Contracts with doctors often contain a clause which doesn't allow the doctors to discuss
Health care 7 with their patients financial incentives to deny treatment or about treatments not covered by the plan (Glazer, 1996). This has caused many consumers, especially those with chronic illnesses, to form organizations with the American Medical Association and physician specialty groups to promote legislation forbidding "gag rules" (Glazer, 1996). One group, Citizen Action, has 3 million members and "has been lobbying in state legislatures for laws that would require plans to disclose how they pay their doctors; give patients the right to choose specialists outside the plan; and provide appeals for patients who get turned down for expensive treatments" (Glazer, 1996).
The doctor-patient relationship is also affected if a patient must switch to a new doctor under managed care. Having a longterm relationship with a primary doctor is important because he or she is more knowledgeable about the patient's history. If employers switch often to other managed care plans, the primary care doctor a patient sees is also likely to change (Glazer, 1996). This affects the physician's practice as well. To keep patients, a doctor is often inclined to join more insurance plans. This is the case for OB-GYN physician M. Gerald Hood of Atlanta who belongs to 15 different plans, but despite this, his practice has declined 50% in the last three years (Bennett Clark, 1996).
Another concern deals with the percentage of the premium cost which goes directly to medical care. The remaining percentage finances administrative costs and profits. Bennett Clark (1996) says that "a plan with 90% of premiums going to medical care is "very good." Some plans, however, set aside up to 25% for Health care 8 administration and profit according to a California Medical Association survey, and Cathy Hurwit of Citizen Action says, "There are a lot of plans that are ripping consumers off" (qtd. In Glazer, 1996). Legislation is being promoted by Citizen Action which requires at least 85% of premiums to be spent on medical care (Glazer, 1996).
Medical research and education is also being affected by managed care.
The HMO, Health Net, like other HMOs doesn't spend money on research and also won't cover experimental or investigative treatments (Larson, 1996). In the past, research has been paid for by patient bills, but teaching hospitals are having to compete with managed care plans for patients (Glazer, 1996). Since managed care promotes preventive medicine to serve community needs better, medical research is becoming a lesser priority.
Managed care is also hurting the uninsured poor. In the past, doctors paid for such people through the bills of other patients, but with managed care, such a cushion won't be available (Glazer, 1996).
ASSESSING PLANS FOR QUALITY
With the concerns managed care is bringing, assessing plans for quality is vital. Close to 600 HMOs exist, and most are new (Spragins, 1996). Managed care plans receive accreditation from the National Committee for Quality Assurance (NCQA), and they are judged on 50 different characteristics such as the credentials of the plans' doctors (Spragins, 1996). Under half of the HMOs have been reviewed, and 37% received full accreditation, 39% received partial accreditation, 11%
Health care 9 received provisional accreditation, and 12% failed to be accredited (Spragins, 1996). These results show that many plans need to improve to be fully accredited. The quality of a plan can also be reviewed if it publishes the results of the Health Plan Employer Data and Information Set (called HEDIS) (Spragins, 1996). Two other quality control measures to look for is the percentage of a managed care plan's doctors that are board certified and if the plan is associated with hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (Spragins, 1996).
Regardless of these quality control measures, another concern exists.
According to surveys, NCQA results aren't used by most employers in determining which plans to use (Glazer, 1996). Cost, rather than quality, is the determining factor in deciding which plan to sign up with. However, employers will need to start assessing plans for quality more now that costs are being controlled (Glazer, 1996).
Managed care will continue to revolutionize the health care industry, and hospitals are being "reengineered" to accomodate the goals of managed care. They will no longer be the "core business" of health care, and they are being replaced by outpatient services which can provide primary care, health promotion, and chronic disease management (Shortell, Gillies, & Devers, 1995). Outpatient care has increased 73% between 1980 and 1992, and 98% of medical care now occurs outside the hospital, with 70% of surgery being done on an outpatient basis
Health care 10 (Shortell, Gillies, & Devers, 1995). Advances in medical technology are causing such growth in outpatient services, and more group practices, ambulatory care centers, home health agencies, subacute units, and hospices are becoming available (Shortell, Gillies, & Devers, 1995).
Shortell, Gillies, & Devers (1995) mention that after assessing the needs of the community, many hospitals find that they have too many patient beds and specialists and too few primary care doctors, home health, an after care services. They also describe how in 1873 there was one hospital bed for 800 people, but in 1994 there was one bed for 200 people, and it is believed that only one bed is needed for 900 people. Some hospitals have an excess number of inpatient beds with some only being half-filled, so both staff and facilities are being downsized, and staff are being trained to perform more procedures (Shortell, Gillies, & Devers, 1995). Many hospitals have closed, and those remaining open have decreased hospital admissions and lengths of patient stay. From 1980 to 1993, 949 hospitals closed, and between 1984 and 1992 there was an 11% decrease in admissions and a 20% decrease in inpatient days (Shortell, Gillies, & Devers, 1995).
The sweeping changes which are occurring in health care are bringing positive changes such as cutting costs and promoting preventive medicine, but these changes are not without concern. Problems arising from managed care need to be understood so that the changes occurring will put the needs of the patients first. With time, it is hoped that the problems occurring will become history. C. Everett Koop (1996) says, "It may
Health care11 take five to ten years to find the right balance of managed care, physician autonomy, and patient rights. Health care reform poses the greatest political challenge to a democratic republic, because each of us is being asked to do something for all of us, and many of us feel what might be best for all of us is not best for each of us. Before we can enact the reform we need in health care, we should agree on the basic values and ethics upon which our health care system-indeed our society-is based, and from which it derives its moral power." Health care is one of the most important aspects of society, and with…