| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Perspectives |
1 Department of Radiological Sciences, University of California Medical Center, 101 The City Dr, Rt 140, Orange, CA 92668.
Index terms: Economics, medical • Perspectives
Managed care, specifically the health maintenance organization (HMO), has now been with us in southern California for several years. It has, without question, brought down the cost of health care, increased the emphasis on preventive medicine, and introduced physicians to a new method of practicing medicine. Managed care has markedly reduced the excesses of indemnity medicine and increased coordination of care, and it has attempted to institute quality care through guidelines and utilization review. HMO management has been subjected to many criticisms, as would be expected with any new program, particularly one of this size and scope. Over the past few years, this column has addressed many of the problems facing patients and physicians and tried to balance them against the virtues of HMO medicine; it has been found that the problems usually overwhelm the virtues. This is not a fault in the concept of managed care but perhaps a fault in the management of that concept.
I thought it would be interesting to find out whether physicians feel that HMO practice in 1998 was more satisfying to them and their patients than in the previous evolving years of HMO medicine. I sent out a nonstatistical questionnaire to 860 family practitioners and general internists, all of whom were primary care physicians (PCPs) in Orange County, Calif. Six questionnaires were returned with the addressee unknown, leaving a balance of 854 forwarded surveys. In the questionnaire, the following questions were asked: (1) Do you feel HMOs have significantly improved patient satisfaction in 1998? (2) Do you feel that HMOs have improved physician satisfaction with HMO practice in 1998? (3) Please list the major complaints expressed to you by your patients about their HMOs in 1998. (4) Please list the three or four major effects that HMOs have had on your practice in 1998.
I hasten to caution readers that this questionnaire was not reviewed by a statistician or public health advocate and was for my informational purposes only. I have no interest in HMO bashing; I am attempting to assess whether physicians feel that HMOs have been responding to their needs and their patients' needs over the past few years. All such questionnaires suffer from bias. The results of surveys of HMO patients usually indicate that approximately 80% of patients are satisfied with this health plan. The majority of respondents to these surveys are healthy individuals; I have not seen any survey of patients with chronic diseases, frequent plan users who experience the problems of delays in treatment, referrals, and obtaining necessary pharmaceuticals.
My survey was dominated by unhappy physician respondents, and therefore its results show their biases. I did not expect much of a response since the answers required essay rather than checked box responses. To my surprise, I received 136 completed questionnaires, which is over 15% of the total. Almost all of the responses were written in longhand and were lengthy. In most of them, anger radiated from the paper. In reading through the responses, I regretted that I had not asked how long the respondent had been in practice. It is difficult for an individual who has practiced indemnity medicine for 20 years to readjust to HMO medicine, which frequently involves more patients, less income, and a more difficult doctor-patient relationship. Physicians who commenced practice after 1994 would be more likely to adapt to and accept HMO practice since they have not experienced indemnity practice.
With the above qualifications, I will try to summarize the responses. Not all of the physicians answered every question. With regard to question (1), 97 physicians felt that there was no improvement in patient satisfaction in 1998, whereas 16 felt patient satisfaction had improved. With regard to question (2), 103 physicians felt that physician satisfaction with HMO practice had not improved in 1998, and nine felt that physician satisfaction had improved. It was of interest to note that in the 136 replies, eight physicians stated that they do not participate in HMOs; three of these eight physicians stated that they had canceled the HMO portion of their practice this year. An additional five physicians stated that they had retired from practice, and the changes in the practice of medicine had hastened their retirement.
In question (3), physicians were requested to list the major complaints expressed to them by their patients about their HMOs in 1998. Obviously, I did not get the patients' comments but rather the physicians' interpretations of the patients' comments. I have attempted to categorize these comments into groups to avoid listing hundreds of slightly variable remarks. The following is a summary of the comments made under patients' complaints to physicians.
1. The complaints about specialist care included the following: delay in seeing or denial of authorization to see a specialist, limited choice of specialists, restricted access to specialists, limited specialist visits, and long wait for appointment with specialist. There were 90 negative comments regarding specialist access.
2. The complaints about treatment included the following: denial of treatment, delay in treatment, delay in authorization of treatment or tests, delay in getting appointments, and long waits in the office. There were 71 negative comments regarding treatment delays and denials.
