Medical Board of California Quality of Care in a Managed Care Environment:
Statement of Concern
“Managed Care” is a reality in Northern California. Over 80%
of the working population is under some type of plan. We are now seeing
a rapid growth of “senior” managed care plans for those on Medicare.
You will no doubt be approached in some manner by various insurance carriers
in the near future. Please remember that nearly all managed care plans
(HMOs, PPOs, etc.) restrict your freedom of choice of who provides your
care and where it is provided. I know the financial savings of many of
these plans are very attractive, but please consider the ramifications
of the restrictions on your choice of coverage. It is hard to put a dollar
value on freedom of choice, but when your health depends on it, it is
critical.
Recently, the California Board of Medical Quality Care published their
report on managed care and its impact on the practice of medicine. Although
it is dry reading, I think you may find it enlightening, especially if
you are considering a managed care plan.
Dr. William Bargar
The Medical Board of California, having convened a committee with the
charge to examine the Quality of Care in a Managed Care Environment has
heard a quantity of testimony from consumers, health providers, regulators,
professional organizations and representatives of managed care plans.
In the course of reviewing the testimony, a number of issues and concerns
have emerged with frequency. Specifically, those issues include a number
which suggest that the business model of managed care as it is implemented
by some plans, may result in an inappropriate restriction of the physician’s
ability to practice quality medicine, and in turn, create negative consequences
for the consumer of health care services. The number and seriousness of
the cases cited during this testimony has caused the Medical Board of
California to consider the serious consequences which grow out of the
imposition of a corporate model in the arena of medical practice.
The Medical Board of California recognizes that dramatic changes are taking
place in the way that health care is delivered as the use of managed care
plans increases. These changes are, as expected, yielding positive results
in the provision of coverage to expanded populations. Unfortunately, the
rapid expansion of the managed care model is also redefining the delivery
of health care in ways that cause grave concern to patients, providers
and the Medical Board of California. Specifically, the restrictions of
medically necessary services, whether as a result of legitimate efforts
to restrict the overuse of medical care services, or for the less acceptable
reasons of cost control, is becoming alarmingly frequent. Managed care
plans controlled as they are by corporate entities, all too often determine
the delivery of care using a corporate business model rather than a medical
model. This cap can result in the denial or delay of critically necessary
medical services, the restriction of the provider’s ability to freely
practice and the placement of the provider in the position of attempting
to be both a healer and a corporate gatekeeper. This serves to place an
inappropriate burden on the physician whose first responsibility must
always be to the delivery of quality medical care to the patient.
… physicians are responsible for the provision of quality medical
care… achievement of this objective is being jeopardized by decisions
which are being made outside the context of the doctor/patient relationship…
The Medical Board of California has the mission to “…, protect
consumers through prior licensing of physicians and surgeons and certain
allied health professions and through the vigorous, objective enforcement
of the Medical Practice Act.” It has attempted to meet this mission
by assuring that physicians are qualified by education and training to
practice medicine and investigating those cases where substandard care
has been alleged. This effort to assure that California’s physicians
are delivering quality care is being thwarted more and more medical decisions
are effectively taken out of the hands of the physicians and are, instead,
determined by plan administrators. The Medical Board of California recognizes
that the movement of a predominately managed care environment will create
changes in the current system of health care delivery as a result of new
market forces being exerted. While it hopes that these forces will self-correct
as the free market model becomes more mature in this industry, the Medical
Board cannot overlook those situations which give rise to environments
which create risks for the health care consumer.
The Medical Board of California finds and declares that there are real
dangers which are imminent if there is not some immediate correction to
the direction in which the system is heading. Specifically, the Medical
Board believes there must be adequate time allowed for the providers to
treat patients, adequate compensation for necessary services and deference
to the provider’s medical judgment if physicians are to meet their
legal, ethical and moral responsibilities to deliver appropriate health
care to the public. On behalf of California’s medical care consumers
the Board emphasizes its expectations that physicians are responsible
for the provision of quality medical care. It further expresses the concern
that the achievement of this objective is being jeopardized by decisions
which are being made outside the context of the doctor/patient relationship
and in a manner which is not always in the patient’s interest. It
is incumbent that providers take those actions they consider necessary
to assure that the practices in question do not adversely affect the care
which they render to their patients.
