272. "One Fuming Physician," the Washington Post, (September 18,1995), pp. C3.
For the past five years I have followed closely the practice of one physician who specializes in primary care, the darling of the new revolution in medical care. We had rushed dinners at least twice a week and often discussed her changing practice.
She is now my wife, Patricia D. Kellogg, who practices in Rockville. And, like so many doctors, she feels hemmed in by a bewildering array of ever swelling, inconsistent and changing federal and state regulations. One night, she nearly choked on her dessert with: "How stupid can it get?" and "I did not believe they could top this one, but . . . ."
Most recently, our conversations have turned to new pressures applied by health maintenance organizations, or HMOs, which attempt to slash costs by paying doctors a flat fee regardless of the amount of care they provide. In this cost-cutting environment, it is the private regulations by profit-making corporations that are changing the very nature of her practice. This is of special importance because a large and growing part of the country's medical services are being HMO-ed as we speak, a trend promoted by both the Clinton administration and Republicans trying to slash Medicare costs.
HMOs, in practice, are rather incompatible with a free, consumer-driven society. Though few are forced to join an HMO, companies increasingly corral their employees in that direction. And while HMOs may indeed be attractive to many people, the effects on the culture of care are hardly insignificant.
Patricia first noted the impact of HMOs when a growing number of patients she had treated for years were forced to drop her because the HMOs that their employers made available did not contract for her services. Soon she was facing a stream of new patients who had joined HMOs that did subscribe to her practice. A year later the turnstile was spinning again as the HMOs revamped their approved doctors' list one more time and employers switched to HMOs that charge them still less.
A primary purpose of a family practitioner is for the doctor to know the patients personally, to have a feeling for their families, for their differences and distinctions. These days, Patricia has a hard time knowing if a patient in the next examination room is one of those who anxiously seeks reassurance for every minor complaint, or a seldom-seen person for whom a seemingly minor complaint is likely to indicate a serious problem. Is this elevated blood pressure persistent, or is it nervousness at seeing a new doctor?
As a result of the high turnover, Patricia often finds herself reading charts, X-rays and lab reports in files she has never seen before, often in cryptic and unknown handwriting. Furthermore, HMOs indirectly pressure doctors to reduce the time allotted to each patient from 15 to 10 minutes -- time that includes reviewing the chart, prescribing medication and taking notes.
Increasingly, Patricia finds her time spent commiserating with her frustrated patients and coping with their anger at HMO regulations -- which she must enforce. For example, rules preventing her patients from seeing the specialists they have come to know and trust. A typical case follows:
Patient A learns she has breast cancer; she asks Patricia to refer her to the Georgetown Breast Clinic.
Patricia: I am sorry that I cannot do this because you are enrolled with an HMO that sends people elsewhere.
Patient A (upset, fuming): But I am told this is the best place in the area for comprehensive treatment of breast cancer.
Patricia spends time explaining how HMOs work. The patient is not comforted. Patricia finally promises: I will try; I'll call the HMO.
A day later, Patricia to the patient: As expected, they will not allow such a referral.
Patient A (defiant): I will go anyhow; I will pay myself.
Patricia: The costs are going to be considerable. Perhaps you could go there for a basic consultation and then seek treatment under your HMO.
While Patricia once referred patients to whomever she considered the best qualified, now she must plow through guidebooks to determine whether or not these specialists are included in the particular patient's HMO approved list. These books are frequently obsolete, which leads to another round of phone calls. Limiting access to specialists is a major money-saver; one wonders, though, if HMOs could be prevented from narrowing the selection unduly in terms of numbers and qualification. And perhaps they could be encouraged to update their lists more quickly through the wonder of computers.
The result of all this HMO-ing seems clear: less time and energy devoted to treating patients. Instead, time is spent on working the system and on reconciling the patients, not to their illnesses, but to the new regulations.
At least as detrimental to the culture of care is that Patricia must now refer patients to a specialist she does not know, or someone she knows all too well. A good primary care practitioner develops a referral list of specialists particularly skilled in a certain technique, or especially able to deal with patients who are withdrawn or abrasive. Such factors cannot be gleaned from the ever-changing HMO approval lists.
