Chapter 28: Health v/s Wealth - the danger of (mis)managed care

"Managed care is not the problem; profit is the problem."

- Christine K. Cassel.

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 thats 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.

Chapter 28: Health v/s Wealth - the danger of (mis)managed care

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