Of Myths and Medicine.

KEY CONCEPTS

* Myth Creation

* Attempting to Explain the Unexplainable

* Syndromes

* Medical Myths

* "More is Better"

* "PPMs will Save Physicians"

* "Defind Contributions"

This article defines a new syndrome that significantly influences medical, societal, and political thinking as it relates to health care--myth creation. Down through the years, this syndrome of applying unprovable and possibly fantastic explanations to otherwise inexplicable situations has been applied to health care issues. This article examines a few of these "myths" to understand them in light of the human "syndrome." The medical myth of "more is better" is as seductive as it is pervasive and we are all caught up in it either as participants, advocates, or opponents. Another myth that was spun--and bought--is that physician practice management companies would help physicians not merely survive, but prosper. Myth number three is that managed care hasn't worked, so we're moving to "defined contribution."

SINGE THE DAWN OF human history, there has been a recurrent cultural "syndrome." Defined as the pattern of symptoms, physical findings, or other stereotypical events, a syndrome indicates a particular social condition. [1] This article examines one that has bearing on medical, societal, and political thinking as it relates to health care--myth creation.

Early man looked up at the sky and saw mysterious events--lightning, meteor showers, and other unexplained phenomena. The psychology that overtook him is mainly unchanged. He found spiritual explanations for that which he could not understand. He created a pantheon of gods who were vested with the responsibility for all that man could not comprehend. He developed a complex belief system to stratify his needs, such as protection from the unknown and prediction of future events.

Agnostics and atheists would contend that religious beliefs, and all beliefs that cannot be proven, relate to this basic human instinct to fill in gaps in our understanding with plausible explanations that provide comfort and a sense that the world is a safe, explainable, predictable place. It is a psychological defense mechanism that permeates humanity.

Down through the years this syndrome of applying unprovable and possibly fantastic explanations to otherwise inexplicable situations has been applied to health care issues. Physician leaders will be called upon to render opinions, judgments, and final decisions on health care topics that, in large part, relate to unprovable issues causing fear, anger, and prejudice among key stakeholders-- patients, administrators, and employers. Let us look at a few of these "myths" and try to understand them in light of the human "syndrome."

Myth #1: More must be better

We're all familiar with this variation of the syndrome. Patients, as well as providers, come to health plans demanding increased benefits for physical therapy for pain, mental health benefits for neurotic conditions, expanded pharmacy benefits for "comfort" drugs. They view the plans' limitations as improper, meddlesome, or, at worst, sacrilegious and immoral.

A physician friend once quoted a patient of his, "Nothing's too good for mother... as long as Medicare will pay the bill." The myth is that health care benefits are not only an American birthright but also a human necessity, and the more the better. It is per se immoral to ask questions of efficacy or cost responsibility. One must conjure an imaginary source of money, time, and other benefits to which we claim a natural right. Those who advocate for "do more" or who ratify the concept that "the aggressor (anybody who wants to do something) always wins" are seen as shamans. In their service, we accept futile expensive care for terminal patients as opposed to dignified death. We support a legal liability system that rewards a few at the expense of many.

Why do we do it? First, because we have the luxury to do so. Others around the world are not as lucky. Second, because we "need" to. The myth of "more" is as seductive as it is pervasive and we are all caught up in it either as participants, advocates, or opponents.

Myth #2: PPMs are here to help you

Early in the past decade, we in the business of health care delivery were exposed to one of the most fantastic and mystifying examples of myth in the history of medicine. Physician practice management companies burst onto the scene. Literally overnight, we saw dozens of organizations rise from oblivion to become public companies with market capitalization in the billion-dollar-plus range. Medical groups were purchased along with ancillary service providers.

Having had the pleasure of walking down the aisle' with three of these market giants on behalf of a large medical group, I became intimately involved in their story. It went like this: "We're health care professionals and we know much better than you how to run the business of health care. We have specialized services at our disposal with expertise on arcane topics, such as billing, coding, collecting, purchasing, contracting, amalgamating and stratifying risk, managing capitation, expanding services, scheduling, chart tracking, physician monitoring, patient compliance monitoring, drug formulary development, and a host of other talents." Whew! How did companies in business for less than a year or two develop all this expertise?

