| |
The delivery of medical care in India today leaves a
lot to be desired. The government has failed dismally
in its goal of providing healthcare for all, and while
some hospitals are international centers of excellence,
the majority of patients do not have access to quality
medical care. While private medical care can be excellent,
it is often very expensive, and since there are no standards,
the quality can be very uneven. This sad state of affairs
results in many patients being dissatisfied with their
medical care, and doctors no longer command the high
prestige they used to.
Since the healthcare industry today is so poorly organized,
it seems very tempting to treat medicine as a business
, in order to manage medical care more efficiently .
The word managed itself is very enticing – after
all, anything which is well-managed is good –
and why can’t medical care be managed too ? The
hope is that managing medical care can not only help
to control costs, it can also help to provide better
medical care by standardizing it to maintain quality
control - after all, the reasoning is, if healthcare
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 organizations (MCOs), such
as health maintenance organizations (HMOs).
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. So much for the promise, which
is such a seductive idea, that it is greeted with an
initial wave of euphoria. 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
. Most doctors in India are quite happy with the concept
of “third party payment” - after all, isn’t
this exactly what MediClaim does ? If the insurance
company is paying, this reduces the financial burden
on the patient – and the doctor is free to charge
more, since it’s not coming out of the patient’s
pocket , and in fact, in the heyday of “third
party payment” in the US 30 years ago, many doctors
did become very rich very soon. So, why not make hay
while the sun shines ?
The key difference, of course, is that with regular
mediclaim insurance , it is the doctor who decides the
medical treatment – the insurance company 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 as the medical authority, with no
one to second guess to 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 "authorizations",
of utilization 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.
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
not forget that the managed care model was introduced
in the US for only one reason – to control the
runaway skyhigh costs of medical care there. The intent
was never to improve the standard of medical care –
which should be a doctor’s only goal. 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 businessmen
and HMOs, so that they often end up fighting against
each other because of ego hassles , medical politics
and professional rivalry.
The list of problems which has plagued HMOs is a long
one – and affects everyone concerned adversely
– doctors, nurses, hospitals, other medical staff
– and patients. In fact, the only people happy
with HMOs today are the HMO executives, who are laughing
all the way to the bank.
Let’s start with the problems patients face. 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 authorization 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 your doctor to even
choose whom to refer you to. He is forced to send you
to a doctor on the HMO’s panel – who may
not be the best for the patient’s particular problem.
However, the effects of HMOs on doctors are much worse.
Most HMO doctors 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.
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 utilization 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 medical 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 authorization
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 commercialization, doctors are forced
to become businessmen – and learn all about new
terms such as cost containment, authorization, capitation,
and gatekeeper ( which you won’t find in any medical
text book !).
One of the most harmful effects of HMOs has been the
poisoning of the physician-patient relationship. 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,
the trust patients used to have in their doctors has
been wiped out, and a doctor v/s patient 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 to 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 organization) , 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 ! Responsibility without power leads
to burnout !
Patients and doctors have already started rebelling
against the excesses of the HMOs in the US. Laws for
patient rights, to protect them against HMOs are being
passed; and doctors are now joining unions, and offering
creative alternatives to HMO models, such as private
practise physician networks.
Managed care will be introduced in India – it’s
simply a matter of time, because 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.” However,
if we import the US model, the only ones who will benefit
will be HMO managers and execs. Doctors in India need
to band together to withstand this danger, for the sake
of their patients – and for their own sake ! The
only time to do it is now - tomorrow may be too late
! Let’s not forget that it’s not possible
to provide medical care without doctors – and
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! Doctors have
traditionally always been leaders – and we will
have only ourselves to blame if we do not act now.
|
|
