Patients in managed health-care plans often find a mound of red tape blocking their path to a medical specialist.
Medical ethicists worry that an even bigger obstacle is emerging - financial conflicts of interest among family doctors who refer patients to advanced care.The American medical ideal calls for doctors to lay out explanations, treatment options and risks for each patient and allow them to make the ultimate choice. For half a century the ideal has been tilted toward the most aggressive and expensive therapies with the assurance that insurance would cover the tab.
Now, there is the threat that the ideal will be skewed toward less care. Doctors are being held personally responsible for the cost of treatment they recommend for millions of Americans enrolled in managed-care plans.
"It all comes down to a system in which decisions about diagnosis and treatment are no longer made solely in the best interest of the patient by those most capable of making the decisions," said Dr. Jeffrey Thurston, a Dallas obstetrician-gynecologist and author of "Death of Compassion: The endangered doctor-patient relationship."
Managed-care executives insist these pressures, properly structured, can control health costs without endangering the quality of care. In the best plans, they say, general practitioners and specialists are encouraged to cooperate to do what's best for patients.
Referral rules vary widely across the nation. In markets where managed care is just taking hold or in plans that are just starting, operators tend to rely on direct controls: requiring each referral to be pre-certified by clerks at a central clearinghouse.
Once health plans and their doctors have more experience in managed care, the system tends to shift responsibility for cost control to providers. They are paid a fixed amount to care for each patient. This is called capitation.
Three months of investigation by Scripps Howard News Service reveal that sending a patient on to specialized care can be a seamless, cost-effective journey, or a cumbersome, sometimes dangerous detour.
A few examples:
- In the waiting room of a Cincinnati specialty practice, patients are greeted with the blunt warnings that THEY and not the doctors are responsible for having insurance referrals in order before they arrive. Some patients leave without seeing a doctor when they realize they don't have the paperwork.
"It seems like everything has to go through the insurance company first. The patient has to wait until that paper comes in the mail before they dare schedule an appointment," said the office manager.
Like many health providers discussing managed-care rules, her bosses would allow an interview only if she - and they - were not identified.
- A 29-year-old Texas woman experienced bleeding and pain during her menstrual period. She called her female "primary care provider" to request a referral to a gynecologist.
"No, we just authorized a referral two months ago," the patient was told.
"But that was with an ophthalmologist for an eye infection," the woman pleaded. No matter. If she was to see anyone, it would have to be the primary physician.
After a painful pelvic exam, the patient was directed to a battery of tests for sexually-transmitted diseases and suspected hormonal abnormalities.
Later, an unauthorized visit to her gynecologist identified the real problems - an infection and the need to adjust birth control pills.
- A Medicare patient in Southern California, a longtime smoker, was treated repeatedly for emphysema. Hooked to oxygen much of the time, he became a near-recluse and suffered from depression.
He enrolled in a managed-care plan and was able to get counseling and a drug for depression. The doctor found a smoking cessation program for him and arranged home visits and counseling. The result? The man is off most medication, rarely needs oxygen and sings in a church choir.
- Specialists are besieged with requests for "curbside consults" from family doctors called on to treat conditions they feel ill-qualified to handle.
In hushed tones, GPs pull colleagues aside to inquire about the likely diagnosis or proper treatment of a patient with a puzzling rash or heart disease. But they dare not actually refer patients to the specialist, fearing the financial repercussions on their own practice.
"There's no longer any collegiality in medicine," said Dr. Nora Goldschlager, a professor of cardiology at the University of California-San Francisco. "It's just wrong to give advice that way, and what you're told depends on how well the doctor telling you was trained."
No one knows exactly how much it costs to clear medical care with insurance middlemen, but it is considerable. Dr. Thurston said he spends an extra two to three hours a day on managed-care issues. Nine administrators and five registered nurses in his office spend their days dealing mostly with insurers rather than patients.
Thurston said it can take his staff up to 4,000 calls, forms, letters and other transactions over nine months to certify arrangements for one birth.
A survey of mostly primary-care doctors by Physician's Management magazine found more than 82 percent felt working in managed-care plans had increased their paperwork. Two-thirds felt referral constraints hurt the quality of care.
Health-plan administrators insist referral systems generally work in the patients' best interest of keeping costs down and avoiding medical excess. They dismiss most complaints as the grumbling of a generation of medical specialists who are no longer free to perform a "wallet-ectomy" on chronically ill patients under traditional insurance plans.
"The old style of medicine waited for you to get sick, but did nothing to help you stay well," said Roger Taylor, chief medical officer for Pacificare, a managed-care company covering more than 2 million people in six states.
