With the introduction of Managed Care, a conflict heretofore not of significance in most situations, arose. As discussed in this text, there can easily be a conflict between the treating physician and the “gatekeepers” of the Managed Care organization.
Managed Care organizations that have become successful have always listened very intently to their providers and to their customers. They have amassed huge amounts of knowledge and statistics and case studies, etc., in order to create their treatment guidelines. While these guidelines are used to evaluate treatment, etc., they also service as an educational tool by providing information to their providers as to the effectiveness of the various procedures, drugs and devices.
Regardless of the amount of information available to the organization, nothing can replace the judgment of the individual physician in treating any individual. The physician may not always be entirely correct, however the input of the physician is absolutely necessary in determining the course of treatment for a particular patient.
Many physicians feel that the Managed Care “bureaucrat” is looking over their shoulder all of the time, and are more interested in the cost of treatment than in the success of the treatment. They strongly feel that there is a definite ethical problem when the guidelines disagree with the care that they feel is necessary for the proper treatment of their patient.
Managed care can only be successful when they completely and totally adopt the position that the appropriateness of care should not be judged on strict adherence to treatment guidelines, but on patient outcomes. Only by analyzing and comparing the outcomes of treatment with the treatment guidelines, and this ethical conundrum be laid to rest.
CASE STUDY: The "Transition of a Doctor”
Profit‑oriented incorporation of medical care is an increasingly common phenomenon. In an interview in Managed Care magazine in August 1994, Dan Aleut, NM, then president of the American College of Cardiology, described the trend of for‑profit HMOs to buy up doctor's group practices and turn them into profit centers for the HMO.
"Increasingly ...large insurance companies (HMOs) are buying patient lives, using vast resources to buy up primary care practices, such that the companies essentially own the patients and the doctors own and control the patients, you can dominate the interaction between the doctors and patients for various motives. The worry is that you control the interaction to make profits."
A California doctor Dr. Charles, an excellent doctor whom his patients will miss for years to come, lost his practice of many years to a for‑profit HMO. Originally he joined a multi‑specialty group of about sixty physicians in a Los Angeles suburb. He had been a family practice physician doing traditional indemnity FFS (Fee for Service) insurance medicine. In early 1990's, the group was struggling because the number of patients was decreasing, a lot of it due to the group's inability to get HMO contracts.
The group was approached by a large multi‑state for‑profit HMO with an offer to buy their group and its facilities (an increasingly common occurrence). The HMO offered to pay each of the partner physicians a handsome sum in exchange for his or her interest in the medical group. In order to get a full share of the buyout; each doctor had to agree to a five‑year contract as an employee of the for‑profit staff model HMO that would then be created‑at a generous salary. After much debate, the partners narrowly agreed to sell the practice. Dr. Charles stayed on as the buyout agreement stipulated and received the generous agreed‑on salary. He had no idea what the future would bring.
Soon after the agreement was implemented, the clinic's patients were notified that during the next year the clinic would phase out FFS patients. Patients who wanted to continue seeing their current clinic doctors would have to purchase HMO insurance. The HMO made enrollment very inviting through a huge advertising campaign drawing on the medical group's excellent reputation.
Within thirteen months, the doctors were seeing only HMO patients. Then the cost-saving push began. Utilization review (UR) nurses hired by the HMO began reviewing each hospital admission. An UR nurse would call a doctor and suggest ways to decrease the length of the hospital stay for each patient. At first the suggestions were fairly benign ‑ arrange for home‑ad ministered IV antibiotics, or discharge a hip‑surgery patient early for physical therapy at home.
Over time, though, the UR nurses grew increasingly aggressive. They challenged every day of continued hospitalization and questioned every admission. The doctors felt hassled by the nurses, but when they complained to the administration, they were told to cooperate with them as much as they could. Feeling the pressure from the UR nurses, and knowing they were being scrutinized by management, the doctors gradually came to admit fewer patients and discharge patients much earlier than before. They were becoming company doctors.
Many patients' medical problems don't meet textbook criteria for hospital admission or discharge but require subtle, informed medical judgment. Dr. Charles' HMO hoped to color cases in these gray areas in its favor. If any argument could be used to contain the cost of treatment of any of the patients, this is the direction that the HMO would go.
