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Chapter One
The Managed Care
Nightmare
QUESTIONS THIS CHAPTER ANSWERS
* Why is my doctor so rushed?
* Why do I get only ten minutes with my doctor?
* Where do my premiums go?
* What's wrong with old-fashioned health care?
* How can this book help me?
If something like this has never happened to you, count yourself lucky. You show up for your appointment on time. With a smile, you greet the receptionist sitting behind a generic white countertop. It's then that you know something is wrong. Barely moving her gaze from the computer terminal, she motions with her hand to an open notebook. "Sign in there," she commands.
You notice then that there are a dozen names already on the sheet, and the ink is still fresh. You turn to the waiting room. It's packed. One woman listlessly leafs through a two-month-old issue of Time . A man nervously looks at his watch, leans back, and then looks again. A child runs through the rows of unpadded seats, unsupervised by his father, who seems to be fast asleep. An elderly man sits in the farthest corner, coughing. This is going to be a long wait, and none too pleasant.
You are due back at work in an hour. You try to expedite your visit by asking the receptionist if you can settle your co-payment now, while you are waiting, instead of after you see the doctor. She points to a sign: "Please pay in full before you leave." That doesn't really answer your question, but you decide not to start a fight. "After you sign in," she drones, "fill out this form."
The form has the same questions you have been asked a dozen times before, but you dutifully answer questions about your past medical history. Then you wait. And wait. Your name is finally called.
You are herded into an examining room, told to strip, and left alone. Then you wait. And wait. That two-month old issue of Time is starting to look entertaining compared to the biohazard warning on a disposal bin that you read as you wait. And wait.
When the door finally opens, your anger and frustration has built to the point where you want to lash out at the doctor. He's not helping. He's obviously impatient as you describe your problem, clearly dismissive as you express your concern. As you leave, preparing yourself for another rude encounter with the receptionist, you wonder: "Did we institute socialized medicine and did someone just forget to tell me? Was I just put on welfare and sent to a county hospital? Aren't I paying good money for health insurance? What happened to that smiling, good-looking doctor on my brochure?"
It's not quite socialized medicine, and it's not the county hospital. It's managed care, and in case you haven't heard, it's the way things are for nearly every American who has health insurance. It happened so quickly that virtually no one, not even the vast majority of doctors, has fully come to grips with the realities and pitfalls of the new system. How quickly did this revolution turn health care around? In 1984, only 15 million Americans were enrolled in a managed care program. Ninety-five percent of those enrolled in a company health plan were in a traditional indemnity plan, whereby the patient could see any doctor, and rarely saw a bill. In 1999, an estimated 83 percent of insured employees were in managed care. Employees still insured by indemnity made up the rest--a mere 17 percent.
It happened way too fast for most of us. We continue to hold onto our old-fashioned ideas about doctors and hospitals--about the welcome mats they placed at their doorsteps, about how the patient was first and the bill was second, about how the best care in the world should be available on demand. Managed care was careful to not let us know that they were changing all that. Their advertisements and brochures assured us that everything was going to be fine.
Now we know that's all a lie, and most of us are furious. But what can we do? Few of us can switch managed care companies like we would switch brands of a consumer product. Few of us can take the time to figure out how this new system works. Hardly anyone can make sense of the alphabet soup of health plans we are swimming in today. We've got HMO, MBHO, IPA, PHO, MSO, PPO, EPO, POS, PPM, or IDS. But any way you arrange these letters, they spell one thing: madness.
This book is going to cut to the chase. Instead of taking you through all the intricacies of each plan and each possible plan, this guide will focus on the questions most important to you, the consumer of health care:
• How can I get the best treatment?
• How can I make my HMO listen to my needs?
• How can I improve my relationship with my doctor?
• How can I make the most of every visit?
These questions will take time to answer, but one very important tip will get you started. Unless you are an active rather than a passive patient, you will never get the care you deserve. Unless you are prepared to stand up for your rights, your HMO will someday let you down.
You might not become a statistic or a sensational headline, but at some stage, your managed care plan's need to make money will come in conflict with your need to be listened to, cared for, and treated. It happens in small and subtle ways as well as dramatic ways. It happened to one of our friends. We'll call her Mara, and let her story illustrate the biggest single problem with managed care--the loss of quality time with your doctor.
