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Managed Care--Out of the Confusion Will Rise the Next Delivery System 

The Noble Profession Through a Crystal Ball--the Future

     For doctors, a funny thing happened on the way to the polls. While traditionally fearing and loathing Democrats like Kennedy and Clinton, they voted for people like Reagan and Bush under whose administrations medicine in their eyes changed forever for the worse. Doctors feared especially the predicted Democratic congress with a Democratic president. They voted for capitalists instead of populists. They felt safe in doing this, for after all they themselves felt like capitalists. They accepted the fact that they had nice houses, cars, and incomes, so they didn't see it coming when the capitalists kicked them out of the club.
     Medicine changed more under the administrations of Reagan and Bush than it had in a hundred years. Under these presidents the regulatory agency OSHA expanded its role in telling doctors, clinics, and hospitals how it would run its labs and protocols. It had teeth to punish those who didn't by levying fines. Merely hanging up a shingle became extinct, because every office had to follow national guidelines. Like the Americans with Disabilities Act was for contractors, OSHA caused increased expense for doctors who scurried to seek mandatory compliance. While fearing liberal candidates, doctors had the rug pulled out from under them by real businessmen who were protected by conservatives. Insurance companies had no trouble convincing employers that medical costs were too high when the first managed care plans emerged. Fee for services had the fox watching the hen house as doctors recommended and performed procedures for which they then charged what they pleased. Too much trust provided anecdotal reports of a few rotten apples plundering the system. So when all doctors were subjected to the surveillance by the insurance companies via managed care, there were few champions for those doctors with the nice houses, cars, and incomes.
     But there seems to be a new fox in the hen house. Doctors aren't the only ones crying now. Employers are questioning the HMOs and PPOs because their employees grumble non-stop about having to switch doctors, about having to see a primary care doctor who either accepts or vetoes referrals to specialists, and about paying the same for all of this major pain in the neck as they did when they had 80/20 policies that let them see whatever doctors they chose, when they chose, and how they chose. Gone are the days when a patient tells another, "Oh, he (or she) delivered all of my babies. That's my doctor." This is because employers' contracts with managed care insurers are changed periodically, and may the best deal win. Drive-through deliveries, out-patient mastectomies, and financially motivated criteria for indicated versus necessary surgeries have caused a backlash.
     Because all of this happened in the background, authored by those who had the most to gain (the insurance companies), there's a particular group of people who feel resentful because they didn't have a say in its design. This group of people are called constituents, and their congressmen and senators are beginning to listen. Lo and behold, the Democrats are coming to the rescue, and doctors can't believe their political eyes. Clinton didn't necessarily want to hurt doctors, he just said he wanted to balance the budget. Never once did he seem to care what doctors made, as long as everyone could see one. I have to point out that this is in contrast to a certain conflict of interest inherent in insurers--if doctors make less, insurance companies make more. Edward Kennedy, to all doctors the devil himself, the champion of national health insurance whose own family I'm sure would always be under the care of a private doctor- -this is the guy who is now introducing legislation on Capital Hill to curb HMOs and PPOs. He and other legislators are gathering bipartisan support to ban gag clauses that prohibit a doctor from recommending a treatment option that may prove more expensive to an insurer; to allow women to by-pass their primary care physicians so that they can be seen by their ObGyn; to prohibit health plans from firing doctors without cause, so that good doctors would have some security when threatened by replacement with a cheaper doctor; to make insurers liable for medical malpractice when refusing to pay for recommended treatment; and to allow "point-of-service" plans so that patients have an option to go "out of plan" to a specific doctor or hospital.
     The states started the ball rolling in this backlash, with federal legislators complementing their efforts. So are the insurance companies the villains here? Let's be fair. They took it on the chin from doctors and hospitals with fee-for-services a long time before doctors had to take it from them with managed care. Fraud and abuse by some doctors and especially by some patients have always had to figure into a bottom line that unfortunately made it good business sense to "do it to them before they do it to you." But I truly believe that never before have we in this country had such an honest and noble profession in our doctors. And I also believe that managed care as it stands right now is an experiment doomed to failure. There's too much dissatisfaction from the customers and now political backlash from those who want to be re-elected by those customers. Out of all of this doctoring, political posturing by hospitals, legislation, increased insurer liability, shameless profiteering, and capitalist flexing will come a new animal altogether.
     The conflict of interest in running a sound company while offering covered services responsibly serves as a fault line that runs deep within the insurance companies and today's world of medicine. Mistakes will be eliminated, successes will be enhanced, and the errors of the trials will be assessed. We haven't peaked yet as a medically mature political people, but what shakes out in the next five years will probably set the blueprint for the next century.
Copyright 1997 Gerard M. DiLeo, M.D., F.A.C.O.G.

