Doctors Seek Cure for HMO's

Voltaire said the Holy Roman Empire was neither holy, Roman, nor an empire. It has been my experience that, similarly, the "managed care" offered by most HMO's today is neither properly managed nor, even more certainly, care.

Because of escalating health-care costs, cost containment has become a major concern, both to individuals and to the government. The promise of lower costs and total, or at least wider, coverage by HMO's has enticed a vast majority of insurance holders into participating and even won ringing endorsements from the government.

True to their word, HMO's have, in fact, allowed patients to pay less for their care than they would under a so-called traditional-care insurance system. Unfortunately, those patients are also getting much less care for their money—and their coverage is far from total. In essence, HMO's strive to provide a uniform low-cost, but demonstrably inferior, level of care to all patients. The concept of managed care and cost containment in an HMO is thus, unfortunately, a misnomer for what really is managed cost and care containment.

In the past, physicians were allowed to make treatment recommendations based on their medical training, their evaluation of each particular patient's needs, and their firsthand knowledge of available medical facilities. Under HMO's, physicians are forced to make recommendations based on HMO guidelines. HMO's, though, are profit-driven organizations, thus all guidelines and decisions are based on the bottom line, not necessarily on what's best for a particular patient.

Often decisions that affect a patient in, say, Durham are made at corporate headquarters hundreds of miles away by board members with no medical background and no knowledge of local treatment facilities. (Physician advisers do help HMO's in setting standards, but those physicians are paid by and working in the best interest of the HMO, not of the patient.) Treatments and hospital stays are no longer patient specific, but are instead determined based on averages (average recuperation times, average responses to drug therapies, and so on). But not everyone is average. For example, a coexisting condition can prolong or exacerbate illnesses, and random complications can always arise. Doctors can request longer hospital stays and additional treatments, but they can easily be, and frequently are, denied by whoever answers the HMO's phone that day. It's basically a reduction to cookbook medicine—someone without any medical training whatsoever can look in a guidebook and determine your time and type of care, all for the sake of lowering costs.

Also to save costs, HMO's may impose gag rules that specifically forbid primary care physicians from discussing all possible treatments, especially the expensive ones, with their patients. Enforced patient ignorance is often seen as more politically correct for HMO's than is an outright denial of care, but the latter is common enough. Because all courses of treatment and especially all surgeries need to be preapproved, HMO's can, on the basis of a cost-benefit analysis, refuse treatment by questioning the its necessity. For example, if a patient had a cataract removed from his or her left eye a year ago and now develops a cataract in the right eye, some HMO's might ask if a new operation is necessary. Does the patient really need to see out of both eyes? The answer is often "no," especially if the patient in question is elderly. In fact, elderly patients are routinely denied expensive and even basic surgeries, solely on the basis of their age. For many HMO's, the benefits of treating or even saving the life of a 75-year-old woman don't outweigh the financial costs.

The example of cataract surgery highlights the often problematic topic of specialist care and the massive incentives offered for keeping patient care to a minimum. Under the HMO system, all specialists must be determined or approved by the primary provider, but these primary providers are "encouraged" to limit referrals: HMO's generally set aside a certain amount of money for referrals. If primary providers keep referrals under a certain number or referral costs under a certain dollar figure, they get to keep the money (conversely, any provider who significantly exceeds standard referral costs or authorizes too many expensive tests can be tossed out of the HMO). Therefore, a primary provider may send patient to specialist for evaluation, and the specialist may then recommend further tests. The patient, though, can't get those tests without permission from the primary provider, who might not want to allow those tests based on financial constraints placed by HMO. In effect, the specialist's hands are tied by primary physician, while the primary physician's hands are tied by HMO guidelines—and the patient is caught in middle.

If the current HMO system is so hazardous to patients' heath, why are more doctors not speaking out against it? Patient advocacy is neatly curtailed by HMO's by a second, tacit (and in more audacious cases, explicit) gag rule stipulating that any doctor who speaks out against the HMO's practices can and will be summarily kicked out. Because of the dominance of HMO's in health care, exclusion from them can destroy a physician's practice.

Of course, HMO's can destroy a physician's practice in other ways, thanks to malpractice liability. Even though doctors are constrained by HMO care guidelines, the doctors, not the HMO's, are legally liable if any complications (including death) arise from this mandated limited care. For example, a patient who hasn't sufficiently recuperated two days after a given surgical procedure will usually be released from the hospital anyway if HMO guidelines limit hospitalization to two days for that particular procedure—sometimes over the objection of the attending physician. If that patient then worsens or even dies, it's the doctor, not the HMO (which insisted on the release date), that's liable.

What alternative do we have to a system of HMO's? Don't necessarily count on a single-payer, government-sponsored health-care system, such as that in Canada, to be a panacea. Although the Canadian system has a good many benefits, it's not without its drawbacks. For example, medical equipment and facilities are very limited because of their cost, thus some Canadians must travel hundreds of miles for proper care, even if such travel threatens their condition. Also, the waiting lists even for common medical procedures can be quite lengthy (thus many wealthy Canadians cross the border into the United States for their health care). Finally, the Canadian system can have as little or less compassion as HMO's: it very clearly stipulates that elderly patients won't have access to certain costly but potentially life saving procedures such as renal dialysis.

The ideal health care system would hold the health of every individual—regardless of race, creed, color, gender, sexual preference, level of affluence, and any other artificial social divisor one can concoct—as its first and foremost concern. It would then consider equally the often conflicting needs and concerns of patients, doctors, hospitals, legislative bodies, and even insurance companies. Such a utopian system might never exist, but that doesn't mean we must settle for the distinctly dystopian, profit-before-patient ethos of HMO's.