We'll then look at what sort of treatment she might have gotten in the old fee-for-service system, explain why those days are gone, and explain why we shouldn't miss them. This is important to understand because your doctor is confronted with this reality daily, and understanding your doctor is the key to getting proper care.
Mara's Story--The Ten-Minute Visit
No one is immune from a system that puts intense financial pressures on doctors. Mara found that out when she went into her HMO for an annual "well woman" visit, which is a simple pelvic exam and pap smear by an OB-GYN. Mara isn't a typical patient--she's a doctor who keeps up with the latest developments in medicine--but her experience is all too typical.
"It was my first visit to this doctor," she told us, "and I noticed that everything was hurried. I get into the table and I'm in the stirrups while he's doing the exam, and I'm trying to ask him a few questions. Being a young, single woman in the nineties, I thought maybe I should get screened for HIV, and I wanted to ask him about that. And I had an ongoing question about irregular periods that I wanted to ask him about, too. But he stopped me before I even got the words out. He just held up his hand and said, "This is a well-woman visit and you're not supposed to have any questions. We're only allowed ten minutes per patient."
Ten minutes per patient. Who sets this rule? What difference does it make? And why would a doctor not want Mara's information and questions? We'll address these questions soon, but first let's see what happened to Mara. "There I am in the stirrups and he won't even take a minute to answer a question!" she continues. "I was so shocked that I didn't press him. He said, `You have to make another appointment if you want to ask questions.' I wanted to get up and run out of the room, but of course I was in no position to do that. So, feeling as though I'd been treated like a child, I just did what I was told and made another appointment."
Many patients would have given up at this point. Maybe that's what some HMOs are hoping for. But Mara was determined to get the most out of her health plan and took yet more time off from work for another try. "I got an appointment with a woman this time," she says, "and once I got there, I found out that she wasn't a doctor but a nurse practitioner. I'm trying to be responsible and take care of myself, so I started asking her all my questions about sexually transmitted diseases. I also said, again, that I wanted to get screened for HIV. At that point, she advised me not to get tested there because if I were to have an HIV test in my records, she said the HMO might look at that and it would somehow count against me. So she pulled out a stack of cards from Planned Parenthood and gave me one and told me that I could go there anonymously and get the test for free."
Mara says the whole experience left a bitter taste in her mouth: "I keep thinking, I'm a doctor, but I still felt powerless to question what they were doing, even though it was infuriating. I'm really busy, and I didn't feel I had the time to fight it. And the nurse scared me about the confidentiality of the test I wanted." This distrust came from only two encounters, and even though Mara didn't lose a leg or have her life threatened by bureaucratic incompetence, the system let her down in almost every way. She got nothing from her visit but a Pap smear. She won't even know the results of the test unless she asks--even if it's abnormal. Although she is a doctor herself, in a position to speak to her gynecologist as an equal, she was humiliated by the situation in his office. What happened?
Why Is My Doctor So Rushed?
Mara's story gives us clues to what is wrong with managed care, but we have to look behind the cold reactions of the doctor and the dismissal of the nurse practitioner to see what made them act the way they did. In truth, they were trained as caregivers, and perhaps never expected that they would have to be so abrupt with their patients. In truth, it's all about money.
"We're allowed only ten minutes per patient."
Mara saw this as an outrageous statement with only one purpose--to give her the brush-off. But there are reasons behind this rudeness. Managed care is, and always will be, a volume business. Mara is in what is called a "capitated plan." That means that the HMO gets a flat rate for covering a group of customers for a set period, whether they come in or not. So there is a real benefit in keeping her out of the doctor's office. If she does come in for a routine visit, there's a real benefit in moving her out the door as quickly as possible, so another patient can take her place. The doctor Mara saw might work on a salary, or he might work on a per-patient basis. Either way, the managed care organization will offer him incentives to keep costs down. Either way, he will be rewarded for moving Mara down the assembly line as quickly as possible.
Allotting ten minutes per patient isn't a way for him to get to the golf course on time. It's a survival mechanism. These days, it's hard for even the best doctors to survive in private practice. On his first day, he might have walked into the clinic with a spring in his step and taken his time with each patient, putting her at ease and explaining each procedure. But by the end of the day, he's four or five patients behind.