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The Noble Profession through a Crystal Ball

Capitalism always wins.
    For doctors a generation ago, when services were rendered and fees were paid for those services, life was simple and life was good.  All one had to do was work hard, work ethically, and care, and life would stay good.  Income would be generous and patients would be appreciative.  Insurance often paid for these services, but it didn’t matter to doctors who paid the fees; in fact, private insurance was easier to deal with than collecting piecemeal from a patient over a period of time.
    When exactly did the good ol’ days start becoming the not so good days?  And then the terrible days? Two major factors influenced this degradation:  posturing for dominance in the pie-sharing and peripheral parasites that distorted the balance.
The pie crumbles
The major players in the medical profit game were the doctors who did the work, the hospitals who provided their facilities, and the insurance companies who levied premiums based on complex formulas that mitigated their risks.  The first two of these earned their money the old fashioned way.  The third, the insurance companies, surfed a profit margin by gambling.  But the gambling rules were set by these powerful players themselves, with self-granted advantages like pre-existing conditions, currying favor in Congress, avoiding Fair Trade restrictions, and delaying payments of money owed.  The bigger the financial entity, the less of a conscience there was, and soon it became abundantly clear to third party payors that they could increase their own profits by lessening the profits of the doctors and hospitals.  How they ate their own pie was one thing; now they wanted seconds.  What was theirs was theirs; what was others’ was going to be theirs, too.
Enter managed care, which was the brilliant methodology that shifted profits that belonged to doctors and hospitals to the more-than-adequate profits the insurance companies already enjoyed.  Managed care was the euphemism; in reality it was managed profits, and the pie soured for doctors and hospitals during the ‘80s and ‘90s.  While doctors in America feared Kennedys, Hillaries, Democrats in general, and the threats of nationalized healthcare, the rug was pulled out from under them by Republicans funded by third party payors.  In a monetary system based on inevitable inflation, the private practice of medicine became the only product in which overhead kept rising but income kept decreasing.  In any other profession, this arithmetic would be seen as a failing business.  But doctors, ethically bound to provide their services without the protection of job actions, continued to bob, sputtering, in the wake behind the wave of profit the insurance companies continued to surf.  And their waves got higher, while the undertow for the doctors and hospitals became worse.
The profit attrition on the tail-end of a medical care episode is further aggravated by the erosion of profit on the front end, i.e., rising overhead.  Government compliance with such acronyms as OSHA, HIPPA, and COBRA are small burdens compared with the rise in overhead the insurance companies have necessitated.  Pre-certification has turned doctors into mere providers, the art of medicine into bottom-line arithmetic.  While such senseless insistence on things like a D&C before a hysterectomy actually allow doctors to be paid twice—two operations instead of one—this doesn’t penalize insurers when reimbursement has now fallen to less than fifty cents on the dollar for both procedures.  What it does do is present the insurers’ most potent weapon—stalling.  The odds are tabulated as scientifically as the house’s odds of the many bets at a craps table.  Taking this particular example, there’s a percentage of a chance a woman may lose her job between the D&C and the hysterectomy, losing her insurance.  There’s a chance that in the three months it takes for severe menorrhagia to resume that it’ll be a bad time for a major surgery, e.g., children in school, up-coming vacations, etc.; such a delay could bump the conclusion of treatment by a year, thereby adding to the odds of not having insurance—or at least the same insurance—by the time a surgery is finally “convenient.”
Pre-certification is nothing more than a gate to administer stalling shackles to a physician’s treatment plan.  If a woman doesn’t tolerate hormonal manipulation all that well, shouldn’t it be her choice as to what legitimate method of treatment she undergo?  She has the right to abort a baby, but cannot choose which treatment plan is best suited to her individually.  With few exceptions (drive-through deliveries and mastectomies), women’s groups are strangely quiet on these matters.
Pre-certification adds a burden of bureaucracy, but it was brilliantly imposed such that the physician’s office supply the extra overhead.  True, there is overhead on the part of the insurer, but this is more than made up for by the profits in manipulating the gate of care.  Pre-certification moves at the speed of cost-effectiveness for the insurers, fewer operators answering phones determined according to a profit formula, not by what’s efficient at the physician’s check-out window when procedures are scheduled.
The U.S. postal service, probably the finest method of moving articles from one place to another in the history of Man, seems to fail miserably when an address of an insurer is applied to the envelop.  It seems that such an addressee can stop mail quicker than Anthrax.  When was the last time you, the reader, mailed a piece of private correspondence to a friend or loved one and it was actually lost?  Once, maybe?  Twice?  Usually, though, it’s never.  Yet with so many claims “lost in the mail” to insurers, this seems to be nothing less than a slander against the postal service.  Is it that much of a stretch to shout, “Mail fraud!”?  Often claims are not discovered “lost” until a clerical checks-and-balances cycle in a routine office methodology announces the failure of payment; and often the repeat claim is then dismissed as exceeding acceptable filing times: 
