The cover story of the January 22, 1996 issue of Time magazine laid out in chilling detail a worst-case scenario of how managed care has reshaped the practice of medicine. It described the experience of one cancer patient – Christy deMeurerses – as she fought to get the treatment she needed to survive. Unfortunately, the story had an unhappy ending; Mrs. deMeurerses died trying.
This patient’s story is frightening, made even more disturbing by the apparent greed of the managed care company executives who denied her coverage for a bone marrow transplant – a procedure they considered expensive “experimental treatment” – then sold out their company shares for outrageous profits.
The article highlights a growing problem we all face: the intrusion of capitation, “gag rules” and other cost-controlling measures into the doctor-patient relationship. Time magazine’s not very subtle implication is that patients can no longer trust their doctors to prescribe optimum care and, worse still, that the physicians’ primary motivation for such action is financial.
Gag Clauses
Gag clauses in physicians’ managed care contracts have raised particular havoc with patient care. These provisions prevent physicians from being completely open with patients about the terms of their managed care coverage. Under a gag rule a doctor might be prohibited from discussing with patients treatments that are not covered by their managed care plan. Physicians can also be barred from referring patients to specialists outside the plan, even when they believe it may be in the patient’s best interest. Other rules may prevent physicians from discussing their financial relationships with a managed care plan, especially if they have incentives to increase earnings by providing less care.
And, there is the greed factor. While many managed care plans have prospered mightily, they have not shared their good fortune with their subscribers. In the case of Christy deMeurerses’ managed care plan, Health Net of Woodland Hills, California, its CEO Roger Greaves received a one-time $18.1 million pay out (along with a guarantee of lifetime health care), when his company merged with the WellPoint Health Network. This amount was the equivalent to the average monthly premiums paid by 134,000 subscribers. It also could have paid for the entire treatment program of 180 patients like Mrs. deMeurerses.
The issue is a redistribution of wealth under the guise of corporate, management of health care. These resources are being taken from direct patient care, from hospital capital expenditures, from academic research, development and training, and from nurses and physicians to the benefit of corporate shareholders and administrative personnel of managed care groups. Until the public recognizes this, organized medicine is impotent to influence change, except to say, “NO!”
The public reaction to the Time story was one of outrage. The American Medical Association (AMA) has launched a major publicity effort calling for all managed care plans to immediately cancel gag clauses. It also has asked individual physicians to review their HMO contracts for any language that might prevent them from openly communicating with their patients and to defy such provisions.
As a result of the ensuing outcry, a new federal bill that would prohibit gag clauses in physicians’ contracts with health plans has been proposed in the House of Representatives. The “Patient Right to Know Act” would bar plans from restricting physicians’ communications with patients. The bill is being co-sponsored by Rep. Edward J. Markey (D- Mass.) and Rep. Greg Ganske, MD (R- Iowa).
Though such legislative relief is welcome, we_as physicians_must do more. Certainly we need to stand up for what is right and ethical in terms of patient care. But, more than that, we need to show both patients and managed care organizations that we are providing proved, effective treatment.
Outcomes Data Will Help
Outcomes data is the answer. Lack of funding for outcomes studies is the problem. Our push should be for establishing these funds rather than railing against the sickening profits of such heinous managed care organizations.
Given adequate outcomes measures, these problems would never occur. I recently had the opportunity to talk with Representative Bill Thomas (R, CA) about the need for some mechanism to force organizations to contribute to well-organized, scientific-based outcomes studies when they deny health care on the basis of the experimental or investigational nature of a procedure. Any denial of care should be accompanied by grant offers to determine if that denial is appropriate. If such a procedure or treatment methodology cannot withstand evidence-based studies, it should not be paid for.
The AANS, in partnership with the CNS, has already taken a first step in the direction gathering outcomes information through the decision to develop an Outcomes Database for our new Internet web site, NEUROSURGERY://ON-CALL® (N://OC®). The Database will serve as a research instrument that can be used for multiple, simultaneous research projects. The proposed system will be designed to provide a basic data collection platform to accumulate common outcomes and demographic data. This platform will form the basis upon which specific research studies may be built.
The system will allow authorized users to enter medical data into the database, edit and update that data, provide a mechanism to prompt the user to provide additional data on a periodic basis, search and browse the data and provide an analysis to study participants in a graphical format.
Personal Thoughts
What does all of this mean to us as neurosurgeons? Has the current controversy affected how we care for patients? Perhaps the following will sound familiar to you.
I recently sent home a patient following a multi-level cervical laminectomyl the day after her surgery. I am not a capitated physician. I was not coerced by a health maintenance organization or carrier to release her early. It was my decision that she would be better served by early discharge since she was at increased risk for infection and hospital-acquired complications. Why then did I still feel guilty? It is this latter insinuation into the feelings that I have for my patients and those they have for me that is becoming intolerable.
As a career Naval Officer, I did not enter medicine to make big bucks. The income I have earned in the practice of neurosurgery will allow me to retire, hopefully, without becoming a burden on society. The reason the public is in the pickle it is right now is that society has not taken upon itself the responsibility of determining the worth of a neurosurgeon, or any other physician for that matter.
The swiftness of change brought on by managed care is breathtaking. The sad truth is we are no longer the sole arbiters of patient care.
Some of our members have suggested that we take an aggressive public stance on this issue. However, we will not have a lot of credibility about patient caring and advocacy unless we first take a good look at ourselves as human beings and caretakers of the public good.