Why managed care matters to you

News staff

Getting medical care used to be simple. You went to the doctor, got treated and expected your health insurance to cover the bills.

It's not so simple anymore, especially for the 2.6 million people in Massachusetts who belong to HMOs.

For many, HMOs mean better health care for less money.

But as managed care tries to keep costs down, the horror stories it breeds are frightening: "drive-by" mastectomies, when women are refused hospital stays after traumatic breast removal; HMO bureaucrats who deny coverage for emergency room visits when heart attacks turn out to be heartburn; doctors who get year-end bonuses if they limit care and don't tell patients about more expensive treatments.

Some say these scenarios are symptoms of an industry in rapid flux. Around since the 1930s, HMO membership nationwide swelled from 25.7 million to 60 million in the last decade. That's about half of all those insured nationwide. With that kind of growth, you're bound to have a few problems.

Critics of managed care aren't so kind. They say the system that once rewarded physicians for doing too much now rewards them for doing too little.

"The incentive now is to limit care," says Dr. Donald Hanscom, a Beverly gynecologist. "Everything is money."

These days many share this grim view of HMOs. After a decade of wooing the public with lower premiums and broader benefits, the honeymoon for managed care is apparently over.

Critics are disturbed by the potential for abuse. They fear HMO members may not get the tests they need, the specialists they want, or the coverage they deserve, especially in emergencies.

They also worry about problems that have plagued the industry elsewhere in the country, such as HMO gag rules that keep doctors from suggesting expensive treatment alternatives.

Although HMOs say their main goal is to provide quality care, the industry has spawned an impersonal lingo that seems to contradict that. Patients who choose a doctor outside an HMO network, either at their own cost or with partial coverage by the HMO, are considered "leakage." Doctors who buck the managed care system to get better coverage for their patients sometimes risk being "deselected" or kicked out of an HMO.

Despite the frightful stories about managed care, most acknowledge Massachusetts has some of the best health care and the most successful HMOs around. Last fall U.S. News and World Report named the Worcester-based Fallon Community Health Plan the top HMO in the country. It was followed closely by the three biggest HMOs in the state: Harvard Pilgrim Health Care, HMO Blue and Tufts Associated Health Plan, which were all in the top 10.

It's comforting to know that some HMOs are doing a good job, but lawmakers are dealing with a frazzled constituency that isn't impressed by ratings. Legislators have responded with a bevy of state and national bills aimed at reining in a booming industry that's pretty much unregulated.

For their part, the HMOs don't see what all the fuss is about. They say industry competition and consumer demand will keep their policies fair and affordable.

"The HMOs are competing not only for cost, but also for quality and member satisfaction. It's a customer service industry when you get right down to it," says Bo Piela, spokesman for the Massachusetts Association of HMOs.

HMOs point to their overall success in reducing costs and keeping most members happy. Each month 700,000 people across the country join an HMO, so it's clear that managed care is here to stay in one form or another.

Critics and cheerleaders of managed care agree that the days of unlimited health care on demand are dwindling. As health care costs nudge $1 trillion annually, some say it's time for Americans to realize that the medical industry has financial limits just like any other business.

"People have been brought up to believe that health care is an entitlement," says Jeanne Holland, executive director of Northeast Physicians-Hospital Organization at Beverly Hospital. "They think 'Life, liberty, the pursuit of happiness and health care on demand.' Consumers need to change their thinking."