Doctors Given Back Control??
Special E-Mail Bulletin
To my managed care e-mail bulletin readers:
I wrote the following opinion piece about a month ago. I've been sitting on this and have now decided to share it with you. I hope you find the commentary thought provoking. Your comments are welcome.
Gil Weber, December 1999
Call me Curmudgeon...
but I don't share the general enthusiasm of the medical community and the public for United Health Care's November announcement that it's returning medical decision-making to doctors. While I welcome the news (and it does start things moving in the right direction), I fear there are land mines hidden under the surface. In time they could explode and create significant problems for everyone but the HMO.
UHC announced that doctors will be in full control of the covered services provided to their patients, and that various forms of pre-authorization and utilization review — at the heart of managed care since the late 1970s — will no longer be used as a means of controlling costs. Now maybe it's that I worked almost nine years at a for-profit HMO and saw the policy development and implementation processes from the inside. Maybe I'm just cynical, and I truly hope time proves me wrong. But the whole announcement comes across as hollow and reeking of self-serving public relations.
I don't believe for a minute that a plan as large and sophisticated as United, as information rich as it is, has just discovered that letting the doctor decide makes sense. What recently has changed in its data or methodologies that UHC had this sudden epiphany (and willingness to share it with the public)? Is it too cynical to think the timing and nature of the announcement has something to do with the increasingly hostile public perception of HMOs and the growing turmoil inside the Washington D.C. Beltway?
For the first time in my 21+ years in managed care HMOs are under the gun — looking at the possibility of losing enrollees as the public reaches the breaking point with horror stories of care denied or care unreasonably limited. And when the patients lose their patience the employers may also consider dropping certain health plans. And when the public and employers both complain loud and often enough the legislators may finally feel pressure to do the right thing. That's when the clock strikes midnight and "managed care Cinderella" turns into a pumpkin. That's when the tight and meaningful legislative action HMOs fear most finally happens.
So it seems to me that UHC is taking a proactive step designed to make itself look good (though you wonder why it is they couldn't do it when the pressure wasn't on). UHC is positioning itself to say "We're responsive to providers and concerned for patients." To that I say "hogwash."
UHC's actions seem designed to protect its own bottom-line — its Wall Street-focused interests — at a time when HMOs appear vulnerable. In part they seem to be positioning the company to avoid paying out litigation settlements. Now UHC can point to the doctor and say "It was the doctor's decision, not ours. Sue him. Sue her."
United's turn-about might look good to practitioners frustrated with all the second- guessing and paperwork hassle. For example, those who never accepted the reality of managed care and never changed their thinking or practice to evolve with the times may see this new found autonomy as a return to better days. But I'm afraid those doctors are in for a disappointment if they believe that medical decision-making won't be questioned and that they're now free to do whatever they please, whenever they deem it appropriate.
Why? Well, United's press release reveals some important caveats if we read carefully. Despite saying it's all up to the doctor they'll still look at each provider's practice patterns. They'll counsel those whose utilization seems off the norm. And they also reserve the right to dump any provider if the counseling doesn't effect the change United deems appropriate.
This is ominous and it should concern all surgically-conservative physicians. It should also concern those physicians who, by virtue of superior reputation with PCPs, optometrists, and other physicians do more surgery or more complex, costly surgery than most of their colleagues.
The former group may find themselves under increased pressure from patients to provide procedures that a physician may not deem necessary or appropriate at this time. Since the patient knows that UHC has announced it won't reject any covered procedure recommended by the doctor that practitioner will be caught between a rock and a hard place. If the physician relents to patient pressure his or her utilization rates and practice patterns will rise from previous benchmarks. You can bet UHC will notice the increase.
And the latter group, the surgical gurus already at the high end of the utilization (and cost) scale, may find that their numbers only go farther into United's "red flag" zones and cause additional scrutiny and counseling. As a self-protection measure to avoid deselection some physicians may have to cut back on procedures. It could be a lose-lose scenario for patients and providers.
And what in the world will happen to networks now holding master capitation agreements with UHC and sub-contacting with ophthalmologists and optometrists? UHC may announce that it won't question the doctors, but will its networks at-risk for a finite pool of dollars also be precluded from putting appropriate utilization and cost controls on network doctors? I can't imagine any network saying to its participating providers "You're free to do whatever you want, whenever, and we'll pay for it." To give up that oversight and review condemns any capitated entity to a fatal hemorrhaging of its monthly funds.
No, it's not as simple and clean a solution as UHC would have us believe. HMOs cannot just wash their hands of all decision-making (and the collateral fallout) and expect us to accept that everything is going to be OK. That's not the fix that's needed. And UHC's announcement totally avoided one critical component of this mess — adequate reimbursement.
Until health plans stop bidding at premium rates that won't support the services required by the populations, and until a larger slice of the premium dollar flows to patient care, this mess is going to remain with us. Already many excellent surgeons are moving from Cataract to Refractive Surgery as reimbursements go down to the point that Cataract becomes a money- losing proposition. I only hope that by the time I need 66984 I'll still have a choice from among many top surgeons.
Yes, it's good to put doctors in charge of the care they decide is in a patient's best interests. And the current system allowing HMOs to shelter behind ERISA or other means to avoid the results of refused authorizations must change. However, an HMO's complete relinquishment of any oversight responsibilities seems to me overkill — good only for public relations. Rather than abandonment of responsibility we need a better process.
It certainly will be interesting to see where things go in the next 18-24 months as other plans look at their systems and public images, and react to happenings inside the Beltway. Should we be surprised if Aetna, Humana, Pacificare, BC/BS or any of the other players suddenly have similar epiphanies?
Hmmm... I hope I'm wrong, but call me Curmudgeon.
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