Ohio lawmakers approve massive managed care bill. (Short Takes: News at Deadline).

The Ohio General Assembly has approved a bill requiring managed care plans in that state to meet new operating standards, The bill was supported by the state's largest physician organization, the Ohio State Medical Association, and Kaiser Permanente.

The Physician-Health Plan Partnership Act addresses an array of managed care issues with the goal of ensuring that patients continue to have access to high-quality health care. The measure sets standards including: prohibiting plans from retroactively denying reimbursement for treatment when eligible patients have been granted prior authorization; establishing a standardized process for resolving patient grievances; and prohibiting contracts that contain physician "gag" clauses to allow providers and patients to communicate openly about treatment options. The bill also allows patients with chronic medical conditions to have a standing referral to a specialist without going through the plan's gatekeeper.

The legislation received unanimous support in the Ohio House in October, House sponsor Rep. Van Vyven said, "Our approach from the beginning was to use the best components of managed care plans as the basis for industry-wide standards."

The making of a physician

So, how has your path been so far? What have you trained for? How does that training fit with what you are doing now? Every physician goes through a long and grueling process of selection, self-selection, and training. That training is built on a foundation of learning, by rote, an enormous amount of information about the human body, about diseases, symptoms and therapies, about tests and diagnostics. Add to that base the skills of gathering more information, plus certain physical skills, such as finding a vein with a hypodermic, or intubating an air passage, along with the mental skills of coming rapidly to a logical judgment based on that information--and you have a basic medical education. The process selects (and the trainees self-select), for people who find this approach congenial. The process is based on the powers of memory, observation, and logic. Though doctors are trained to consult, it is at root an individual process. And it is reactive--the doctor responds to the presenting situation.

And there is a meta-training as well, a set of assumptions, postures, and beliefs that is often unspoken, but is in its consequences as powerful as anything a physician learns. In his rounds, the intern learns not only that he must know everything, but also that he must appear to know everything. For the patient to have confidence, the physician must seem an Olympian. The fledgling physician learns to hide his ignorance, to dissemble his fear, to elide his vulnerability.

Today, out on the floor, in the clinic, in the executive suite at the health care center, things are changing. Medicine is changing, health care is changing, even the patients are changing. Increasingly, you are being asked to exercise skills that run against the grain of your training. Patients are demanding more information and taking more responsibility. Some of them are going on the Internet and researching their particular condition more deeply than you would ever have the time to do. Managed care is pushing at the edges of ethical practice, demanding that physicians operate in ways that may not be in the best interests of the patient. At the same time, outcomes management and other new ways of improving quality

James A. Hawkins is Publisher of Healthcare Briefings, a newsletter available in print, on cassette, via fax, and on computer disk. He can be reached at 800/338-5486.