As the waiting room fills, patients begin to grumble, some walk out, and some might even call their HMO and threaten to leave the plan if they're ever kept waiting that long again. The HMO calls the clinic administrator and holds over his head the $20,000 a month that the HMO pays the clinic for covering their customers. The administrator then finds the root of the "problem," namely, the fresh-faced doctor who took time with his patients. The young doctor is told that if he doesn't see his patients on time, he's fired.
There probably isn't an official "ten minutes per visit" policy. The HMO would probably be shocked if it learned that a doctor was telling patients to shut up and not ask questions. But for the doctor on the front lines, trying to keep costs down for his clinic, and ultimately for the HMO, it's the only way to survive in the high-pressure managed care environment.
"I was so shocked that I didn't press him."
Patients have a long way to go before they get over that shock. Most of us still think of health care as a right, necessity, or gift. Most of us think of medicine in terms of the comforting face of Dr. Marcus Welby, and of course, HMOs try to give us this image in their ads. We desperately want to be put at ease, especially during an exam like Mara's. We still think that all we have to say is "Fix me up, doc," and all the resources of modern medical technology will be at our feet.
But health care is business. HMOs operate on tight margins and take huge risks. Like any other business, they will try to extract the most value from every interaction. But unlike other businesses, customer service does not seem to be a priority in managed care. If Mara had been served the wrong meal at a restaurant, for instance, she undoubtedly would have pressed the waiter for the right response. Why didn't she do that here? Because it was the last place she would have expected to find rudeness and impatience. Even though we distrust our HMOs, we still let our doctors treat us like children.
"I refused to go back to that first doctor."
In Mara's HMO, the next doctor she sees might not be as rude, but will be just as rushed. And if Mara silently skips from one doctor to the next, her file will tell some doctor down the line that she is a difficult patient. Her paper trail will tell the story of a patient who is hard to please. As unjust as this may sound, it's true that doctors think about these things when they review a patient's file. There's a way around this: work with the doctor you've got. In the next few chapters, we'll show you how to turn a harried doctor into a helpful doctor, preserving the relationship that forms the foundation of good treatment.
Instead of working past the rudeness we encounter in our health plans, most of us complain to our friends, stew silently, or vote with our feet. Others complain bitterly to administrators, countering rudeness with a belligerence that may never pierce these bureaucrats' thick hide. There might be a time when you have to deliver a failing report card about your doctor, but the first and best thing to do is to speak up and get his attention.
Back in the days when we saw doctors in private practice, there was, of course, no one to complain to but the doctor himself. Doctors knew this, and wouldn't dream of letting a patient walk away dissatisfied. But in managed care, many doctors know that you are stuck, and many know how few patients actually complain. This new system requires a new approach. We could dramatically improve our care if we chose to speak up.
"I found out she wasn't a doctor, but a nurse practitioner."
Under managed care, we see many fewer doctors than we used to. It's all part of cost-containment--nurse's salaries aren't as high as doctors', and as HMOs try to keep their profits up, nurse practitioners will be called upon more and more frequently to give advice, care, and prescriptions. If the nurse practitioner is properly trained and supervised, the system actually makes a lot of sense. And as we will see later, the savings are often passed on to the consumer.
But clearly, Mara was disappointed when she got to the office and found she wasn't going to see a doctor at all. The rule of thumb in dealing with HMOs is to assume nothing. If there's a way to cut costs, they will do it.
"So she pulled out a stack of cards from Planned Parenthood."
There are times when you should go outside of your HMO for a test or service. This isn't one of them. Confidentiality in this case is a smokescreen. Every patient the nurse practitioner sends to Planned Parenthood for a test saves her employer money. When the HMO reviews her cases, and sees how little her patients have cost them, she is rewarded with bonuses. From the standpoints of public and personal health, the NP has done exactly the wrong thing by discouraging someone who could be easily tested right then and there. The fact that she has a stack of cards ready suggests that she's done the very same thing many times before, which is unfortunate.
The result? Mara once again puts off being tested. At this point, she's also completely forgotten her question about irregular periods, and it's unlikely that she will be able to take off work again to deal with these concerns. On top of that, she feels neglected and angry, and probably won't be inclined to visit her HMO again unless she's actually sick. She's now just the kind of customer the HMO accountants want.
Where Do My Premiums Go?