Dr. Charles felt that he was being second‑guessed on every diagnosis and every treatment. Initially, he had gone along with the extremely close supervision because he admitted he learned a lot about treatment as the HMO had "volumes" on various treatment procedures. However, he found himself in the position of having to treat a patient that he had known for years and had treated in the pre‑HMO days, and to treat the patient according to the HMO guidelines, instead of what he knew instinctively and from years of experience, would be much better treatment.
He sold his interest in the group, and moved his practice to a small town in Montana.
Physicians are expected to do everything possible to prolong life, regardless of how long a time. In those countries that have single payer or socialized medicine, this is not the practice.
The issue of cost arises when it is apparent that the patient may continue to live for a very short time, or in a very reduced capacity if they do survive. This is rationing at its worst, but is a way of life (or death) in many countries.
In the United States, many people have living wills in anticipation of severe disabling illnesses or injuries. The Patient Self‑Determination Act makes it mandatory that patients be asked if they have a living will when they are admitted to a hospital.
As an example, in the United Kingdom which has socialized medicine, patients with kidney failure who are over age 65 are normally refused kidney dialysis. In the U.S., the fastest growing segment of society using dialysis are people over age 75.
At this time, we in the United States are horrified at the idea that we may have to eventually ration health care. However, it must be conceded that the more resources are stretched to provide health care, the more likely it becomes that we may have to face the question of rationing.
Managed care reduces pressure on medical care costs, and therefore the less likely it is that we will have to face the questions of rationing. By reducing pressure on medical care costs, Managed Care can help us postpone or possibly eliminate having to make this terrible decision.
STUDY QUESTIONS
1. The input of the physician is necessary in determining the course of
treatment.
A. never
B. absolutely
C. seldom
D. questionably
2. Physicians are expected to do everything to
A. prolong life.
B. shorten life.
C. collect their fees.
D. avoid forming HMOs.
3.. In the United States, patients entering a hospital are asked if they have
A. car in the parking lot.
B. prescription drug card.
C. living will.
D. relative working at the hospital.
4. When Americans are told that they might have to ration health care
A. most of them could. careless.
B. they are horrified!
C. they join HMOs.
D. they cancel their Fee ‑ for ‑ Service plan.
5. Many physicians feel that Managed Care
A. is more interested in the cost of treatment than in the success of the treatment.
B. is more interested in the success of treatment than in the cost of the treatment.
C. is more interested in making more money for the physicians than in proper care.
D. is highly flexible and always approves a doctor’s course of treatment.
6. Managed care can only be successful when they completely and totally adopt the position that
A. the only true and accurate method of determining proper treatment, is the cost.
B. the appropriateness of care should be judged only on patient outcomes.
C. the appropriateness of care should be judged only on strict adherence to treatment guidelines.
D. most physicians look upon managed care as a bureaucrat looking over the shoulders of the doctors.
7. The issue of health care cost arises
A. when politicians want a football to toss around before election (this is not the right answer, but it is an interesting thought…).
B. when a young, healthy persons joins a health club.
C. when it is apparent that the patient may continue to live for a very short time, or in a very reduced capacity if they do survive.
D. very infrequently in a retirement community.
8. Marie is 72 years old, in relatively good health until she had a stroke. The prognosis is that it will take a lot of expensive therapy and then there is not much hope that she will ever really be able to have a meaningful recovery. The difference between what doctors in a country that has socialized medicine might do, and what most doctors in the United States might do, would be
A. that doctors in socialized medicine countries would probably do everything in their power to have Marie lead a normal as possible, and function life for as long as possible.
B. that doctors in the U.S. would probably just not prescribe therapy because of her age and physical condition, or any other type of relatively expensive treatment.
C. not different at all. They would all try to return her to a productive life if possible, with no cost consideration.
D. doctors in the U.S. would probably prescribe therapy and any other type of treatment, and do everything within their power to get her recovered and active again.
9. By reducing pressure on medical care costs, Managed Care can help
A. speed-up the possibility of health care rationing.
B. postpone or possibly eliminate medical care rationing.
C. keep more politicians in power.
D. put a cap on physicians incomes.
10. The Patient Self-Determination Act
A. allows HMO patients to choose their own doctors.
B. makes it mandatory that patients be asked if they have a living will when admitted to the hospital.
C. makes hospitals admit uninsured patients.
D. allows patients to go to Canada for treatment if they wish.
1B 2A 3C 4B 5A 6B 7C 8D 9B 10B