3. The complaints regarding formulary included the following: denial of effective drugs, formulary too restrictive, cheaper and less effective drugs ordered, only generic drugs available, limited amount of drugs, and constant changes in formulary. There were 61 notations regarding formulary.
4. Remarks regarding the doctor-patient relationship included the following: poor doctor-patient relationships, not enough time with patients, long wait for appointments, physician indifference, poor communication with physician, and no personal contact with physician. There were 41 notations relating to poor doctor-patient relationship.
5. The comments regarding choice of physician included did not see doctor of choice, different doctor each visit, and no continuity of care. There were 22 notations relating to physician choice.
6. The remarks regarding HMO procedures and regulations included the following: patient confusion about HMO policy and procedures, misleading advertisements of what HMO covers, and misinformation from salesman. There were 11 comments relating to HMO regulations.
7. There were seven comments objecting to the increased copayment for drugs.
8. Remarks regarding coverage for elective surgery and rehabilitation included no coverage for rehabilitation, no coverage for cosmetics, and no coverage for durable equipment. There were six negative comments relating to coverage for elective cosmetic surgery and rehabilitation equipment.
There were a number of other categories of complaints in which less than five comments were listed; these comments included the following: forced to see a non-MD, wanted to see a specialist when getting a Pap smear, patients older than 65 years are undergoing restricted levels of testing, hospitalization too short, forced to go to a hospital or emergency room that was a long distance from home, need for preapproval to go to walk-in facility or emergency room, cannot reach the doctor by telephone, and have to go to several different centers for laboratory, x-ray, and other special services.
With regard to question (4), a summary of answers on how HMOs have affected the physician's practice in 1998, the major comments were as follows:
1. The comments made about office procedures included the following: increased paperwork, had to hire more staff, too many chart reviews, too much clerical work, and increased telephone calls. Fifty-seven notations on increased clerical work were made.
2. Comments relating to income included decreased income, reimbursements were less than costs, and financial uncertainty. There were 35 comments relating to loss of income.
3. Remarks relating to control of practice included the following: not enough time with patients, no control of practice, too many patients, and cannot manage care of patients personally. There were 27 comments relating to the loss of control of the practice.
4. Remarks related to the doctor-patient relationship included the following: worsened doctor-patient relationship, patient anger at physician, and lessened respect for physician. There were 21 comments on the doctor-patient relationship.
5. Comments related to specialist care included the following: loss of control of referrals, lack of qualified specialty personnel, and difficulty in getting permission for referrals or procedures. There were 13 comments on problems related to specialist referrals.
6. Comments regarding the formulary included the following: constantly changing formulary, each HMO formulary being different, and cannot use drug of choice. There were 12 comments on problems with the formulary.
7. There were seven comments regarding problems with patient continuity, including increased turnover of patients and patients assigned to other PCPs.
8. There were eight comments regarding a decreased number of patients, but there were also four comments that there were too many patients.
9. The comments regarding patient visits included unnecessary visits and visits instead of phone calls. There were eight comments regarding repetitive or unnecessary phone calls and visits from patients.
Other categories of comments in which there were less than five remarks included the following: patient was assigned to another physician, wrong to evaluate physicians by the number of visits and laboratory tests they ordered, patients who need the most care cannot be given sufficient time, the PCP provides care in an area of medicine in which he or she is not trained, PCP cannot perform procedures for which he or she is trained because in capitation programs these procedures must be performed by the specialists, PCP cannot follow patients in hospital, too many repetitive orders, and added costs to PCP (eg, for vaccines) without increased reimbursement.
From the 16 physicians who had noted that HMOs have substantially improved patient satisfaction in 1998, there were a total of 15 positive statements regarding improved patient or physician relations with HMOs. Some of the positive comments included "In 1998 I had more open discussion with my patients about the costs and values of noncovered benefits than I had previously," "I believe our office population shows improved patient satisfaction in 1998," "I am with Kaiser, and the majority of our doctors and patients are delighted with the system," "I have had no negative comments from my patients," "I am happy with the system," and "My practice is 95% HMO, and I and my patients are quite satisfied." There were other statements regarding easier access to specialists and second opinions in 1998, faster appeals, more choices and plans, and better service from consultants.
