PERSPECTIVE ON HEALTH CARE : Barefoot and Pregnant on a Minefield : Sometimes, those writing the rules have a financial stake in keeping patients dissatisfied.
This country has more than one crisis in health care. There are crises of availability, of technology, of cost, of entitlement and of education. There is also a crisis of gender.
At a glance, this might seem like the least of our problems. After all, medical school admissions are approaching equal numbers of men and women. More recently, Dr. Frances Connelly resigned to protest the old-boy mentality at Stanford’s medical school, later returning to practice there after her complaints were addressed.
But there remains a more insidious sexism, which discriminates against women on the provider and consumer sides of medicine and has yet to be confronted by those who would plan our medical future.
I am a primary care provider (PCP) for a managed-health-care plan. The strength of these managed-care arrangements lies in their cost-effectiveness. This requires limiting specialist care to cases that exceed the expertise of the primary care provider.
How often specialist care is limited for all medical conditions and problems, I can’t say. But one unique referral situation by virtue of the patient population and the length and expense of care required is pregnancy.
For a variety of reasons, not the least of which is a litigious social milieu, most standards of care require an obstetrician to care for an expectant mother. For many women, the choice of their obstetrician is an important factor in their satisfaction with a long and risky health experience.
Over the past decade, in response to the demand for a system more in tune with patients’ needs, many women medical school graduates have chosen to specialize in obstetrics and gynecology. Further, the men in the field have developed a higher degree of sensitivity to the issues of pregnancy and have tried to optimize the experience of childbirth for their patients. I call this progress.
Enter managed-care planners. The economic goals of these medical politicians stand in the path of what has heretofore been considered headway. Because obstetric care is the most expensive item in any plan, the object in designing provider panels has become to steer pregnant women elsewhere. This is done by keeping the choice of obstetricians as limited and unattractive as possible.
This becomes even more likely when providers for a given plan are involved in making its policies. The PCP, the cornerstone of managed-care plans, operates as a gate-keeper to ensure that patients are cared for as cost-effectively as possible. For this, they are paid on a “capitated” basis: They receive a set amount per patient assigned to their care. The “capitation” amount reflects, among other things, the profitability of the plan.
Specialists, however, are paid on a fee-for-service basis. The money a plan pays to specialists ultimately decreases the amount available to the plan’s PCPs. In this scenario, what gets paid in pregnancy-care benefits to obstetricians directly affects the dollars available for the paychecks of the PCPs running the show. PCPs begin to feel that their incomes are being diverted into the plan’s maternity benefits.
Discouragement is offered in subtle ways. By having doctors with less-than-sensitive bedside manners, by not signing women providers and by enlisting obstetricians who are phasing out their practices (meaning a lack of continuity from one delivery to the next for a given woman), these plans avert prenatal enrollment.
Women and those men conscientious about making their practices attractive to child-bearing women lose by virtue of not having the captive patient population available to other specialists within these plans. The patients lose by having to choose obstetricians whose appeal is limited. In short, the situation calls for bringing on the patients--all, that is, except pregnant women. I call this discrimination.
Managed care works effectively on many levels to stem the tide of rising health-care costs and to maximize utilization of existing resources. Because of its unique nature, however, pregnancy will require payment schemes that may not be applicable to other specialty areas.
Patient dissatisfaction in the field of obstetrics can have far-reaching effects. Some women who have a bad experience might opt for home delivery. Others might be less likely to follow doctors’ advice in subsequent pregnancies. Excellence in prenatal care is crucial to our well-being. Ensuring this high standard of care requires that cost be reimbursed where cost is justified.
I would urge those attempting to negotiate the quagmire of medical politics and solve enormous health-care inequities to be mindful of the equally insidious injustices apt to result from solutions that may be less fair than they seem.
By all means, attend to arguments on all sides of the issues. But in your final analysis, please be guided by those whose interests do not conflict with hard-won social progress. I call this imperative.
