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."