The majority of physicians volunteered additional comments in question (2), in which they were asked whether physician satisfaction had improved in 1998. Some of the comments that cannot be categorized were "The patient and doctor have a relationship with the insurance company but not with each other"; "A patient in pain may wait weeks to see a specialist for authorization of procedures or treatment"; "Paperwork is mind boggling"; "Separate authorizations for initial consults, procedures, and follow-up visits"; "Items listed in complaints are no different this year than the last few years"; "Most patients say they prefer regular insurance but do not have the choice since they can't afford the price"; "We have many irate patients who feel they don't get what they pay for"; "Interference from plans affecting the treatment of patients [has] increased"; "If HMOs had morals, we would not need laws to govern them"; "There are too many nonspecific guidelines"; "Employers buy the cheaper, not the better, plans"; "I have not met one PCP who was happy with HMO practice; however, they like PPO [preferred provider organization] practice"; "Complicated problems are covered by PCPs not necessarily qualified"; "Patients are promised the moon and disappointed by reality"; "Payments to physicians are so low that they don't cover office costs"; "The `megamergers' of HMOs have played havoc with health care"; "The economics of scale are a force maximizing profits, with operational efficiency and effectiveness deteriorating"; "The side effects of HMO work are increasing stress, diminished job satisfaction, and less pride in one's work"; "I now see more patients, spend less time with patients, and see more angry patients"; "Patients say to me, `you seem rushed—you don't spend enough time talking problems over with me"'; "After getting authorization to see a specialist, a patient has to wait 3–4 weeks for an appointment"; "I resent the stonewalling by the IPA [independent practice association]/HMO, with delays leading to poor care and patient anger"; "To the HMO, the sick patient is a member with limited rights; to the doctor, the sick person is a patient"; and "Formularies for each HMO are different and always changing, making it impossible to keep them straight."
As you can see, the most frequent and repetitive comments suggest that problems relating to specialist access, delays and denials of treatment or tests, access to drugs through the formulary, and patient-doctor relationships are the most troublesome. Comments regarding how HMOs have affected the physician's practice were centered on increased clerical work, decreased income, loss of control of the practice with not enough time with patients, loss of control over referrals, poor doctor-patient relationships, and again, problems relating to formulary.
The mere fact that 136 handwritten, lengthy essays were returned showed the intense interest in the subject among the physicians in Orange County. It is of interest that the majority (95 respondents) felt that there was no improvement in patient satisfaction in 1998 and that 101 felt that physician satisfaction had not improved in 1998.
Eight physicians indicated that they do not participate in HMOs, and several others indicated that they would like to leave their relationship with HMOs but still participate in PPO programs. From some of the comments, it was obvious that physicians today regard PPO and Medicare patients as their prime patients. There were several comments that patients fail to understand a contract before they sign it and then are disappointed or angry to find that areas that they assumed would be covered are not covered. David Mechanic (1) noted this in 1995 when he stated that much of the difficulty is because patients pay little attention to the formal language of insurance contracts, and access issues typically are not noted until the patient faces a serious illness and is denied care.
It has been said that managed care has created a rationing system in medicine. In reality, health care has always been rationed; the rationing depends on the supply and distribution of physicians and the ability of the public to pay. Managed care has on paper developed guidelines for care, credentialing of physicians, and compulsory utilization review and quality controls. These are all useful tools, but their effectiveness depends on how they are used and enforced. For example, under indemnity fee-for-service, there was no method for quantification or detection of overtreatment. Under managed care, excesses in treatment have been sharply reduced, but many physicians now feel that there is no method for the detection of undertreatment.
Pellegrino (2) stresses the difference between the obligations and ethical responsibilities the physician has to the patient and those he or she has to the managed care organization. The physician has a covenant of trust with his or her patient and a contractual obligation to the health plan. In capitation plans, the physician may be placed in a difficult position regarding his or her covenant with the patient, contractual relationship with the health plan, and self-interest in increased earnings. Pellegrino stated that when fiscal incentives and disincentives are devised to control the physician's decisions, primarily for purposes other than the benefit of the patient, they may work against the physician's obligation to the patient. This may occur when a physician is rewarded for postponing or eliminating tests, consultations, or hospitalizations. In this sense, capitation may be unethical. There may be a conflict between the physician's self-interest and his or her obligation to the patient. The physician should not be placed in such a situation; this is the main reason why I feel capitation is morally wrong.