"In first-generation HMOs, you may have a primary-care doctor asked to be a care manager for the patient for a set fee, while the plan also contracts with specialists who are only paid when they're used. So, there's some tension in those relationships," Taylor said.
Dr. Charles Inlander, president of the Peoples Medical Society in Philadelphia, says, "To the extent that pre-certification prevents some of the tremendous numbers of unnecessary procedures done in this country, it's a good thing. But they can also go overboard in restricting care."
Health-plan officials concede that referrals have been a source of consumer and physician complaints and say the days of centralized pre-certification of all referrals are winding down.
"We were finding that pre-access prior approval for nearly all primary-care physicians was expensive to administer and not satisfactory to providers or members," said Paul Romano, a vice president at Aetna Health Plans. It is eliminating pre-certification requirements for most procedures.
Patients may see less paperwork, but they may not know that doctors are still guided by insurance analysts and their own economic interest in deciding what care to recommend. Many plans legally restrict doctors from telling patients how they're paid.
Under new managed-care arrangements, "there is no threat that doctors will do more out of selfish economic motives," wrote Dr. Norman Levinsky of Boston University Medical Center in the New England Journal of Medicine. "Since the threats and blandishments used to induce physicians to meet managerial expectations are covert, the process of informed consent is undermined."
At Aetna, doctors will continue to report all referrals, Romano said, because "we need to look at that data and manage that way, so we can take the doctor aside and say you seem to be referring people too much for this treatment, when most of the available research says there's a better way to make them well."
But many plans continue to judge providers on cost more than outcome.
Dr. Thurston writes of a heart surgeon being despondent because he'd lost three of six open-heart patients in one month in the operating room or soon after.
"But not everybody was unhappy. He got a certificate in the mail (from an HMO) for being the `low cost provider' in cardiovascular surgery for the month of June... ICU time is very expensive and if your patients die on the table, it's extremely cost-effective."
Increasingly, managed care organizations rely on direct financial incentives for doctors to keep costs in check. These include flat fees for each patient, out of which doctors must pay for all the care they provide and sometimes also for the care they refer patients to as well.
Other plans set aside a percentage of a doctor's annual payment to be awarded as a year-end bonus if various cost and performance goals are met. Some give prizes; others are buying physicians' practices outright and re-hiring the doctors.
One study of 108 managed-care plans by Mathematica Policy Research in Washington found that 50 percent of the HMOs using salaried doctors and 74 percent of those contracting with individuals or group practices adjusted payments according to how much health care patients received.
"Most plans don't want to micro-manage referrals and if they capitate the payments, they don't have to," said Dr. Peter Kongstvedt, HMO consulant with the Blue Cross/Blue Shield Association.
Dr. Seth Spotnitz, a neurologist in Gadsden, Ala., sees financial incentives as "a dangerous trend for patients, because it puts the doctor in the position of thinking they can make more money by not treating.
"I mean, do you really want to read in the local paper that your doctor won a trip to Hawaii from your insurer for being the lowest-cost provider in your plan?"
In San Antonio, however, Pacificare sets aside part of its payment to physician groups as an incentive bonus that will only be paid if specific goals for patient satisfaction and service are achieved. Cost is not a factor.
"There is a potential downside to these arrangements, but we try to set up management to get the maximum out of the good and minimize the downside," Taylor said, by spreading the financial risk among large groups of doctors or allowing individual physicians to escape the full blow if one or two patients turn out to have very expensive illnesses.
"But we're in a very tumultuous, rapidly changing time in health care, and we can't pretend that there won't be some rough spots in the road. There are some plans that aren't as good at emphasizing quality as others."
Worries about managed-care quality have frequently been expressed in state legislative battles, usually fueled by physician and insurance company money, over "patient protection" laws that require HMOs to allow patients to see doctors outside their networks. Eighteen states have such laws applying to at least some health providers and hundreds of others are pending, including several in Congress.
Spotnitz is also president of the National Organization of Physicians Who Care, a national organization of some 3,500 doctors who advocate the patient's right to choose his or her own doctor.
One of their projects is a state ballot initiative in Oregon this fall that would, among other things, ban plans that offer a fixed amount to care for each patient. Pacificare, one of Portland's larger HMOs, is, of course, opposed.
"Managed care is just moving into rural Oregon and there are many well-developed groups in Portland that are doing well in managed care, pre-paid care, and I think some of the doctors that haven't joined are afraid they'll be disenfranchised in this new system," said Taylor.
"But rather than compete in the market, where you ought to have this competition, they're trying fight legally the direction the whole country is going."