If Mara never again shows her face in the clinic that treated her so poorly, that clinic will still be paid. Mara's employer will still pay her HMO about $100 per month to cover all her needs. If she doesn't have any needs, her HMO pockets that money or uses it to cover patients who require more intense care. Again, this is called "capitation," and is at the heart of why she was rushed through the system. Let's take a look at how that $100 is divided.
About 15 percent goes to administrative costs. Ten percent goes directly to profit, leaving about $75 per month. One-half of that $75 is put away in case Mara is ever hospitalized. The other half ($37 a month, or about $440 a year) goes to the group of doctors who are responsible for her care. Her $440 goes into a pool with the payments, sometimes more, sometimes less, of perhaps 10,000 other patients, and that money has to pay those doctors whether they are treating ten patients a day or twenty patients a day.
Many of the doctors getting Mara's $440 per year are in specialty clinics, like the women's clinic she visited. The clinic might get as little as $3 per month from Mara's original $100. So clearly, they need that $3 per month from as many patients as they can get in order to cover overhead, salaries, and equipment. The administrator who oversees this clinic watches costs very tightly, and if he does well, he gets a bonus every six months. He's also rewarded for keeping referrals down, and obviously has no incentive to experiment with new life-saving treatments or tests. We think that as managed care evolves, this system of bonuses will be removed, either voluntarily or through regulation. But even if that happens, one thing will stay the same: the need to keep a tight lid on costs.
There's nothing inherently wrong with keeping costs down. The old way of practicing medicine allowed costs to run away at twice the rate of inflation for decades. Most health care consumers didn't mind or even notice--as long as someone else was paying the bill. And the fawning attention of doctors was easy to get used to. So let's take look at what might have happened if Mara had visited a private practice doctor under the traditional fee-for-service system. As we will see, the older system has some serious drawbacks of its own.
What's Wrong with the Old-Fashioned Way?
Did you know that the practice of getting health insurance from your employer became widespread only because of a historical accident? Trade unions had been fighting for benefits since the nineteenth century, but in 1940, only 12 million Americans had health insurance through their jobs. It took a world war to get many employers to offer this expensive benefit.
During the Second World War, the government froze wages to keep inflation under control. Employers faced a labor shortage, but couldn't offer higher salaries to attract workers; the War Labor Board, however, permitted them to compete for employees with benefits packages. Before long, offering health insurance was standard. After the war, the now-established practice continued, and by 1950, 77 million workers had health insurance through their employers. No one planned this system, but it was very easy for us to get used to.
We got the best care money could buy when we were under traditional indemnity plans. We chose our doctors, paid our deductibles, and probably didn't even think about how much it cost beyond that. Doctors and hospitals knew this, and they did pretty well. The conventional treatment strategy called for tests to check every possibility, no matter how remote. Every advance in medical science was a new opportunity to increase costs. But the most important difference between the fee-for-service system and managed care is this: under a fee-for-service or indemnity plan, each patient who walked through a doctor's door was a benefit. Under managed care, each patient who asks for care is a cost.
So what would have happened if Mara had indemnity insurance? She walks into the office of Dr. Rich, a doctor she chose. This doctor takes her time. Mara first sees her in an opulent office, with pictures of the babies Dr. Rich has delivered and souvenirs from exotic vacation spots. The doctor has reviewed Mara's medical history, as well as her insurance plan. During their conversation, designed to gain Mara's trust, Dr. Rich learns that Mara is a doctor as well. They establish rapport, and then adjourn to the examining room.
Mara now asks about HIV screening. The doctor offers to do the test in-house, and give her the results that day. She then suggests a baseline mammogram, which can be done by her associates. In answer to Mara's irregular periods, she recommends that her hormone levels be checked with yet another test. She also tells Mara to monitor her periods closely and come back for a follow-up in a few months. In passing, Mara mentions a new blood test she's read about called CA-125. The test will tell Mara if she's in a high-risk group for ovarian cancer. Dr. Rich doesn't hesitate to add this to the battery of tests already planned.
Mara is what they call a "good" patient, meaning she has good insurance. She gets the maximum care the system can offer. The doctor extracts the maximum value from the visit. Mara leaves feeling listened to, respected, and well treated. So what's the problem? Let's take a closer look at Mara's visit with Dr. Rich.
