The People vs. Managed Care

Chapter 17

Evolution By Revolution

1) Give physicians and patients the final say on diagnosis and treatment;

2) Give patients the right to appeal a health plans' medical decision with an independent, timely, fair external review;

3) Hold health plans accountable when their actions cause a patient injury or death;

4) Extend protection to cover all insured Americans;

5) Provide point of service language, so that all insured employees have an opportunity to choose, at their own expense, an option that allows them to go outside the network of health care professionals chosen by the employer;

6) Permit all insured individuals to use the "prudent person" standard to secure emergency care; and

7) Have all insurance programs make full disclosure of benefits, exemptions, costs, limitations in services, decision rules and appeals process.

CONFIDENTIALITY. The patient's right to privacy and the confidentiality of medical records have suffered under managed care. In an environment that gives little attention to patients' rights, reckless entrepreneurs have seen the opportunity of using medical records to deny insurance coverage, to dismiss sick employees, to deny employment to those at risk for some illness, even to deny financial credit to those who may not be among the healthiest. Such abusive and cruel use of personal information has not been properly addressed by a congress uninterested in the rights of the individual.

Congress is likely to debate the privacy of medical records time and time again. Professionals will continue to challenge legislation that would allow banks, insurance companies and brokerages to combine and share information.

Sharing of data on customers, which opens lucrative new marketing possibilities, is a dream for banks, securities firms and insurance companies. The medical records provided by a medical insurer could lead an affiliated bank to deny a loan to patients suffering from selected illnesses. The same records, provided again by the medical insurer, may lead to denial of life insurance and other protections.

All these abuses may happen without the patient's participation. Dr. Richard Harding, APA Vice-President, articulated the position of medicine on this serious matter when he insisted before congress that any bill on privacy should specifically prohibit disclosure of medical data without specific patient consent.

COLLECTIVE BARGAINING. Governor George Bush of Texas, at the beginning of his campaign for US President, signed into law the bill that gave the right to collective bargaining to physicians in Texas. He had before allowed the implementation of legislation that challenged the ERISA exemption in Texas. These two events have placed Texas at the very front of the struggle for patients' rights in the age of managed care.

The Quality Health Care Act, the Campbell antitrust bill, has obtained a large number of cosponsors in the House. This bill will in effect create a more balanced situation in the so far uneven struggle between managed care conglomerates and health professionals.

The neutral onlooker would marvel at an extraordinary event: while managed care companies come together, share information and strategies, and create increasingly powerful structures with complete impunity, the federal government has been ready to use anti-trust legislation against those who challenge the powerful managed-care trust.

As in many social and scientific changes, health care financing may not evolve slowly: whether the Republican congress changes its ways or gets replaced, other forces may come to bear in the direction of sudden, revolutionary change:

MANY HMO PRACTICES ARE INCREASINGLY UNACCEPTABLE. The day is far-gone when patients, physicians and the public might accept the HMOs claims that HMOs can reduce health costs without damaging quality of health care.

The Minnesota Physician-Patient Alliance (MPPA) in 1996 sought to determine what portion of HMO revenues is spent on health care and what portion on administrative services. This task turned out to be close to impossible: "Each of the three largest Minnesota HMO's (Medica, HealthPartners and Blue Plus) are embedded in complex webs of profit and non-profit companies including for-profit subsidiaries, some of which are offshore."

The final paragraph of the Minnesota report can be applied to many situations around the country:

We call on Minnesota's HMOs to open the books of their non-profit companies and of their affiliates and explain to Minnesotans where their health dollars are really spent. We call on them to detail their relationships with for-profit vendors and subsidiaries. We call on them to explain the rationale by which so many millions of health care dollars are spent on care management and administration rather than in true health care. Minnesotans deserve a health care system that spends its health care dollars directly on true health care.

The California Medical Association's "1997-1998 Knox-Keene Health Plan Expenditure Summary" doesn't give much room for solace. Out of the ten California Plans with the lowest expenditures for services, four were "non-profit" (one wonders where the money went).

Patients enrolled in profit-making health insurance plans are significantly less likely to receive the basics of good medical care, including childhood immunizations, routine mammograms, pap smears, prenatal care, and lifesaving drugs after a heart attack. (24) In other words, the free market is compromising the quality of care. This has been known by many patients for years.

The conclusion of the JAMA study(24) is predictable:

Our findings suggest that the decade-old experiment with market medicine is a failure. The drive for profit is compromising the quality of care, the number of uninsured persons is increasing, those with insurance are dissatisfied, bureaucracy is proliferating, and costs are rapidly escalating. We believe national health insurance deserves a second look."

Consumer Reports recently (1999) rated HMOs. A worrisome trend was for those with the worst ratings to band together in the same areas of the country: four of the five worst ratings were given to California companies.

California has seen aggressive strategies by money grabbers for many years.

In most other fields (buying a car, buying a house, buying almost anything else), getting the worst product leads to moving on to buy elsewhere. Not here. As Consumer Reports explains,

Many consumers have few choices for their health care coverage, because employers offer few options. As HMOs continue to merge, there are even fewer choices this fall.

The Consumer Reports writer expected that public demand and government intervention would bring sanity to this "marketplace".

In the meantime, physicians and nurses make their unhappiness known whenever possible. The Kaiser Family Foundation and the Harvard School of Public Health conducted a survey of physicians and nurses in the first half of 1999. 61 percent of doctors said that at least once a month, or even once a week, insurance plans had denied coverage of a prescription drug for one or more patients. Thirty one percent said they had experienced a denial of hospital stays on a weekly or monthly basis, and 42 percent had encountered a denial of diagnostic tests or procedures that often

When this kind of survey hits the media, the American Association of Health Plans rushes to deny the findings. Any one who has studied the formularies put out by the plans will wonder how is it possible to refuse in writing to cover some medications and then deny that this is happening.