When it comes to referring people who need psychiatric help, my wife is even more boxed in. She cannot refer many patients at all, but must send them to an HMO-run desk that determines if they need service and who is going to provide it. "There is no way they can begin to know what I know about the patient's psychological problems," Patricia laments.
Many HMOs do not allow for lab work and chest X-rays to be conducted in a physician's office. This prohibition on "self-referrals" does serve to reduce health care costs. But it also forces Patricia to ask a patient with a high temperature to traipse from her office to a radiology office a mile away, to a third place for blood tests, and then back to her office for treatment. Many patients at this point are fit to be tied.
In trying to save $ 270 billion out of the Medicare budget over seven years, the Republicans are proposing to push old people into HMOs and other "managed care" options. The Clinton administration is hardly in a position to complain. Its ill-fated health care reform plan not only included a requirement that employers offer "managed care" options, but it is now allowing the states to encourage senior citizens to join HMOs by offering them enticing discounts on their supplemental "Medigap" insurance.
If the White House and Congress could see the view from the ground up, in Patricia's practice, they might well stop in their tracks. What is happening to Patricia is certainly happening elsewhere, based on the handful of accounts I have read. The nation has focused recently on reducing health care costs and the need to cover those millions of Americans who are not insured. It might be argued that to achieve these goals, some delays and inconveniences are an acceptable price. However, what seems to be happening is a relentless drive for profits by the HMOs (and high salaries for their CEOs) that has the potential to undermine care -- at least if one takes the view of one typical primary care practitioner.
Over the last two years, increasingly outright discussions of financing and M&A (yes, merger and acquisitions) have taken ever more time and energy in Patricia's professional life and our dinner conversations. When we first met, I was amazed at the conniptions she and her partners went through when they faced a missed diagnosis (not to mention a misdiagnosis). Informal consultations were frequent: "Come take a look at this rash"; "What do you make of this chest X-ray?"; "Is this benign or . . . ?" These conversations have not stopped, but now I hear her talk much more about selling the partnership of which she is a member to some large corporation or hospital chain.
Patricia and her partners strongly believe that HMOs, health insurers and corporations that self-insure favor large providers rather than dealing with numerous small ones. They reportedly prefer a "one-signature" contract that provides all the services (including specialists, hospital and home care) over those that provide only ambulatory care. Hence, Patricia's eight-member partnership fears that the days of their kind of medicine are numbered; they are actively looking to be acquired.
But by whom, and for what price? Should they accept stocks as part of the payment? Who will assume the remaining obligations to retiring members? How many management prerogatives will the partners keep after they are taken over? These are major topics of deliberation these days, and they consume more than time. There is constant tension, conflict and headaches -- none particularly conducive to a culture of care.
The same issues are replayed in the hospital to which the partners admit most of their patients, a 350-bed suburban facility that does not provide some services. It does not have "peds" (which I learned stands for Pediatrics) or "hearts." It is actively seeking to merge with one of the larger hospitals in the area. This small hospital brought in a consultant who examined potential mergers and reported back to the physicians, which in turn led to complex negotiations. There is never a dull day at the hospital, but an increasingly significant part of the turmoil is now focused around issues such as M&A, rather than how to improve care.
The results seem to indicate a trend that a task force of leading ethicists and medical administrators warned against in 1993: The culture of care will be undermined and may ultimately be lost if health care comes to be treated as just another industry or business. Highlighting economic considerations at the expense of moral, humanitarian and social consideration may end up reducing costs, but at the price of ultimately bankrupting the system's integrity.
Maybe HMOs need to be required to commit themselves to multi-year contracts, rather than be free to constantly switch their health-care providers. Maybe we need to focus on cost reduction that also enhances quality of care: more defense from defensive medicine (unnecessary procedures performed to protect the doctor's backside) and no reimbursement for procedures that have no established efficacy (such as prescribing antibiotics for viruses).
True, physicians were never immune to mammon. However, many developed a sense of balance between the quest for more income and careful attention to the needs of their patients. This delicate balance is now deeply disturbed. We need to turn our minds to looking for ways to slow down rising health care costs and to ensure broader access to health care, but also to nourish quality.
Amitai Etzioni is director of the George Washington University Center for Communitarian Policy Studies and author of "The Spirit of Community" (Simon and Schuster).