Why I Left NAMCP — The Risks of Managing Without Caring

Victor S. Dorodny, MD, MPH
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In April 1996, I resigned my position as the President of the California Chapter of the National Association of Managed Care Physicians (NAMCP). The main reason for this action was the fact that the NAMCP and its publication Managed Care Medicine (MCM) are guardians of the status quo in managed care.

NAMCP and MCM devote an enormous amount of time and space in their publication to articles dealing with care delivery methodologies in managed care. But, they have never addressed provider concerns such as HMOs’ refusal to approve visits and procedures recommended by the provider, and provider concerns with liability for failure to provide care to the patient in this situation. They have never published an article or had a presentation devoted to providers’ obligation to fight the insurance carrier on the patients’ behalf. Nor have I ever seen an article or presentation advising providers to aggressively pursue the plans’ appeal and review process in partnership with their patients, or to document the appeals process and outcome in the patient medical record.

In my previous capacity as the President of the California Chapter and member of the Editorial Board of MCM, I have attempted to introduce the concept of patient/provider partnerships to the membership and medical community as a whole through its official education and communication vehicle. Unfortunately, my attempts to educate and enlighten were met with resistance from Executive and Editorial leadership.

Such unwillingness by NAMCP to address these issues could be perceived as the organization’s reliability and dependence on corporate sponsorships. In other words, NAMCP is not interested in examining the anatomy of “risk shifting,” possibly for the fear of offending the “sensitivities” of its sponsors and advertisers.

In the past days of fee-for-service, at the beginning of a year, an insurance company knew exactly how much premium was coming in, and given the actuarial assumptions, had no idea how much money it would have to pay out in claims. Hence, it was at “risk” of not making as much profit as it would hope for.

In the new, wonderful world of managed care, at the beginning of the year, a health plan still knows exactly how much money is coming in, but it also knows how much will be paid out to service providers under contracts. Notwithstanding an occasional fine by the regulators or a settlement of a multimillion dollar lawsuit, there is no more risk in the health plan business to justify the exorbitant profits they continue to enjoy.

The question is what happened to “risk?” If you listen to health industry experts, they will tell you that health plans are “shifting” or “sharing” risk with physicians. It means that the physicians and other service providers are handed a predetermined amount of money at the beginning of the year to take care of all of your health needs, no matter how complex and expensive.

The delivery of care to consumers is further complicated by a conflict which is at the heart of the design of managed care — the clash of a health plan’s own core values — the fiduciary obligation to provide the least amount of services to their “captured lives,” while maintaining an obligation to their stockholders and bestowing exorbitant executive compensations.

This state of “confusing incentives,” to say the least, means that every time you see a doctor, the physician balances his sound clinical judgment and basic ethics with concerns for the bottom line and being “deselected” — kicked out of a health plan. These concerns are ever present despite California law protecting providers from deselection when they act as their patients’  advocates.

It appears that “risk” has been shifted again, and we, the health care consumers, are at risk!

We are at risk of limited or having no control over our health care decisions and choices. We are at risk of having restricted access to accountable, appropriate, and high  quality health care.

Many people that are considering a new health plan through their work or seeking health care insurance, do not bother to learn all the facts about the managed care plan before they enroll.

Like the risk of AIDS with unprotected sex, an unprotected exposure to managed care could be as risky. One needs to know ahead of time how a health plan makes operational decisions that impact ones coverage, referral patterns, continuity of care, ability to obtain care outside a health plan’s network, grievance procedures, etc. Not having this information or inaction could jeopardize your life and well-being.

So take it from one who knows,  when enrolling in managed care, read the fine print and ask questions to make sure you are well covered. Your life and health may be unprotected and at risk!

 Dr. Dorodny is board certified by the American Academy of Pain Management and the founder and President of Health P-R-O Consultants. His address is P.O. Box 50013, Pasadena, CA 91115.

Originally published in the Medical Sentinel 1997;2(2):69-70. Copyright ©1997Association of American Physicians and Surgeons (AAPS).



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