Health care costs keep going up.
People want their premiums to be low-
er. People need to be realistic about
what their health insurance does.'
-- Dr. Harris Berman, above, CEO
of Tufts.
Health care costs keep going up.
People want their premiums to be low-
er. People need to be realistic about
what their health insurance does.'
-- Dr. Harris Berman, above, CEO
of Tufts.
By KELLEY BOUCHARD and MARY K. FITCH
News staff
When Dr. Walter Harrison started his medical career 25 years ago, managed care was practically unheard of. If a patient even had insurance, he had a traditional fee-for-service plan.
About 10 or 15 years ago, Harrison saw a change. Patients started to come into his office with HMO plans aimed at managing care as well as costs.
That change isn't such a bad thing, says Harrison, chief of pediatrics at Salem's North Shore Medical Center.
"For too long the health care industry has been an open sinkhole," he says. "There was a huge amount of waste in the system."
Managed care, Harrison says, has forced the whole health care industry to become more efficient. That's why the system is not only here to stay, it's thriving.
For the most part, however, HMOs have been unregulated throughout their decade of tremendous growth, and there have been problems. HMOs have limited patients' choices, resisted referrals to expensive specialists, and sometimes denied necessary care.
The backlash has begun. The public, the government and several advocacy groups are pushing for rules and regulations to ensure HMOs don't put cost controls before patient care.
Don't hope for miracles, though. As a consumer, expect some positive changes in the future, but also plan to encounter many of the same problems that exist in the managed care system today.
"I think the HMOs are a great working model," says Dr. Miguel Martinez, a family practitioner in Salem. "They just need to be tweaked and fine-tuned."
Some legislators applaud HMOs for trying to contain spiraling medical costs, but also know that consumers must be protected from cost-cutting measures that impact quality care.
Last year alone 1,400 bills were introduced nationwide, resulting in 56 new laws in 35 states. More is on the way.
"We have a responsibility to make sure there continues to be access to good health care," says state Sen. Frederick Berry, a Peabody Democrat. "We cannot compromise the health care of our families in the name of cost efficiency."
That attitude prevailed on Beacon Hill last year, when lawmakers stepped in to prevent so-called "drive-through" deliveries. HMOs were sending mothers home from the hospital just 24 hours after giving birth. Now, state law requires HMOs to cover at least a 48-hour stay.
Congress is also taking charge. In March, Democratic U.S. Sen. Edward Kennedy introduced one of two bills that would bring sweeping changes to managed care at the national level.
The proposed laws would crack down on everything from "drive-by" mastectomies to gag rules in HMO contracts that prevent doctors from telling patients about more expensive treatment alternatives.
Meanwhile, President Clinton in March established a 34-member advisory committee that would review HMO policies and recommend changes aimed at protecting patients from arbitrary rules and ensuring quality care.
Back here at home, the state Legislature is reviewing more than 40 bills grouped into a "megabill" that is aimed at regulating managed care. The proposed legislation would, in part, limit the financial incentives HMOs pay doctors to keep costs down and force HMOs to cover "reasonable" emergency room visits.
The megabill also would establish a state authority to police the managed care industry as recommended in a February report by the state's attorney general.
"Many things we hear about managed care are troubling," Berry says. "Certainly when basic health and safety issues are at stake, state government should play a watchdog role."
Laws won't fix everything, experts say, because there is still a limited pool of money to take care of everyone's health needs.
As long as that's the case, don't expect health care on demand. Managed care patients will still have primary-care physicians, required referrals to specialists, and limited choices for treatment.
Doctors, too, foresee continuing problems. Right now, they're inundated with paperwork required by HMOs. Every time there's a referral to get a test or see a specialist, they must fill out forms. That's not going to change.
They also predict that the government will become more involved in health care, either by setting up some form of universal coverage or by regulating more carefully the money spent on Medicaid and Medicare.
"I think it will be hard to keep the government out," says Dr. Curtis Prout, a senior physician and instructor at Boston's Brigham and Women's Hospital. "The government will have to subsidize care of the poor and the elderly, and the government will want control over this large amount of cash."
Prout and other doctors say government involvement will create even more paperwork and bureaucracy. For the consumer, that may mean more referral requirements and a longer wait to see specialists or get tests.
Doctors also think that increased government regulations will limit the HMOs' efforts to keep costs down. If the government requires overnight stays for every operation, unlimited access to specialists, and test procedures on demand, HMOs will have to dramatically raise premiums as the fee-for-service plans have done for years.
HMOs say people ultimately will have to choose between limited services with affordable premiums and unlimited care with sky-high fees.
"Health care costs keep going up. People want their premiums to be lower," says Dr. Harris Berman, CEO of Tufts. "People need to be realistic about what their health insurance does."
Despite lawmakers' attempts to regulate managed care, many experts think HMOs will continue to limit care. In fact, some doctors predict that limited care may lead to the rationing of care they already do in other countries.
Guidelines would help doctors decide who gets more costly and rare procedures such as organ transplants. Under that system, even a famous person like Mickey Mantle would have had a tough time getting a liver transplant, given his advanced age and overall poor health.
Dr. Prout, a Manchester-by-the-Sea resident who recently published the book "Demand and Get the Best Health Care for You," admits that rationing sounds harsh. He supports the idea of providing health care for all, but questions why we should approach the subject any differently than other human needs, such as shelter and food.
"Certainly no one in America should starve," Prout says, "but no one is proposing (that we give) out free food to everybody."
As he says, the bottom line is money.
"No health plan says, 'No, you can't do it,'" Prout says. "They'll say, 'You can do it — if you pay for it.'"
© Copyright 1997 Essex County Newspapers