COMMENT
The dangers of managed
care
Aniruddha
Malpani
The delivery of medical care in India today leaves
a lot to be desired. The government has failed dismally in its goal of providing
health care for all. While private medical care can be excellent, not only is it
often very expensive, its quality can also vary considerably. Since the
healthcare industry today is so poorly organised, it is tempting to treat
medicine as a business in order to manage medical care more efficiently. The
hope is that managing medical care can not only help to control costs, it can
also help to provide better medical care by standardising it to maintain quality
control. After all, if health care is a service industry, why not manage it as
one?
In its broadest sense, managed care can be defined
as any attempt to influence the access, delivery, or financing of health care.
It can also be considered to simply be the application of business principles to
health care. In current everyday use, the term managed care often refers
specifically to managed care organisations (MCOs), such as health maintenance
organisations (HMOs) (1).
The concept of managed care is a US model, which
also explains why it is so attractive for Indians - after all, anything made in
the US must be good! Managed care has become a buzz word in medical journals,
which are now full of guidelines, protocols, and pathways, created to help
doctors to provide standardised high quality medical care. It seems to be the
perfect marriage, in which business managers concentrate on minimizing costs and
running hospitals efficiently, allowing doctors to concentrate on being doctors
and providing medical care to their patients. This is why when managed care
companies send out their executives with their sales pitch to doctors, most are
happy to sign up. Isn't this is win-win situation? The doctor now becomes a
'preferred provider', and gets more patients through the managed care referral
network. After all, isn't this simply a better method of paying for medical
treatment? The doctor does not have to worry about collecting payment from
the patient, since the managed care organisation pays. Isn't this just a form of
third party payment?
The key difference, of course, is that with regular
indemnity insurance (such as MediClaim), it is the doctor who decides the
medical treatment and the insurance company simply pays the treatment money (fee
for service) according to their published guidelines. Thus, the financial risk
of falling ill is underwritten by the insurance company, leaving the doctor the
sole medical authority, with no one to second guess or cross-question his
medical decisions. However, managed care organisations (usually called HMOs, or
health maintenance organisations), play an active role in managing how
money is spent. They set guidelines for medical care, choice of medications, and
can limit access to specialists in order to improve cost-effectiveness.
Treatment decisions by physicians often require the blessings, or
"authorisations", of utilisation reviewers and HMOs can refuse to pay for
care if they do not think it is appropriate - and this can hurt both
patient and doctor.
The list of problems which plagues HMOs is a long
one, and affects everyone concerned adversely - doctors, nurses, hospitals, and
patients. In fact, the only people happy with HMOs today are the HMO executives,
who are laughing all the way to the bank. We need to learn from the US, before
we find ourselves in the same mess they are in now - at least we have the wisdom
of hindsight to help us. Let's start with the problems patients face (2). The
biggest one is of access, and it's very difficult for patients to get an
appointment to see their physician - waits of upto 3-4 weeks are the norm. For
complex problems, the difficulty is far greater. It can be very difficult for
the "primary care physician" to refer the patient to an expert - because the
doctor needs authorisation from the HMO before he can refer the patient for an
expert opinion, and HMOs are understandably reluctant to refer patients to
specialists - after all, specialists are expensive. Also, it's not possible
for the doctor to even choose whom to refer the patient to. He is forced
to send the patient to an approved specialist on the HMO's panel - and this
specialist may not be the best for the patient's particular problem. However,
the effects of HMOs on doctors are much worse (3). Most HMO doctors in the US no
longer look forward to seeing patients, because they are compelled by the HMO
efficiency experts to see "x" number of patients per day. They are treated as
mindless automatons on a factory assembly line, who have to process one patient
in 10 minutes, no matter how complex the problem. Doctors who spend too much
time on a patient actually get pulled up, because the bottom line is no longer
the quality of care, but rather its cost.
This is why doctors working for HMOs are often
under considerable stress, and many burnout quickly. For one, their
actions are always being scrutinized and analysed. "Big brother" watches the HMO
doctors closely, by a mechanism called utilisation review (UR), in which clerks
scan medical records to ensure HMO guidelines are being obeyed to keep costs
down. Since HMOs are run by bureaucrats, they believe medical care can be
applied by following "cookbook" rules, and any deviation from these guidelines
leads to punishment. The ability of the doctor to make decisions
individualized for the particular patient is taken away, making medical care
very impersonal and uncaring. Since the focus is on maximising profits,
doctors spend more time on the paperwork, rather than with the patient.
Everything needs to be documented, never mind caring about the patient. Also,
because doctors need authorisation for everything, they spend half their life on
the phone, talking to clerks, explaining why their patient needs a particular
medical procedure, or why hospitalisation needs to be extended in a given case.
