'Primary care physicians are some-
times put in the position of choosing
between what's best for themselves
and what's best for the patient. For-
tunately, most doctors make the right
choice.' -- Dr. Joseph Heyman, above,
president of the Massachusetts Medi-
cal Society.
By KELLEY BOUCHARD and MARY K. FITCH
News staff
For years Dr. Thomas O'Shea put the needs of his patients first. When they came to him with aches and pains, he did whatever it took to get them well.
But in the decade before he retired last year, the longtime Peabody pediatrician witnessed the advent of HMOs and grew to resent their interference.
They limited when he could order expensive tests, monitored what drugs he prescribed, and told him which specialists his patients could see.
After decades of quarterbacking his patients' needs, O'Shea didn't appreciate having HMOs look over his shoulder.
"You can only serve one master, and that's the patient," says O'Shea. "You can't serve a second master, and that's the insurance company. These HMOs come in and dictate what we can do. They got between me and my patients."
In the old days, when you needed a doctor, you paid what you could afford, even if it was only a basket of eggs. You knew the doctor was working for you.
When most people started buying health insurance just after World War II, the doctor-patient relationship remained essentially unchallenged. If you were sick or hurt, your doctor took care of you and your traditional idemnity policy like Blue Cross/Blue Shield paid for it.
Times sure have changed.
Now under managed care, many doctors get paid up front by HMOs, which impose strict budget guidelines and scrutinize physician performance every step of the way. They also offer year-end bonuses and other financial incentives that encourage doctors to keep costs down.
The growing influence of managed care has created an ethical dilemma for doctors who, at least in theory, can make more money if they give patients less care. Whether or not doctors cave under the pressure to limit care, the bottom line is that HMO cost concerns have invaded the examining room.
Most physicians agree that good doctors would never deny necessary care, but they're still troubled by the questionable ethics of managed care.
"It's very damaging to the doctor-patient relationship to have even the perception that doctors have a money incentive to provide less care," says Dr. Donald Hanscom, a Beverly gynecologist.
Hanscom says the problem isn't so much that physicians might refuse to give medically necessary treatment, but that some doctors might talk patients out of more expensive procedures just to save a buck.
For example, Hanscom says, a doctor might encourage a patient to stay on birth-control pills rather than have a tubal ligation, more commonly known as "getting your tubes tied." At the end of the year, the money saved by not doing the operation would end up in the doctor's pocket.
"The doctor says to himself, 'You keep taking the pill and I can use the money left over at the end of the year to spend Christmas week in St. Thomas,'" Hanscom says.
It's a grim outlook, Hanscom admits, but he says it's realistic, given the fact that many doctors now get paid by HMOs.
"The man who pays the piper calls the tune," Hanscom says. "When the doctor ends up being an employee of the insurance company, your obligation to the patient is certainly co-opted."
HMOs keep costs down by creating a network of doctors and hospitals that generally accept lower fees for increased patient volume. HMO contracts also limit expensive treatments and referrals to specialists.
HMO members, in turn, pay lower premiums but sacrifice the ability to get unlimited health care on demand. In most cases they must use doctors and hospitals within the network or risk being denied coverage.
On the plus side, managed care concentrates on preventing illness by covering things like annual checkups, prescriptions, vaccinations and gym memberships. HMOs also help keep doctors from doing unnecessary tests and procedures that some say are common under traditional indemnity plans.
HMOs pay doctors in a variety of ways. Under capitation, HMOs pay primary-care physicians a monthly or quarterly fee for each member in their care. The fee usually works out to about $20 to $25 per month per patient.
Doctors use that pool of money to care for all patient needs, whether it's yearly checkups, blood tests, mammograms or operations. The less care patients need, the more money doctors get to keep.
HMOs also pay some doctors, particularly specialists, on a traditional fee-for-service basis like indemnity plans. Newer preferred provider organizations, or PPOs, combine the choice of indemnity plans with the broader benefits of HMOs, but they generally cost a little more.
Most HMOs also give doctors financial incentives that encourage them to keep costs down. They give year-end bonuses when doctors meet certain criteria for quality care and member satisfaction. Some HMOs also offer so-called withholds, which is a portion of a doctor's salary that is set aside and released at the end of the year if he stays within budget.
Another way HMOs keep costs down is through "utilization review." By reviewing patient records and requests for procedures, HMOs keep track of everything doctors do, from writing prescriptions to ordering operations. HMOs use this information to lasso doctors who overrun their budgets. They also target doctors who do a lot of expensive procedures or prescribe too many expensive drugs.
Utilization review can work in the patient's favor. For instance, if a physician is found to be doing more Caesarean sections than other doctors, the HMO would provide comparative statistics and ask the doctor to consider less-invasive approaches to difficult births.
HMOs say such close oversight and budget controls give doctors incentive to keep patients healthy and to avoid unnecessary treatment. Critics of managed care say it may encourage some doctors to withhold necessary treatment so they can pocket the difference.
"Primary-care physicians are sometimes put in the position of choosing between what's best for themselves and what's best for the patient. Fortunately, most doctors make the right choice," says Dr. Joseph Heyman, president of the Massachusetts Medical Society and an obstetrician/gynecologist practicing in West Newbury.
To help doctors deal with that dilemma, the society last fall issued ethical standards for working within the managed care system. In part, the guidelines make it clear that doctors shouldn't withhold care for financial gain and should disclose any financial incentives they get to keep costs down.
"With managed care, there are pressures on primary-care physicians that give them more difficult ethical issues to deal with than ever before," Heyman says. "You need some guidelines for what's acceptable behavior and what's not."
Despite any apparent conflict between cost and quality, some doctors don't think managed care presents such an ethical challenge. They've been able to order necessary tests and perform required operations without interference from HMOs.
But when it comes to dealing with their patients' health plans, doctors admit they have different ways of handling the restrictions of the managed care system.
Dr. Miguel Martinez, a Salem family physician, says he's not worried about what kind of health insurance his patients have when they walk into his office. It's a habit he learned as an emergency room doctor who had to treat patients without regard for their ability to pay. He finds that's still the most ethical approach under managed care.
"I'd rather go in and deal with the patient," Martinez says. "I'd just as soon not know what type of insurance they have because I don't want to have a bias."
Martinez and others say most doctors choose the medical profession to help people and would never sacrifice quality care for the almighty dollar.
"It's clear that the patient is primary in all that we do. Having said that, it comes down to the doctor and what kind of person he or she is," Martinez says.
Dr. Maury McGough, a Salem internist, says she pays close attention to her patients' insurance to ensure they get the best care possible. But cost, incentives and bonuses are not her concern.
"I don't think (knowing how I'm going to get paid) would compromise me," McGough says. "I choose to be a primary-care physician because it's my calling. It's what I do. I don't make my medical decisions based on the financial ramifications I'm facing. I don't even think about it."
© Copyright 1997 Essex County Newspapers