Doctors often work for free. 
But it’s not volunteering.  They do enough “volunteering” with “life-and-limb” call lists necessary for staff privileges.  No, this work for free is an irony, because there is money involved—the money that stays with those who had committed to pay according to a contract.
Whether it’s money owed, money stolen, or procedures delayed, it’s money that is invested on the insurers’ end.  Have you ever played Monopoly with a kid you knew was a cheater and he appointed himself the Banker?  In the game of professional life, doctors have just given away Boardwalk and Park Place for Baltic and Mediterranean.  And they are seldom passing “GO.”  They are seldom collecting their “$200.00,” or in managed care, their $85.00…if they’re lucky.  Often they end up “taking a ride” on the managed care railroad.
Fear of nationalized medicine was such a bogus issue for doctors—so much book knowledge and so little common sense!  The government doesn’t care how much money doctors make.  It’s only interested in a balanced budget.  Insurance companies, on the other hand, care how much anyone else makes, because if they can conspire a way to have someone else make less, they make more.  And conspire they do, exempt from Fair Trade laws.  Doctors cannot organize lest they face big fines or even do some prison time.  Insurers will pursue any infraction, freshening up the cells next to Dr. Kevorkian, who would likely want the company of those who would be sent there by entities who are killing medicine.  Insurer-assisted medical suicide for doctors.
Capitalism always wins.
    When the food fight for dominance in the pie-sharing is over, bottom-line arithmetic attracts the bottom feeders which distorts the ecological balance at the deeper levels.  In the surfing metaphor, as the insurers continue to surf oblivious to the damage done below sea level, the art of medicine is eaten away even further by those who evolve to bite at doctors’ tails. 
Enter the peripheral siphons
Whenever a sizeable volume of money changes hands, such a cash flow attracts peripheral participants.  Most of these are helpful—pharmaceucticals, ambulance outfits, home health nursing, and so on.  Lawyers, the guardians of the universe, have made medical malpractice law a major field.  True, some doctors provide legitimate cause for being sued, but this is a minority.  For the most part, doctors are sued for complications, not malpractice.  Additionally, the many suits that fail to ever go to trial use the actual suit as discovery—the decision to sue based not on merit but so as to begin information gathering.
Some say the malpractice insurance fiasco was a major factor in the demise of medicine as we know it, but this is only a subcategory of the rise in overhead.  Malice toward unscrupulous lawyers and frivolous suits only serve to take the heat off the main architect of classical medicine’s destruction.  Insurers have a buffer zone, because malpractice suits and premiums are an emotional barrier to the pain of the silent, relentless dangers of decreased reimbursements.
Hospitals, themselves victimized, have allied in strange ways with insurers, accepting Hitlerian anti-aggression pacts—like Chamberlain did—from insurers in exchange for business.  But each new fiscal year redraws the European borders of such alliances.  Doctors are powerless to manipulate the hospitals, fearful of crossing the COBRA lines.
Insurers are fiscal quarter-wise but long-term foolish.  By that is meant that each quarter, if profits go up, someone gets promoted along with a higher target for the next quarter; if profits go down, someone gets fired.  Insurers eat their young every quarter.  Unfortunately, they extend this philosophy to their drones.  Even though there may be plenty enough work for two doctors, a new doctor out of training is bought for less than a more experienced doctor who is thrown away like yesterday’s newspaper.  New doctors become experienced doctors then become jetsam.
The evolution of medicine has concluded with practitioners of the art being devolved into “providers.”  Long live medicine!
Doctors are trained with a subliminal message that they’re not a business, but something special.  When the realities of a business start to toll, doctors begin to feel they really aren’t all that special.  A tax for this, a tax for that, a fee for this, a license for that—it all builds up into responsibilities doctors are too busy to assume, relegating it to employees who just don’t care as much as the doctor cares. 
Advertising, or the lack of advertising, has become a phobia, pushing doctors into absurd fees for Yellow Pages, local magazines, and even radio and TV.  Where word of mouth used to determine the success of a practice, now advertising is seen as the vehicle for patient delivery.  But this is a misconception.  It’s whether one is in a little book provided by an insurance company that determines the patient base.  And that little book’s content can be changed very quickly.
Capitalism always wins, and the modern independent physician or group is a failing business.  Maybe not this year or the next, but soon.  Unless something happens.
But if Capitalism always wins, then the equal and reverse Newtonian law is that nothing will happen until is has to, and then it does.

