silence on Myths of Managed Care
By Thomas A. Shragg (as printed in the Sacramento Bee)
As the enrollment in managed care health plans continues to grow, a greater percentage of my patients no longer have direct access to my office. The HMO's now require that patients get a referral for every visit to see me in my specialty practice of pulmonary medicine. For many patients with advanced emphysema, chronic bronchitis, cancer or AIDS I am the only physician whom they have seen. Consequently, these patients must now find a doctor to be their primary care physician or, as the insurance companies term them, the "gatekeeper."

Several weeks ago I was walking in the hospital hallway when I met an internist I know. I  asked this well trained, compassionate and very competent physician if his practice was open and if he could take on the primary care tasks for several of my patients. His answer was no:  I've Just been audited by the insurance companies. They tell me that my profile is too high. I can't take on any of your patients; they tend to be too sick."

This physician was told by the insurance companies that he is spending too much money on referrals, lab tests, x-rays, etc. His statistical average dollar per patient expenditure was too high. Patients with chronic diseases, such as the patients I care for, are likely to need medical services. If he agrees to be the physician for these ill patients, he risks being penalized. He would like to care for these ill patients. He would be good at it. But he simply cannot afford to be a doctor for too many sick people.

Like my friend, many physicians are screening patients before accepting them into their practice. Patients are asked what diseases they have, what medical illnesses they suffer, what medicines they use. Digitalis indicates a heart condition. Theophylline indicates that the patient has potentially costly respiratory problems. And if the patient uses AZT....

The myth of managed care is that it encourages keeping the patients well. The reality is that too often it simply rewards a failure to accept or treat sick patients. There is a difference. The Justification for managed care is that in an era of diminishing resources, it controls costs. Unfortunately as it cuts costs, managed care insurance plans also cut care. There simply is not enough money we are told. Sacrifices must be made. Ironically, the day after my physician friend reluctantly refused to take on my patients, the headlines in the Bee read.  "Billions at issue in for-profit conversion of health plans." Clearly there is plenty of money in the system. Clearly too, medical care has always been managed.

What is changing is that the physician and the patients are no longer in control of many medical decisions. We are witnessing a major shift in power. The patient no longer owns an insurance policy; rather the patient's life is now owned and brokered by the insurer.

In the late '60s and '70s there was a general movement toward greater patient involvement in their own care, The book "Our Bodies, Ourselves" for example, exhorted women to stop being passive, to ask questions of their physicians, to find out why a given treatment was recommended why a certain medication was prescribed-after all, it was their health.

The system that is evolving is antithetical to this type of self-determination. Managed care  is a system of forced treatment limitation. Most referrals, procedures and even hospital stays now require approval of an often unseen insurance company reviewer. Who empowered these companies to make medical decisions, in effect to set medical policy? Whereas governmental policy decisions are open to public debate, insurance company medical decisions are not.

As reported in The Bee, many HMO contracts now have clauses barring physicians from publicly saying anything detrimental about HMOs. My partners were told directly by representatives of one major plan that if I wrote anything about them, our group would lose all of their patients. Many physicians now work as salaried employees of insurance companies, exposing them to still greater scrutiny and possible control.

We all expect physicians to render honest and unbiased medical recommendations. But it's becoming less and less likely that they can continue to act as vocal advocates for their patients.

There is nothing wrong with revamping our medical system to streamline treatment, omit needless procedures and halt non-beneficial practices, But we cannot leave the shaping of our health care system to bottom-liners at the insurance companies.

The health care system is in desperate need of regulatory control. Earliest this spring, House Speaker Newt Gingrich called for congressional investigation of the managed care industry. There have been similar calls at the state level. But it remains to be seen whether the managed-care industry can be checked.

The Wall Street Journal reports that insurance companies and HMOs have amassed billions  of dollars in cash reserves. Recently the head of one large insurance company made much more than $10 million in a single year. Considering the immense wealth, influence and power of the insurance companies, can we expect that legislators will be vocal advocates for the public in setting health care policy?

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