That long conversation Mara had with Dr. Rich wasn't charity work. Dr. Rich is in demand, and will charge $300 for an initial consultation, $150 for each follow-up visit. So she has no need to see six patients an hour. She also knows that Mara's insurance plan will allow her to go down the road to Dr. Wealthy any time. In this situation, it pays to be polite.
Dr. Rich's offer to get results from the HIV screening the same day is welcome. It's hard to wait for days for a result as important as this. But if Mara had to pay herself, would she be so eager for the expedited test? The difference can be hundreds of dollars. Most people in this situation would put up with the wait, but Mara doesn't have to--her insurance company will handle it.
A hormone test might get to the root of Mara's irregular periods, but chances are the answer to the problem can be arrived at much more simply. Has Mara actually tracked her irregularities? How serious are they? Does she have a real reason to be concerned? Would an oral contraceptive prescription take care of the problem? These questions do not enter the doctor's mind--a test is the answer to everything.
And while we're on the subject of tests, why is Mara getting a CA-125? Does she have particular reason to think she is in a high-risk group? Does she realize that this test is still new and might give her an ambiguous result? Even worse, this and other tests carry the risk of "false positives," which would lead to even further tests, and possibly invasive procedures.
Every time we subject ourselves to a test or procedure, even a screening test, we put ourselves at risk. The problem is more widespread than you might think. One-fifth of all patients who leave a hospital take with them an infection or some other more serious problem that they didn't have when they checked in. An average of 180,000 patients die preventable deaths each year due to human error, mistaken judgment, or negligence. The sad thing is that so many of these tests, so many of these procedures that prove ultimately harmful, have been performed unnecessarily.
A study by the Rand Corporation in 1988, when less than 40 million Americans were enrolled in HMOs, examined in detail a wide sampling of procedures and found that 25 percent of them were "questionable." Even the numbers for serious and invasive procedures were high. Looking at coronary angiographies (which diagnose blockages in heart arteries), the author of the study found that 17 percent were "inappropriate." Another 9 percent were "questionable."
Tests aren't the only things that have been overdone. The cesarean section is a frequently needed operation, but why was it on the rise? By the mid-eighties, 23 percent of our children were born by cesarean--8 percent more than the rate recommended by the Department of Health and Human Services and twice the rate in Western European countries.
Are European women just stronger than American women? Or could it have something to do with the fact that hospitals can charge an extra $4,000 for each cesarean? How many of these and other procedures were done just because someone--namely, an insurer--would pay for it? How much suffering has medical science caused in the pursuit of higher billing? Even a relatively noninvasive and "low-risk" screening test such as a blood test for cancer can lead to a tremendous amount of mental anguish, especially if the result is a false positive (the term for a result that falsely indicates the patient has the disease).
Even if our hypothetical Dr. Rich did what she believed was in Mara's best interest, the practice of piling up bills has a social cost. When all the tests are done, and the follow-up visits complete, who pays for the $2,000 of tests that were ordered on Mara's behalf? We all do.
The insurance company raises its premiums, passing the cost of Mara's tests on to everyone covered by the plan. Mara's employer sees the premium increase, subtracting from the company's bottom line, so raises and bonuses are lower for everyone the following year. The government receives less in payroll taxes from Mara and her colleagues, less in taxes from the insurance company, and pays out more in Medicare and Medicaid costs to Dr. Rich and the many other doctors operating under the same assumptions. We all know what that means--higher taxes. We all pay for unnecessary tests and procedures.
What's wrong with old-fashioned health care is that no one has an interest in questioning, for example, whether Mara needs sameday HIV screening results. Those unnecessary costs paid for by indemnity insurance really add up. By 1994, we were spending 14 percent of our gross domestic product on health care. That's one out of every seven dollars spent in this country. Two billion dollars a day. Four thousand dollars per person per year. Real money.
But now the pendulum has swung to the other side. Instead of living in a free-spending health care system, we are at the mercy of penny-pinching managed care administrators. No one seems to be looking for a middle ground. Our employers are sick of paying high premiums, and managed care is the only relatively inexpensive option. So it falls to us--the actual patients in managed care--to work in, with, and sometimes against the system we've been dropped into.
How Can This Book Help?