In 1995, 33% of physicians had contracts in capitation programs. In a 1996 report (3), the Advisory Board of a Washington, DC think tank found that in 1995, in some managed care plans, specialty procedures dropped by 75%, leading to a marked rise in catastrophic cases. Some of the interesting findings in the report were that patients are not aware of what is covered in their contracts when they sign on to a health plan. There should be a clear and easily understood list of services covered and not covered, as well as easily understood statements regarding copayments, choice of providers, methods of obtaining appropriate referrals for specialty care, the ability to use services outside of the plan, consumer grievance procedures, incentives or disincentives to physicians for rendering care, what drugs are in the formulary, how referral policies and quality assurance programs operate, specifications of coverage for emergency and chronic care, and procedures for patient grievances (4).
Today, managed care restricts the entitlement of covered services to those that managed care administrators consider necessary for its patients. Most health care organizations are pragmatic enough that they try to attain their goals more by deterrence and negotiation than by direct exercise of power. From the questionnaire responses, it is obvious that the processes of utilization management and of advocacy and appeals impose considerable costs on the practicing physician in terms of time, frustration, and loss of professional autonomy. Differences of opinion between clinicians and utilization review boards contribute to patient dissatisfaction, hostility, and lack of trust. It is still not totally clear what obligations physicians have to patients with regard to informing them of disagreements with management about referrals, treatments, and tests. From the opinions of PCPs in Orange County, Calif, and probably those in other areas of the county with high penetrations of HMO capitation programs, there is still considerable confusion, disagreement, distrust, and unhappiness between physicians and the HMO management.
The Orange County Register (5) recently published an HMO report card—the results of a survey of 11,500 members of 19 different plans. Overall satisfaction was approximately 80%. Patient satisfaction decreased in the same areas as those reported in this survey. Patient satisfaction with ease of referrals was 59%; with authorizations, 71%; with time allowed with physicians, 74%; and with explanations of tests and procedures, 74%. Remember, this survey of plan members included primarily healthy patients. I am sure the percentage of satisfied respondents would decrease substantially if the survey respondents were limited to those who are frequent users of physician services.
Crabtree (5), the author of the above report, stated that a bad or good plan is relative, depending on an individual's health care needs and budget. Consumers frequently pick health plans based on price, assuming that they are not going to use them. Nichol (5), a health care economist at the University of Southern California, said that consumers pay for an inexpensive automobile, but when they get sick they want the performance of a luxury car.
Indemnity medicine of the 1970s and 1980s was unregulated and excessively costly. Managed care has the ability to control excesses, reduce the cost of health care, and provide many benefits for patients. To me, the problems in today's version of managed care arose from three major factors: first, the demise of the Clinton health plan followed by the total departure of government from health planning; second, the failure of physicians to become primary planners in molding managed care rather than in opposing it; and third, the abrupt entry of entrepreneurs into managed care and the massive changes made overnight with little forethought. I believe that as managed care evolves over the next 10 years modifications will occur. I believe that managed care may evolve into three segments: (a) basic capitation for Medicaid and indigent patients, which will be subsidized by the government; (b) modified capitation for individuals of modest incomes, which will allow levels of choice, from basic care to point-of-service, second opinion, and direct access to specialists, each with price variations; and (c) the remainder consisting of PPOs that resemble today's Medicare, with the patient paying 10%–20% of the physician's bills but the plan covering hospital costs. The PPO may also have levels of care such as pharmacy coverage.
I have always believed that it is the responsibility of the government to protect the patient in a profit-driven health care system. I believe that in the near future all states will have regulating boards that will oversee managed care and be the final arbiter of grievances.
We must realize that the negativity shown by physicians to managed care must be expected when the practice of medicine has changed to a system where physicians' incomes decrease as does their control over the patient. However, physicians are adjusting. Most now consider PPO and Medicare as acceptable forms of medicine which they did not several years ago. HMO capitation in medicine is obviously not accepted by the bulk of practicing physicians, but HMOs are changing, and many now offer gradations of access and care for a price. If I am correct that the bulk of medical practice in the future will be a variant of PPO practice, I believe this will be accepted by the majority of practicing physicians. The problem with many of the HMOs in managed care today is too much management with not enough attention to care.
Footnotes
Address reprint requests to the author.
Received October 16, 1998; accepted November 4, 1999.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
