Managed Care:
Practicing medicine without a license

Today, cost of healthcare is the primary concern. With cost, rather than access, the primary concern of government and individuals, the health insurance industry has been able to usurp the function of gatekeeper from the physician. While it was once the physician who decided who would be treated, what medical tests would be required, the proper treatment, and when they would be discharged, it is now the insurance company that mandates such policies. For instance, if you have pneumonia, the health insurance company mandates that you shall have x number of physician visits, y number of visits to a pulmonary therapist, etc., all this without regard to the specifics of your case! These decisions are often made by someone sitting behind a desk who majored not in medicine, but in art history!

While usurping the function of gatekeeper from the physician managed care agencies have also managed to insulate themselves from the responsibility associated with that function. I speak of professional liability. In a recent court case involving malpractice, the HMO argued that they had no professional liability for the lack of adaquate treatment because their decisions were only administrative! (CNN, Nov 17, 1996) While I agree that the function of gatekeeper is critical to cost control, it can not be divorced from professional liability.

The HMO function of gatekeeper includes the practice of "gagging" the physician. I.e., if the physician knows that you need an MRI to properly diagnose your illness, and MRIs are not covered by your policy, then the physician is under contract with the HMO to not order an MRI and to not tell the patient that the assessment is incomplete! This is more than an administrative action on the part of the HMO. It is practicing medicine without a license! (It is notable that the HMOs think that physicians should still be held responsible for malpractice even though the HMOs determine the testing and treatment proceedures!)

Legislative alert: President Clinton, in response to the HMO's arguement that they have no professional liability for their "administrative decisions," has proposed legislation that will associate the gatekeeper function with professional malpractice liability. Please write to your congressional representatives to support this change. It is desperately needed.

The managed care industry uses it's own flawed policies to justify itself. Managed care facilities mandate that a patient have a limited (and usually insufficient) number of visits for a particular diagnosis. Physicians quickly learned that it was easier to simply change the diagnosis than to argue for an exception to the policy. Managed care policies, therefore, generated a mountain of biased data that "proved" the treatment it allocated for a given disease was adaquate in almost all cases when in fact it was not!

Managed care policies have changed access criteria from those in need regardless of cost to minimizing cost regardless of need. While something has to be done about the rising cost of healthcare, managed care is fundamentally unethical. It is insensitive to need.

Managed care is not completely flawed. Healthcare professionals used to over-prescibe, over-treat, and just plain coddle patients, due in part to fear of malpractice lawsuits and in part because nobody cared about cost. All that has ended, and that is a good thing because anything that lowers the cost of healthcare without reducing quality is desperately needed.

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