Then there was the "value proposition." I heard from no less than three major; public companies that they had a solid business plan constructed as follows:

* We will purchase all of your assets.

* The doctors will work for you, while the staff will work for us; and this will be a stable situation.

* We will take 18 percent of your gross receipts to cover our legitimate overhead and profit. The 'street' demands this. However; owing to our expertise, we will make up this 18 percent loss and more, so that your physicians will experience no decrease in personal earnings.

* Since we're a public company, it's not enough to say that this plan makes adequate profits. Every year we will have to come up with new ideas to generate profit from you through infinite growth, ever-expanding services that generate profit, or other as-yet-undiscovered techniques.

* Within five years we will own all health care groups, as this is the ultimate way to finance and manage them.

Many groups bought what they were selling. The myth was too good not to believe. I attended an investor meeting in Washington where bankers, lawyers, and economists predicted what was so obvious to them and what would become dogma to the rest of society--PPMs were here to stay and the future was rosy. So physicians took cash and/or stock and turned over the keys. In record time, however, it became apparent that the promises made could not possibly be fulfilled.

There was only one way to generate the profits necessary to feed this new and ravenously hungry mouth at our table. Physicians had to work harder to make less money. The shock was profound. Soon the street discovered the myth, as earnings did not keep up with expectations. Here we are ten years later with that industry in shambles. The acronym "PPM" is gone from our business lexicon. Though a few remain with wholly different business plans and strategies, me rest nave gone under, leaving a trail of unpaid physicians and hospitals and the pending lawsuits that typically follow.

We suspended our own good judgment in this quest and suffered the inevitable consequences of our ignorance and, in some cases, our greed.

Myth #3: Managed care hasn't worked--we're moving to "defined contribution"

The latest in a string of medical myths is not yet played out; therefore, it must be considered speculation. It may turn out to be fact rather than myth and it is up to the reader to determine if the fact pattern is sufficiently similar to the other examples to predict the outcome.

Historically, the premise was that managed care organizations (a.k.a. insurance carriers, HMOs) were organized to contract with employers to manage the health care expense of employees. The government acted as employer with Medicaid and Medicare recipients as "employees." The MCOs created contract and benefit language designed to limit reimbursement for health care services to those it felt were medically necessary and appropriate and set reimbursement policies for those benefits deemed covered services. The employer community, in its own paternalistic way, monitored the care and cost-effectiveness through exercises, such as annual re-contracting and HEDIS initiatives, on behalf of its employees.

Over the last decade we saw health care premiums flatten and even go down. However, a current view shows premiums on the rise again, in most cases double-digit inflation. Patients are less satisfied than ever with their perceived care. The government is under pressure to legislate the public's displeasure through punishing policies, exposing MCOs to new theories of liability, as well as new rights for patients to determine what is appropriate care. Employers feel a sense of liability risk as well. Though there are no legal precedents, they are convinced that it is only a matter of time until they are enjoined in a case along with an MCO for mishandling a clinical situation.

And what is the latest panacea for this unexpected MCO failure? The concept consists mainly of new language. Yes, it seems as we are going to solve this crisis with semantics! Instead of a "defined benefit" of health care services offered to employees, we will now have "defined contributions" made by employers. Employees can use these contributions to purchase the health services they need based on their own collective, extensive health care economic backgrounds.

The new language is lifted from the lexicon of pension plans, in which employers may define a contribution made annually to an employee's pension plan or, alternatively, define an eventual benefit the employee will have at retirement, which then dictates contributions. What this has to do with health care benefits is obscure at best. Let us look at some instructive quotes from recent health care economic literature to shed light on this phenomenon:

* "After long relying on managed care companies as their weapon against health costs, U.S. employers are considering a fundamental change in strategy: turning the fight over to their employees." [2]

* "All the employers we interviewed expressed greater concern about premium hikes in general than those that might be specifically attributable to elevated liability risk. Two reported ongoing internal discussions about the attractiveness of a defined contribution approach. Such discussions had been motivated by discontent with managed care, the prospect of cost increases, and a sense that their capacity to meet employee health care expectations was waning." [3]

* "Employers might not supply adequate information or support for employees to make rational decisions. Some employers are using the 'Yellow Pages' approach to purchasing health care, telling an employee, 'Here's $5,000 and the Yellow Pages. You figure it out.'" [4]

And then there's my favorite:

* "With the continued negative press and backlash surrounding the term managed care, 'Defined Care' offers an opportunity for a new terminology that all existing players can embrace--an HMO can be a Defined Care plan, a medical group can be a Defined Care provider, an employer can offer Defined Care arrangements to their employees. Managed care plans that adapt will still flourish in this new environment, but under the larger umbrella of a new name--Defined Care." [5]

Where shall we begin?