The exasperation factor is tremendous, and the waste of time and energy is huge
. Doctors are also hamstrung in making decisions. Thus, only drugs which are in
the HMO's formulary can be prescribed -if the patient needs an alternative
which may be superior, but more expensive, the HMO will simply not
pay for it.
Payment is another sore issue. Since the HMO has so
much financial muscle. it is the HMO who decides payment terms - when and how
much to pay. Often, payments are too little and too late, with the result that
doctors get squeezed - and in fact, doctors in the US today often end up losing
money by seeing patients (since the reimbursement from the HMO does not cover
their overheads). Many are now finding that they need to work harder and harder
for less and less, so that like the Red Queen in Alice in Wonderland, they need
to run in order to remain in the same place. With the introduction of HMO
commercialisation, doctors are forced to become businessmen - and learn all
about new terms such as cost containment, authorisation, capitation, and
gatekeeper (which you won't find on any medical textbook) (4). However, the sad
fact is that physicians are very naïve as businesspersons, and even though they
think they are very clever, they are easily manipulated by HMOs, so that they
often end up fighting against each other because of ego hassles, medical
politics and professional rivalry.
One of the most harmful effects of HMOs has been
the poisoning of the physician-patient relationship (5). The doctor has simply
become a health care provider, and his professional status and reputation has
been destroyed. Doctors are given financial incentives for reducing costs - and
this is obviously going to affect the quality of care the doctor provides, as he
tries to skimp on expensive treatment. In fact, patients have become very
distrusting of doctors in an HMO system, because they feel that doctors are
denying them the medical care they need. Thus, in a few short years in the US,
the trust patients used to have in their doctors has been wiped out, and a
doctor v/s patient adversarial relationship has been created.
To add insult to injury, the HMO applies
constraints as to what the doctor can do and cannot do - but if something goes
wrong, then it is the doctor who has to bear the full brunt of the patient's
wrath - after all, how can an HMO clerk be held responsible for medical
decisions? This means that doctors are now sandwiched between the HMO management
and their patients - and receive flak from both sides. In fact, some experts
even wonder if it is possible for doctors to practise medicine ethically in an
HMO setting, when they are answerable to two different masters - the HMO
management (to keep costs down) and their patients (to provide high quality
medical care). Physicians now have to play a fine balancing act between their
duty to their employer (the managed care organisation), the health interest of
their patients, and their personal livelihood. What a far cry from the 'good old
days' when all the doctor had to worry about was looking after the patient's
best interests.
Patients and doctors have already started rebelling
against the excesses of the HMOs in the US. Laws for patient rights, to protect
them against HMO abuses, are being passed; doctors are now joining unions, and
offering creative alternatives to HMO models, such as private practice physician
networks.
Managed care will be introduced in India. It's
simply a matter of time that it will be 'exported' to India as it has been to
Latin America (6). After all, we are talking big bucks. As Dr Arnold Relman, the
past Editor of the New England Journal of Medicine, noted, "Health care is being
converted from a social service to an economic commodity, sold in the
marketplace and distributed on the basis of who can afford to pay for it." (7)
However, if we import the US model, the only ones who will benefit will be HMO
managers. Doctors in India need to band together to withstand this danger, for
the sake of their patients - and for their own sake. Let's not forget that it's
not possible to provide medical care without doctors. If we are united, we can
act as our patient's advocates, and support a model that's patient-centered as
opposed to one that just cuts costs.
References:
1. Fairfield Gillian,
Hunter David J, Mechanic David, and Rosleff Flemming. Managed care: origins,
principles, and evolution. BMJ 1997; 314: 1823.
2.
Fairfield Gillian, Hunter David J, Mechanic David, and Rosleff Flemming. Managed
care: Implications of managed care for health systems, clinicians, and patients.
BMJ 1997; 314: 1895.
3. Rodwin MA. Conflicts in managed
care. N Engl J Med 1995;332:604-607
4. Kassirer JP. Managed care and the
morality of the marketplace. N Engl J Med 1995; 333: 50-52.
5. Kassirer, J.
P. Managing care - should we adopt a new ethic?. N Engl J Med 1998; 339:
397-398
6. Stocker K., Waitzkin H., Iriart C. The exportation of managed care
to Latin America. N Engl J Med 1999; 340:1131-1136.
7. Relman, A. Criticizing
the takeover of public hospitals by commercial businesses, New York Times
January 25, 1985. Simpson's Contemporary Quotations.
Dr Aniruddha Malpani, Malpani Infertility Clinic,
Mumbai 400 005. Email:malpani@vsnl.com.