When we looked around at how other books for patients grapple with the problem of managed care, we knew we had to offer a different approach. Too many of these guides advocate a "take on your doctor" approach. Patients were being told that they should question their doctor's every move, ask him how he is paid, and make sure an HMO bureaucrat isn't controlling him. We know that's the wrong way.
At the same time, many of these guides made patients think that they should expect the same care and attention that they got under the old system. We know that's wrong as well. For one thing, we aren't convinced the old system was that great, as we just discussed. For another thing, it's just not realistic. We can't go back.
When you read this book, you will get to see many ugly things about managed care. We are sorry to say that you will also get to see the ugly sides of a few of our physician colleagues. But just because we think you should work with them doesn't mean we think you should accept inferior care. The doctor who treated Mara was dead wrong to talk to her in the way that he did. When you are in a situation like that, you can either try to win the doctor over to your side or you can fume about how you have been mistreated. Only the first way will help get your medical problems resolved.
So please keep in mind that we are talking about the way things are, not the way we think things should be. When you left indemnity insurance and signed up for managed care, you traded your Lexus for a used Honda. You expect your Honda to work, but you don't expect it to have every frill your Lexus had. You will sometimes have to gently coax it up a hill. You will have to spend a little more time at the repair shop. Your managed care plan is the same way. It will get you where you want to go, but you have to put a little more work into it yourself.
The other thing we noticed about the current HMO self-help books is the fact that preventive medicine is left completely out of the picture. That's a real problem for us, since we know that a little prevention can help you avoid most of the problems associated with HMOs. In fact, HMOs should be working day and night on ways to get their patients into preventive programs. It's a common-sense way to produce real savings, but they just don't do it.
That's how this book was hatched. Dr. Theodosakis, director of the Preventive Medicine Residency Training Program at the University of Arizona College of Medicine, has seen how lives can change with a little preventive push. Dr. Feinberg, medical director for managed care and outpatient services at the UCLA Neuropsychiatric Institute and Hospital, has an insider's view of how managed care treats and mistreats patients. When we talked about what this book should do, we realized that we couldn't just paint a rosy picture for you. The realities of managed care are tough. But we can give you the tools to pull you and your family through.
Each chapter addresses a specific part of managed care, and delivers immediately useful tips on how to improve your experience with your HMO. Our appendices cover issues related to specific diseases, and include forms to help you with your information. Here's a rough guide to what you will find in this book
The next chapter you will read covers the reasons why you shouldn't let your relationship with your doctor go bad. Even if he's a pill, there are ways you can get through. There is a real person behind that brusque and hurried manner. You will need that person on your side.
Chapter 3 shows you how to make it through the ten-minute office visit. There's a simple method for delivering medical information. All doctors know it, and now that ten minutes is all you have, it's time to start speaking their language. The method you will learn is called HEAD.
Chapter 4 is a quick guide to problem doctors and how to get through to them using the method taught in chapter 3. We also show you how to tell if you have a real lemon on your hands, and when you should switch physicians.
Chapter 5 is devoted entirely to the high road to health--prevention. Here you will learn not just the basics, but also how to make your HMO a partner in prevention.
Chapter 6 covers what you will need to do if you get sick. Your HMO will often try to give you the cheapest treatment. This chapter will show you how to get the best.
Chapter 7 hits HMOs where they live. Denial of care is the single most frustrating and life-threatening thing that can happen to a patient. In this chapter, we show you how to appeal, and how to use the magic words "medically necessary."
Chapter 8 will help you watch out for your children in managed care. They have special needs, and are at special risk in an HMO. We'll show you how to keep those risks at a minimum.
Chapter 9 is for seniors, but anyone who has an elderly relative in managed care should read this short chapter as well. Everyone over sixty-five in managed care should have an advocate, and this advocate could be you.
Chapter 10 clears the muddied waters of psychiatric managed care. This is the care that health plans love to deny more than any other, but it's care that many of us really need. This behind-the-scenes look at what happens in the HMO's mental health wing will prepare you for the struggles of managed mental health care.
The final chapter provides a brief look at what might happen to managed care if the trends we see today continue. But since no one knows where it's really headed, we also use this chapter to share our dream of where we'd like it to go.
But you don't have to wait for that dream to be realized to make managed care work for you today. The realities of managed care are manageable. Anyone can do it. In the coming chapters, we will show you how.
Copyright © 2000 Routledge. All rights reserved.
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