The politics of medicine


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The Health Maintenance Organizations : HMO's



At a recent conference in San Francisco, a symposium on the future of medicine in the USA, was held. A speaker from Germany spoke about how he could not believe that American Doctors had allowed HMO's to be inflicted on them, and that they now had to ring up nurses, or clerical staff who made decisions on whether a patient could have tests or procedures done.

And you know - he's absolutely right. Everything is inverted.

Several points require highlighting.

1. Health care is expensive, but health care is perhaps the foundation of society. Everyone should have a right to health care within reasonable limits. But those limits should be set by doctors, perhaps in co-operation with business, and not by business alone.

In fact the doctors advising business, almost invariably, were unsuccessful in clinical practice, and as a result went into career changes. You hardly ever see good clinical doctors moving to administration. I see it here - all these doctors are telling us how to run things - it's bizarre. But they are now making fat salaries and in my opinion couldn’t care a hoot about patients.

Quote of the month - from a former physician, now running the medical section of a large insurance company establishing one of the largest HMO schemes in South Africa.

"We are only interested in outcomes, there is no need for bedside manner, it is irrelevant"

That summarizes HMO---business by statistics, neglect of individual patients, autocratic decision making, so called cost saving, but in the end business, business, business and finally - profits, profits, profits, for the HMO’s of course.

2. I don't believe that the cost saving is going through to the individual at all.

In fact the insurance companies have saved corporate contributions to medical schemes, thereby making business happy by reducing their contributions to the medical schemes of patients. The savings that are directly produced are simply redirected into the hands of the administrators and shareholders of the HMO schemes. This is directly visible as seen by the mega million salaries of the heads of the schemes in the USA, and the high gains of the share companies.

This is totally unacceptable, and needs widespread exposure.

3. The patient himself has lost all individuality

He has no / fewer choices. He often HAS to go to specific preferred providers. In the early formation of HMO's, these providers are again usually the least successful doctors who joined the organizations because of insecurity of their own practices. I see it here now. Newly qualified, and inexperienced doctors, or basically "failed" practitioners, are the first to join. Once there is a kink in the armour, more have to join, as the whole castle falls down because of weaknesses in the structure, and widespread "panic" of doctors not versed in business.

They perceive that they will be so deprived of referrals, and that they will be so economically stressed, that they cave in and sign the nearest contract. All of these contracts have been written by businessmen and actuaries in the favour of the HMO's. The doctors are clueless about business, and usually are entrapped by fine print and by the time they wake up in the morning their practices don’t exist, and their patients are no longer their own. Lifetimes spent building up "goodwill" are gone.

4. Choices of contracts are critical.

Capitation schemes simply convert all risk from the medical schemes and HMO’s to the doctors. So it becomes a situation of depriving patients of health care, as the care will result in no income for the doctor. How any legislation permits this I have no idea. Doctors are human, they make mistakes. They also have children, houses, and eat like everyone else. If it costs their income to refer patients to specialists or to do tests, then the basic answer is that they aren’t going to. That translates into risk - for the doctor - but worse - for the patient.

Provider models, mean that health care is controlled by gatekeepers with financial restraints leveled by non medical people, but at least if its fee for service, a proper motivation can be made on behalf of the patient, for the necessary procedures or tests.

It is extremely interesting how the HMO’s advertise that the people who make decisions on the phone about authorization for tests "are trained", when in fact the reality is that they are almost clueless.

Provider models restrict patients to certain doctors - frequently inferior and often not the best specialist in that field of medicine required.

The gag clause - that doctors couldn’t tell patients " that alternative therapies or tests or specialists" were indeed available, has to my knowledge been outlawed in the USA. Thank goodness - but the outcry shouldn’t have stopped there. It reflected the dark forces at work in the actual foundations of the HMO’s. The fact that it is business, and profits that count - not savings, and certainly not patients and their well-being.

I feel that doctors are demoralized. I am the 3rd doctor in my family (second generation), and it will be the last. My children will not be encouraged to do medicine. We are becoming employees at the mercy of business. We are working at great physical risk (with disease all around us), great financial risk (medico-legal risks displaced by the HMO’s, for decisions we don't even want to make) , poor salaries,( especially under shrinking capitation schemes).

The answer is peer review. The problem of costs of health care were / are multi-faceted.

Firstly cost of the medicine technology that exists. We cannot stop research and advances in technology. No-one wants that, and someone has to pay for it. What we can stop is the abuse and over-servicing of their use. That should be strictly enforced. I see over-servicing complaints on the "peer review and ethics committee" that I sit on. We would love to stop these schemes, but can only go as far as stopping schemes that come to our attention. i.e.. We have to get a complaint before we can act. But we need an honest incorruptible profession backing us up.

In a recent example of hospital kickback for referral, (where a complaint had been specifically made), we faced a hostile feedback when we tried to do something to stop that obvious ethical indiscretion. The answer is to stop the rot. Weed out the bad doctor, from the system. Those doctors were unable to distinguish between right and wrong, and instead of stopping the malpractice, simply attacked the group that singled them out, and continue to do so.

However with all the smoke around, No-one is seeing the real light. The problem contrary to the propaganda of big business, are not the doctor, but the costs of drugs, hospitalization, and the medical schemes themselves. This seems to have been conveniently forgotten, as the limelight has been cast on the doctor only, as its easy to bash the poor doc who has never been trained in business, except to write cheques.

Costs of medical schemes and medical aids in our country have outstripped the rise in doctor’s incomes and inflation. Why? Because the administration and administrators of the schemes are laughing all the way to the bank. Some schemes actually pay the administrators more, the greater the turnover of payouts to patients is. This means that there is no motivation to reduce costs, before the schemes out price themselves, collapse and then turn into HMO's on the pretence that "it was the doctors fault"

All in all - it makes you sick. I certainly am sick of it all - but that means I may have to get treated in an HMO - and that keeps me going.

Dr David Gotlieb


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drdoc on-line
Cape Town
South Africa
December 1997

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