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The HMO (Attrition) Plan: It's Doctor vs. Bureaucracy

June 01, 1997|Lloyd M. Krieger | Lloyd M. Krieger is a resident at UCLA Medical Center's Integrated Plastic Surgery Program

In the old days, the doctor decided why, when and how to treat patients. Nobody asked questions or challenged medical decisions. The interaction between doctor and patient was almost holy. A treatment plan was determined in the privacy of the doctor's office, and nobody could interfere with its execution. Those days are over.

The advent of managed care has made every treatment decision subject to negotiation. There is pre-approval for hospital admissions and surgical interventions. There are limits on length of stay in the hospital. There are constraints on which medicines may be prescribed. There are restrictions on when and why to obtain specialist consultation.

Some constraints are overt: If you do not get pre-approval from the managed-care plan, the patient may not be admitted to the hospital and you may not undertake treatment. Other limitations are more subtle. Managed-care plans often put doctors' income at risk for the treatments they provide. More treatments lead to less income; fewer treatments lead to more income.

A colleague of mine is a neurosurgeon. He once did a complicated surgery to remove a brain tumor. The patient's managed-care plan approved one day in the intensive-care unit following the surgery. That day came and went. The patient still had uneven breathing. Her blood pressure and heart rate continued to fluctuate dangerously, as is often the case after the brain is manipulated in surgery. The doctor decided she needed another day in the ICU: She still needed minute-by-minute monitoring and physiologic fine-tuning.

The doctor phoned her HMO to obtain approval for the extra day of ICU care. The HMO's utilization-review nurse consulted a guide book that outlined the HMO's policies for allowable treatments. It stated only one day was allowed in the ICU. So she denied the extra day. The doctor felt that it would be medically unacceptable to transfer the patient out of the ICU. He kept her there. The next day he was called by another utilization-review nurse from the HMO. She explained that since the second day of ICU care had not been approved, its cost would be deducted from his surgeon's fee. "You'd better transfer the patient out today," she warned. Then she made a joke: "If these ICU costs keep adding up, the deductions will surpass your fee. Not only won't you get paid for caring for the patient, you could wind up owing us money."

As a resident training to become a plastic surgeon, I treat many patients who have had disfiguring operations to remove cancer. One of the most common procedures is breast reconstruction following mastectomy. Reconstruction is a two-step procedure. First, a sphere of tissue is created to form the new breast's mass and shape. Once this has healed, another operation recreates the nipple.

I once had a patient who underwent mastectomy and desired reconstruction. The surgery team performed the first step. But then the patient's HMO said it would only cover one operation for reconstruction, insisting the second step of the procedure was "cosmetic." The patient eventually did have the reconstruction completed, but only after a six-week delay during which her doctors fought the HMO's bureaucracy in a long appeal process.

This demonstrates the most subtle method by which managed care limits care: It wages a battle of attrition. In this case, to get approval for the second part demanded hours of effort on the part of doctors and office staff. It required routing through the HMO appeal system, asking whom to appeal to next, making more and more phone calls, enduring seeming eternities placed on hold, writing and rewriting letters, filling out specialized treatment request forms. In all, a treatment request or appeal might require 10 or more hours on the part of the doctor and far more time from his or her office staff. The limited number of hours in the day demands that doctors pick their battles--not every treatment is worth such extraordinary effort. So managed care limits care by simply making it logistically difficult to obtain permission. Doctors fight for the truly important cases. But many times when there are smaller--though still real--benefits for the patient, doctors concede defeat.

Many doctors are demoralized. They feel like they have taken a beating in recent years. Their incomes are down. They are no longer self-employed. Medicine is no longer the prestige occupation it once was. Some physicians are opting to retire early or switch professions. Others have taken to whining.

But the current malaise afflicting doctors is not really the result of shrinking incomes or declining prestige. Physicians train years to learn how to practice medicine. They work long hours practicing their field. Under the new health-care system, that training and hard work often seem irrelevant. A bureaucrat dictates how doctors are allowed to treat their patients.

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