Everything published to date suggests that in the defined contribution (defined care) environment, the employee experiences more freedom of choice of health plans. As far as I am aware, these health plans haven't changed any of their internal benefit policies to greet this new concept.

Patients will experience little change in the care they receive. They will be sent to the same physicians who tend to participate in all available plans. They will experience the same policies as far as medical necessity for services is concerned. Cosmetic procedures and treatments considered investigational by the plan will still be denied. They will be restricted to choice of hospital and other ancillary providers as they always have been.

Should they choose to change plans mid-disease to meet their new individualized needs, it is unlikely that another plan would accept them without applying a preexisting illness exclusion. They will still be subjected to the inflationary forces of drug costs, new technology, and other influences. The physicians will still be frustrated by bureaucratic medicine and reimbursement reductions forcing them to see 40 or more patients per day.

I do not understand how shifting the burden of choice onto patients is somehow indicative of our newfound respect for them. Patients have no insight into judgments of quality or cost-effectiveness regarding health care providers. For years, employers and their highly compensated consultants proved that they could not make these judgments either; that's why they are shifting responsibility onto the employees. Was there ever a better example of circular logic?

And then there is the arrogance of suggesting that by simply changing our terminology, we will, in fact, create a positive change in our health care system. This insults the intelligence of the public and does it in a rather insidious way. We propose to use creative language to allay public fears, while coincidentally exposing them to new and inestimable risks. What will we say to them when they have made a catastrophic mistake in judgment lured by false promises of lower cost? Caveat emptor? I think not.

While we wait for the discussion of defined contribution to ripen and clarify, we might ask ourselves if we are witnessing a real phenomenon of merit, with promise for improving health care delivery. I don't believe it is cynical, but rather pragmatic and mindful of our recent past, to consider this yet another myth--promulgated on partially correct economic theories and misguided loyalties and goals. Those who put stock in the "new" concept do it not only at their peril, but also to the detriment of typical American citizens who have relied on a benign force more informed than they to protect their interests in this most important of life's risks.

Conclusion

Myths are a way for people to deal with what they fear, what they cannot understand, and what they choose to blame for their own vulnerability. It is a moral issue that arises here. What is our responsibility as health care professionals in this dilemma? I propose we view it as physicians, keeping the patients' best interests foremost. This is not paternalism. It is the responsibility that comes with knowledge and the ability to reason and to see things clearly. It is ultimately our choice to stumble in darkness or let in the light..

Edward Lowenstein, MD, is a pediatrician by training, as well as a physician executive and long time ACPE member. He founded a large multi-specialty practice in Orlando, Florida in 1983 and has been involved in medical group management physician leadership, and information systems development since then. Currently, he is engaged in health care consulting.

References

(1.) Webster's New Universal Unabridged Dictionary. New York: Barnes & Noble Books, 1996.

(2.) Winslow, Ron, and Gentry, carol, companies consider Letting Employees Handle their Health-Benefits Decisions. The Wall Street Journal. February 8, 2000.

(3.) Expanded Managed care Liability: What Impact On Employer coverage? People-to-People Health Foundation, Inc. (Project HOPE). Health Affairs. November/December 1999.

www.projhope.org/HA/novdec99/180602.htm

(4.) Kenneth Abramowitz, Analyst, Sanford C. Bernstein. Quoted in Managed care Online. March 2000.

www.definedcare.com/article1.htm.

(5.) Riddle, Clive. Defined care: Introducing the Term for the Emerging Health care system of the 21st century. Managed Care Online. March 2000.

www.definedcare.com/article1.htm.