Care are Needed in Managed Care Revolution

A health care revolution is well underway in this country. It's called managed care; and it's radically changing the practice of medicine, the relationship of a patient to a physician, even the medical outcome for some patients.

While doctors are losing their professional input in this new scheme, it's scary to think that thousands of corporations and health maintenance organizations are shaping the future of health care in this country's loosely regulated market, often pitting the interests of patients and doctors against one another.

Although many patients appear to be quietly accepting these changes, prodded by tempered premium hikes, it is the doctors who have been mounting their own quiet revolution, as well they should.

Managed care opens them up to increased liability exposure as they are forced to practice under imprecise guidelines set by those with a profit motivation, as they discourage some to seek specialists, or as they are forced to deny costly care under the guise of "experimental" treatments.

In New York, about 20 Long Island anesthesiologists filed a federal lawsuit last year against Aetna Health Plans, charging that the insurance company's refusal to negotiate the terms of its managed-care contract endangers the quality of their medical care.

One neurologist in Colorado has gone so far as to establish a company, American Medical Consumers, to dispatch "personal medical advocates" who will negotiate patients' care with their insurers.

And late last year at a meeting in the nation's capital, the American Medical Association House of Delegates endorsed various policies that placed the quality of care and physician autonomy above cost containment goals. But, like it or not, the AMA will be marching arm-in-arm with managed care executives into the 21st century if affordable health care is to survive.

Managed care, though, must not become a euphemism for cheap services. Americans still deserve quality health care. And it cannot be left to the business curmudgeons to define the doctors' standards of care.

More and more, though, it is the courts that are being forced to resolve the debate over quality of care and malpractice, as well as wrongful denial of access to medical care. Take, for instance, the case of Vivian O'Rourke, who was treated at a Hinsdale hospital.

O'Rourke is one of a growing number of patients who found herself denied insurance coverage for procedures that are determined by her insurer to be "experimental," when, in fact, some insurers and courts have found the treatment recommended a reasonable medical solution.

In O'Rourke's case, it was high-dose chemotherapy with a bone marrow transplant for the treatment of breast cancer. In taking her insurer to court, the patient's complaint was dismissed with prejudice on the grounds, inter alia, that an exclusionary clause in the policy denied such coverage. O'Rourke v. Access Health, Inc., 1996 WL 376454 (Ill.App.1st Dist., decided July 5, 1996). The health insurers' medical staff, an undefined and perhaps evolving term in itself, was vested with the authority to determine whether a procedure was experimental.

It is apparent that while managed care executives are trying to make their operations more efficient, a systematic method for assessing the ethical dimensions of their decisions is not even in place. Health insurance companies need to establish a universally accepted authority that regulates new medical procedures and that determines when a medical procedure crosses the line from experimental to standard.

What's more, the medical community must rally together to force insurance companies to allow physicians without a profit incentive in the managed care scheme to create practice guidelines.

Instead, case managers and review boards at managed care companies are determining inconsistent medical guidelines for the type of treatment an illness requires, the length of a hospital stay, even access to a doctor. Physicians often carry out these mandates in an effort to remain a part of the managed care plan and, therefore, maintain a patient base.

Most managed care plans, in fact, have implemented systems that give physicians financial incentives to do as little treatment as possible, while health care executives are rewarded with multi-million dollar contracts and stock option bonuses for their adeptness in crunching costs.

These executives need to provide to the American public proof that practice guidelines have been set by independently professional sources and are not triggered solely by a savings incentive.

Although some experts complained that the health care system is hemorrhaging and in need of surgery, the industry must guard against unhealthy reform that will make all of us sick in the end.