Physicians Agree That Managed Care Is Not

¶ … physicians agree that managed care is not doing the job it was originally created to do. Although reform efforts have not worked in the past, many doctors believe now is the time to revisit reform to combat the lack of health care access to a growing number of Americans, escalating costs, and deteriorating quality. This paper explores the evolution of managed care, and its problems and possible solutions from the viewpoint of two organizations representing the interests of physicians.

In 1993, President Clinton introduced a plan for regulated health care reform in response to escalating costs and the growing ranks of the uninsured. From 1970 until the time of the reform proposal, health care spending had increased from $74.4 billion to $752 billion annually. The Clinton proposal was met with huge opposition from the "medical industrial complex" comprised of insurance firms, pharmaceutical companies, hospital suppliers and medical device companies and from the public who had been led to believe that the plan would give the average American less choices and higher costs. After the plan was rejected, Americans turned to managed care to control health care costs, to improve the quality of care, and to preserve their choice of provider and insurance plan. By 1999, ninety-one percent of all employees with health insurance were enrolled in managed care programs ranging from Health Maintenance Organizations (HMOs) that require enrollees to select from a network of doctors, to Preferred Provider Organizations (PPOs) that provide more flexibility in doctor selection at a higher cost than HMOs.

Many physicians are disappointed with managed care, believing that it has achieved none of its original objectives. Organizations representing doctors such as the Physicians For A National Health Program (PNHP) and the American Medical Women's Association (AMWA) articulate their goals for patient care and cite the problems with managed care's ability to meet them. These two organizations endorse universal access to health care, cost containment, and high-quality services for patients and point to the problems with our current system to achieve these goals.

The AMWA states that there were over 43.4 million uninsured people in 1997 with reasons ranging from employers who do not provide health insurance, part-time and temporary workers who do not receive benefits, self-employed who cannot afford insurance, waiting periods for eligibility, pre-existing medical conditions, divorce, and people who do not believe that they will need insurance. The AMWA believes that lack of universal access to effective health care is the major barrier to improving health for U.S. residents. THE PNHP expresses that doctors frequently avoid procedures, consultations, and costly medications for uninsured patients.

In addition to lack of insurance, the PNHP and the AMWA point to other factors that restrict access to health care. These organizations are concerned with the increases in patient cost sharing in the form of increased co-pays and deductibles, believing that even some of the insured may have difficulty affording health care. According to the AMWA, some payments in the Medicaid and Medicare systems are so low that physicians discontinue treating these patients altogether.

Health care costs are out of control under managed care, rising at annual inflationary rates of over 11% per year. The PNHP and the AMWA do not view physician fees as being responsible for rising health care costs; instead they blame managed care inefficiencies. PNHP states that cost-control measures have not slowed the growth of administrative costs, curbed ineffective or marginally effective services, or reined in excessive managerial or professional salaries or profits. The AMWA attacks managed care's lack of emphasis on preventive medicine as causing significantly higher-cost treatment in the long-term. The AMWA also believes ineffective policies such as unrestricted access to emergency rooms drives up medical costs.

According to the PNHP and the AMWA managed care's cost cutting measures that have focused on cheaper care have significantly impacted the quality of care a patient receives. They believe that managed care frequently fails to provide for basic services such as immunizations and prenatal, primary and preventive care. A few of the many issues that PNHP lists are: denial of care, discrimination, geographic maldistribution, lack of continuity, failure to provide beneficial prevention, substandard providers, diagnostic errors, unnecessary procedures, and sub-optimal medication prescribing/usage.

The AMWA feels that lack of parity in reimbursement for mental health services and chemical dependency treatments is a significant barrier to care. The PNHP and AMWA are also concerned that managed care has brought more complexity such as thousands of different insurance systems, multiple and competing review procedures, and piecemeal coverage that force doctors to reduce their time on patient care in favor of required paperwork.

As a solution, both the PNHP and the AMWA advocate health care reform. They are in favor of universal access care available to all people on the basis of medical need rather than financial ability. Under PNHP recommendations, a National Healthcare Program should be created that covers everyone under a single public plan, federally mandated and funded but administered locally. Both organizations endorse comprehensive care that includes basic primary care, prevention, early detection, chronic care, mental health, chemical dependency, acute, and specialty care. They advocate cost containment by curtailing bureaucracy, particularly in payment procedures and fostering health planning. The PNHP endorses a single-payer system while the AMWA proposes access cards that are issued to each person to lead to automatic reimbursement to the provider.

PNHP argues that there is ample evidence that universal health care can work. It points to Canada's implementation of a national health program as an example of success. After Canada implemented reform, visits to doctors by patients with serious illness increased. Canadian mortality fell below those in the United States after being higher than this country's rate for more than twenty years. PNHP believes that Canada was also able to contain costs because of single-source payments. The more than 1500 private health insurers in the U.S. now consume about 8% of revenues for overhead in comparison to Canada's overhead costs of only 2 to 3%.

It's still to be seen if the PNHP and AMWA can gain public support. Reform has failed in the past because people have believed that they'll be giving up quality and paying more to foot the bills of the uninsured. And, the powerful medical industrial complex reinforces these notions to maintain their profitable status quo. While the managed care system has its flaws, it may have to get worse before it gets better because this may be what it takes to rally public support for health care reform.

Bibliography better-quality alterantive; single-payer national health system reform. Retrieved on February