A new creature crawls out of the surf
Americans need health care.  The status quo isn’t going to survive for long.  The backlash will occur to fill the vacuum of the bright star that went supernova then flew apart.  Doctors who think they can go back to the good ol’ days are pathetic—we’ve already lost this fight.  Whatever takes the place of the practice of medicine as we knew it will have to work for everyone, and even the insurance companies will be powerless to stop it.
It makes capitalistic sense that if something can be done cheaper, yet just as safely, it will gel as the next metamorphosis in medicine.  Do we really need obstetricians to deliver babies?  Do we really need surgeons to remove gall bladders?  Or urologists to read cystometrograms?  These are mechanical actions.  Internal medicine and family practice has known this for years, employing physician extenders to do the busy work, merely overseeing and authorizing their actions.  What do we really need the years of schooling for, when removing a gall bladder is step A followed by step B?  No, we need the experience and judgment for the complications.  For the art.
Consider the anesthesiologist.  Supervising a number of rooms being adequately staffed by nurse anesthetists, the gas flows just as freely and safely as having an M.D. in each and every room.  It is capitalistically ridiculous for three obstetricians to be managing three deliveries at the same town in the same hospital.  Or three hysterectomies.  Imagine, then, a tech who only removes gall bladders; a tech who only performs and records cystoscopy; a tech who only does endoscopy—all under the supervision of a hospitalist who is a specialist in the respective procedure.  Only “incision” snobbery of a barber pole mentality will resist such an inevitable change in medicine.  Midwifery is coming for all the disciplines of medicine.  They’ll be called “midsurgeons,” “midternists,” or “mid-doctors.”
As an obstetrician-gynecologist, I have operated with a tech who is so accustomed to my way of doing things that I would rather have him there than some doctors I know.  There is no question that this gentleman could do a hysterectomy as well as another OB-GYN.  My expertise—how I outrank him—is that I’ve spent a residency of all-night parties dealing with alligators up to my ears.  I would be perfectly comfortable stepping into a problem hysterectomy and addressing a problem. 
Far-fetched?  We’re anticipating a world wherein a surgeon in one location manipulates joysticks to perform laparoscopic surgery at another location.  This is cheaper and safer.  This middle step down the fanciful future will be fetched, not far-fetched.   It’s coming.  I don’t embrace it or champion it—just predict it.  What will delay it is not doctor resistance, but popular resistance.  Folks are going to want their doctors doing these things.  Until there are premium savings.  Then there will be a scramble to be employed as the hospital’s hospitalist or even the insurance company’s hospitalist, because people, no matter how much grumbling it is accompanied by, will accept any change that means less of a deduction from their paychecks.  And once firmly in place, this medical model will itself see a gradual rise in premiums for patients until another breaking point is achieved.  But that’s “tomorrow guy’s” problem.
Malpractice insurance will become the next flood insurance, provided by the government.  Florida comes to mind, in flooding as well as in malpractice liability volume.  Insurance companies will still make money, manipulating the roulette wheel legislatively as usual.
There will be fewer doctors trained and fewer doctors working, the 90% of work that is uncomplicated being done by proficient technologists.  Doctors of today who don’t survive the transition will do what they have found a way to do already—make money in other ways besides practicing medicine.

©2002 Gerard M. DiLeo, M.D., F.A.C.O.G.

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