The assault on managed care. (A Member Responds).

The lead articles in this issue of The Physician Executive highlight the rapidly increasing level of frustration with the health care system that has resulted in an assault on managed care. Physicians are lamenting the intrusion of managed care organizations in physician-patient relationships; patients are demanding access and choice; and employers are complaining of the ever-increasing costs of health care.

As Earl R. Washburn, MD, points out in his article, "California Heats Up: Will a Jury Decide the Future of Medicine?" physicians affiliated with the California Medical Association, as well as physicians in other associations, and patients (for example, Chipps, Johnson, and Wilmer, to name a few) are fighting back. Increasingly targeted are doctors making utilization decisions. The era of managed care has reached a critical point.

Current methods of health care cost control are simply not working. The California Medical Association, for example, cites inadequate reimbursement rates (cap rates) that fail to cover medical services contracted by patients in health care plans. Utilization management incentives are structured in a way that rewards physicians who deny care to patients who need it. These practices undermine the physician's ability to use her best professional judgement in making medical decisions based on patient need.

A remedy?

Is there an alternative to the denial model? The specter (and, indeed, reality) of litigation is causing managed care organizations to reconsider the structure of the entire system. Two factors are identified in these articles as possible solutions to the health care dilemma and may provide remedy to this serious situation:

1. In Richard L. Reece's interview "HMOs on Trial: A Texas Lawyer Seeks HMO Accountability and Equilibrium," George P. Young, JD, suggests that all parties involved, including doctors, patients, and managed care medical directors, must be committed to the system and accountable for their respective roles. Physicians must be responsible for decisions they make on behalf of their patients. Medical directors must take responsibility for the utilization decisions they make on behalf of their companies. And patients must be responsible for living healthier lifestyles, making thoughtful, reasonable, cost-conscious health care decisions based on physicians recommendations, and following through on recommended screening.

2. As Young points out, huge punitive damages against health management organizations will not result in reform. More effective methods he describes include: (1) the demand by patients for choice in health plans; (2) individuals shopping for the best plans available (including those found on the Internet); and (3) defined contributions for employee health benefits. These actions will best facilitate true managed care reform.

In David O. Weber's article, "Managed Care Medical Directors Under Fire," Elizabeth Gallup, MD, argues, "a far better use of resources is to improve quality than to do traditional utilization management." We must shift the focus from utilization management to quality assurance. Instead of trying to tease out and discourage unnecessary or inappropriate utilization of health care, a new breed of incentives must be instituted that rewards appropriate, cost-containing decisions by physicians. These quality performance rewards promote the attainment of HEDIS indicators, high patient satisfaction scores, and guideline compliance.

The time for serious and thorough health care reform is at hand. We are faced with a daunting task. Currently, a gap exists between evidence-based medicine and the delivery of health care. By closing that gap and reducing substandard variation, we will greatly improve care while lowering cost.

As Linda Peeno, MD, states, "How exciting it would be to bring to bear everything we've learned about disease management, population health, and best practices and apply them with consistency to patients (Weber, 2000)." When we commit ourselves to managing health care effectively, everyone benefits, especially the patients.

Sheila R. Sawyer, MD, MMM, CPE, FACPE, is Medical Director of Integra Health in Cedar Rapids, Iowa. She can be reached by calling 319/297-9421 or via email at [e-mail].