The Long and Short of Managed Care

Author: 
Vernon L. Goltry, MD
Article Type: 
President's Page
Issue: 
May/June 1998
Volume Number: 
3
Issue Number: 
3

Much of what has appeared in the press and in medical literature concerning managed care has centered on various and sundry horror stories of denial of care by managed care companies and the resultant patient suffering. The talk, of course, is about greedy physicians, hospitals, etc., to the detriment of the patient. Certainly, some of this is true. The nature of HMO/Managed Care reality is, from beginning to end, denying medical care for profit. There is little, if any mention, however, of the much more devastating long-term effects of the HMO/Managed Care concept with respect to (the lack of) quality and irreversible damage to medical care.

The HMO/Managed Care philosophy of denying referrals, especially to specialists and, therefore, decreasing their variety of cases and patient load has an effect no one has talked about yet, and that is the old axiom of “use it or lose it.” If a specialist in one of the surgical specialties, for example, does not continue to do an adequate number of technically demanding procedures to maintain his surgical skills, the phenomenon of atrophy of disuse will come into play and those skills will be diminished or lost. The same is true for fine-tuning clinical acumen with the development of diagnostic skills with a variety of diseases. Specialists in all the specialties, some more than others, must maintain an adequate, ongoing, hands-on experience to maintain their skills. The gradual and slow devastation to the quality of care due to atrophy of disuse is going virtually unnoticed. No one is addressing it.

A second long-term effect of the HMO/Managed Care philosophy began to be noticed in training programs several years ago. As HMO/Managed Care companies refuse to refer to training centers because of cost, they deprive young, upcoming medical students and physicians-in-training of adequate experience. As training programs receive less and less pathology, their students lack adequate hands-on experience to emerge from these programs as well-trained physicians. The effects of this subtle, slow, insidious atrophy of disuse will not be felt for one or more generations.

A third long-term effect of the HMO/Managed Care concept is the alienation of patient and physician. The physician and others involved in medical care delivery such as hospitals, nursing homes, etc. are being portrayed as money-grubbers by the government bureaucracy. The designation “unnecessary medical care” can be extended to virtually any care not immediately lifesaving. Since a good 80 to 90 percent of all medical care delivery involves quality of life conditions, the HMO/Managed Care bureaucracies can (and often do) classify as “unnecessary medical care” as care being delivered for any medical condition that is not immediately life threatening. Thus, patients have been led to distrust the recommendations of their physicians, and to believe that physicians, hospitals, home health services, and the medical care delivery system in general are dishonest and greedy — all denying care for profit.

As people become angry at a real or perceived injustice, especially on a national level, they go to the government to solve their grievance. Government, having created the problem in the first place, through the push for managed care by the Nixon Administration in the 70s, is now asked to correct the problem: The result is more devastating government intrusion. Predictably the ultimate solution that will be proposed by the government (and accepted by a frustrated American people) will be nationalization of all medical care under the rationale that the free market (a.k.a. managed care — which is anything but free market!) has failed.

Laura Archer Pulfer, columnist for the Cincinnati Inquirer speaking August 2, 1996 on National Public Radio made the following comments:

Here is what I would like to do. I would like to put all the doctors in this country in a big drafty auditorium. They would be wearing paper robes equally drafty. Here is what I would say to them: Isn’t it about time you rescue medicine from the questionable mercies of business and politics? You were the smartest kids in the class so why are you letting everybody else tell you how to do your job? You people who became doctors were the brains, the bookworms, the merit scholars, the Eagle Scouts, the hall monitors. You were the ones whose homework the rest of us copied because you had the answers. You are the people with the magnificent arrogance to put your hands around a pulsing human heart. You are the voices that are bright enough to give us the bad news. Are you scared of a bunch of bean counters? Why have you allowed insurance companies and managed care to demand that young couples leave the car running when they enter the maternity ward. Where have you been — on some extended golf holiday? Is it the money? Is it us? Are you tired of taking care of us and our untidy illnesses? I beg of you — get back in the game. When I am sick I’d still like to know there is a doctor in charge not some MBA. I certainly don’t want Hillary Clinton or Newt Gingrich or Ted Kennedy to be taking my temperature. Okay? Now, get out of those ridiculous paper robes and start acting like doctors again!

Dr. Goltry is the President of the Association of American Physicians and Surgeons and an Otolaryngologist in Boise, Idaho. His address is Imperial Plaza, 200 North Third Street, Suite 203, Boise, ID 83702.

Originally published in the Medical Sentinel 1998;3(3):78. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).

 

 

 

 

 

 

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