In furtherance of these concerns, it is the position of the Medical Board
of California that decision-making authority over the determination of
medical necessity or appropriateness of a proposed treatment is the practice
of medicine and requires a license to practice medicine in California.
This is without regard to where the person is located. Additionally, the
Board extends this standard to include medical directors of health care
service plans, other health care delivery organizations, insurers and
other organizations with authority to determine medical necessity or appropriateness
of any treatment. The Board also believes that the denial of a requested
treatment for a condition which may be life threatening or may result
in persistent disability or illness should be timely and in writing, and
should contain the reason or reasons for the denial. Finally, the Medical
Board of California commits to maintaining the oversight of the emerging
managed care environment and proposing statutory and regulatory action
which furthers the goal of providing quality medical care to California
consumers.
It is very important that others who are interested in, and have the responsibility
for, quality in the managed care environment, most notably the California
Department of Corporations and Health Services, join the Medical Board
in this important endeavor.
Restructuring of Medical Care and
Your Relationship with Your Physicians.
Recent changes in managed care have led to the formation of multiple local
individual Practice Associations (PAs). Although our names may appear
in a booklet as providers, it is important that when you sign up for a
health plan or when you change primary care providers, that you check
to be sure that you can return to the doctors that you are already using,
and that this primary care doctor will refer you to the doctors that you
have been using. If you fail to do this, you may lose access to your doctor
because your primary care physician may refuse to refer you. You must
find out about this before you select a primary care physician.
We have joined many programs in order to continue to make ourselves available
to as many of our existing patients as possible. It is important for you
to remember that with all the changes in the health care field you must
do your part to continue our professional relationship. Remember, you
still have a choice…
Community Resource for Older Adults
For the Sacramento area, there is a brochure compiled by the Sacramento-El
Dorado Medical Society Alliance which provides information from Adult
Day Care to Volunteerism. This is not a total listing of resources, but
if you are interested in obtaining this information, call the InfoLine
Sacramento at: (916) 498-1000.
The American Society for Gastrointestinal Endoscopy states that patients
with prosthetic joints scheduled for any endoscopic procedure, antibiotic
prophylaxis is not recommended.
The Senior Connection:
Eskaton, a not-for-profit corporation, offers several services for those
in the Carmichael/Sacramento area. Currently this free service includes
classes on different topics. For example, the 1996 Winter/Spring schedule
of classes were:
• Facing Life Changes
• Fit & Fabulous
• Gesundheit – Allergy alert
• Medicare/Managed Care – Update
• Volunteerism – Lending A Helping Hand
• Making your Wishes Known
Beginning in August the classes include:
• When the Pain Doesn’t Stop
• Who will It Hurt When I Die
• Sleepless in Sacramento
• Making The Most of Your Retirement
• Financial Forecasting
Also offered is a five-week series of classes designed to provide instruction
and support for caregivers who are caring for family members or friends
at home. Free information is available for seniors and their families
who need assistance regarding health care, housing, social, legal and
financial services. Case Management services are also available on a fee-for-service
basis. This is for seniors with multiple care needs and families requiring
additional assistance in utilizing appropriate resources.
For more information contact the Senior Connection at: (916) 334-1072.
HIPSTERS Club Support Group
For total hip or total knee replacement patients or candidates When: 4th Thursday of each month Where: UC Davis Professional Building
4301 X Street Time: 9:30-11:30 a.m. Information: Marcia House, President – 366-7648
Addie Lester, Secretary – 455-5285
New Fellow
Our newest fellow is a native Californian from Redding. Dr. Brian Edkin
completed his internship and residency at Vanderbilt University Medical
Center in Nashville, Tennessee. His interests include family activities,
exercise, golf and pets. Dr. Edkin and his wife Shanna look forward to their
return to California with their fourteen month-old daughter, Emily Margaret.
Dr. Thomas Blumenfeld will be staying in Davis and working in Sacramento
at the MedClinic. We all wish him the best of luck.
Quality
of Care