The Challenge of Regulating Managed Care

4. A Physician’s View from the Trenches

  A Physician’sView from theTrenches Clifton R. Cleaveland A sixty-two-year-old dredging foreman with long-standing hypertension develops intense lower abdominal pain and fever. He describes the pain as the worst he has ever experienced. In the third day of his illness, he comes to my of‹ce, where examination con‹rms a distended, very tender abdomen with diminished bowel sounds. He is febrile and his white blood count is elevated. Abdominal X rays show multiple air-›uid levels. I admit him to the hospital with a tentative diagnosis of acute sigmoid diverticulitis and request surgical consultation. Antibiotics, intravenous ›uids, and nasogastric suction constitute initial therapy. Slowly he improves. On the second day of his hospitalization, I remove the nasogastric tube and begin a clear liquid diet. The surgeon recommends continued close observation. Later that morning, an hour after the patient’s ‹rst oral intake, an unidenti‹ed utilization review nurse from his managed-care organization determines that further hospitalization will not be authorized. An appeal to the company’s medical director is denied. A severely depressed female with long-standing complex hypertension responds dramatically to Prozac. Her managed-care plan delegates mental health services to a behavioral health organization. As instructed, my patient dials a toll-free number for consultation with an unidenti‹ed person with unspeci‹ed quali‹cations. Subsequently, the health plan noti‹es me that the only drug approved for use in my patient’s case is amitriptyline, a previous treatment failure in my earlier care of this patient. I use samples of Prozac from pharmaceutical representatives to meet her needs. Many clinicians feel that George Orwell is the ultimate architect of managed care in its current form. The “Big Brother” of his novel 1984 is a paradigm for the perfect utilization reviewer for a managed-care company—omniscient, unidenti‹able, and beyond challenge (Orwell 1950). The form of managed care and the extent of its penetration varied widely and wildly in the United States in 1997. While states such as California and 61 Minnesota had evolved sophisticated systems of managed care throughout the 1990s, other states, particularly in the Southeast, had but limited experience with this new health-care entity. As with a biopsy, where you place the needle will determine what you get. Experiences for physicians in the new health-care climate will vary from state to state and from specialty to specialty. In a single community, primary-care physicians may work under the terms of capitated contracts, while their subspecialty colleagues will be reimbursed through feefor -service schedules. The literature dealing with physicians’ experiences in managed care is rife with anecdotes that mostly re›ect horror stories. Health Care: The Way We Were Managed care in its various forms is a response to an unsustainable pattern of medical practice. In the early 1990s medical costs had attained runaway status and we as a nation were lurching toward a meltdown in expenditures for health care. Individuals and companies alike coped with rising health insurance premiums , which increased far faster than did the cost of living. Health economists predicted the bankruptcy of the Medicare program within a few years unless additional funding or reduced services were legislated. In many states, Medicaid expenditures represented a budget buster that threatened to squeeze out other necessary societal services such as public education and welfare (Eckholm 1993; Lee, Soffel, and Luft 1992; The Economist 1991). While the media extolled the latest thrilling advances in medical technology , the costs for this technology raced upward (Ginsberg 1990). Driven by insatiable public and professional demands for the latest test or treatment, costs for individual patient and outpatient diagnostic and therapeutic encounters could quickly spiral into the tens of thousands of dollars. Technological marvels stimulated entrepreneurial zeal of companies, hospitals, and physicians . The entire health-care industry was suddenly “hot,” and there were few restraints on its behavior. Despite health-care expenditures that far exceeded those of other industrialized nations, the United States lagged in virtually every measure of clinical outcome, and polls regularly showed the disaffection of most Americans for their health-care system (Blendon and Taylor 1989). Americans with healthcare insurance could pick from a lavish menu of diagnostic and treatment options, but an increasing number of our citizens—35 to 40 million by various estimates—had no health insurance of any kind. Many poor Americans either worked in low-wage jobs for employers that provided no health-care bene‹ts or cobbled together one or more part-time...