Valley Commentary : ‘Managed Care’ Takes Decisions Out of the Doctor’s Hands : The time has come to get rid of the insurance companies, their enormous executive salaries, obscene profits, constant interference and ‘fine print’ manipulation.

An 80-year-old woman, many years my patient, came to my office the other day in respiratory distress. It was quickly evident to me that she was in heart failure. I told her that she would need an X-ray and medication.

She told me she had signed up with a health maintenance organization since her last visit. My secretary called the HMO. As I suspected, we were not on this particular part of the plan. I asked my patient why she had signed up if she intended to continue to come to me.

She told me that representatives from two plans had been coming to her house for weeks, “hounding” her to sign. She told them that she wanted to keep her regular doctor. She finally agreed to sign when the salesperson told her that my name was in their book.

Intentional or not, that was misleading information. Yes, my name is in their book, but not for the plan to which they assigned her. By coming to see me, she was “out of network.”

When you get medical services outside a network like the one she had joined, the insurance company pays nothing. This is true even if the doctor whom you chose is signed up with the same insurance company but is affiliated with a different network of doctors.

This is very confusing to patients and is seldom adequately explained by the insurance companies’ sales forces. The moment my patient signed, I was no longer her primary physician. She had been assigned to a total stranger--a doctor who knows nothing about her and has yet to see her.

Why did she join this insurance group? Although she stated that they hounded her into it, the reason most Medicare patients join managed-care plans is the promise of free medicines and no annual deductibles. Their only obligation is a small co-payment, usually $10 or less, for each visit and prescription.

She can continue to be my patient, but it will cost her. When she signed with the HMO, she gave up her Medicare card, and the HMO will not pay for outside care.

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I treated her heart failure, and I’m pleased to report that she responded well. We avoided a paramedic run to the emergency room in the middle of the night and most likely prevented hospitalization.

Does the HMO care about all of this? Probably not. After all, none of this costs them a cent, and the hundreds of dollars given to them monthly by the government is theirs to keep after small monthly fixed per-patient fees to doctors.

Insurance companies have taken medical decision-making away from patients and their doctors. They have accomplished this by using the concept of “managed care.”

Managed care is supposed to save money by controlling the wasteful use of unnecessary medical services. The concept is a good one, but it sometimes backfires by giving insurance companies the option of refusing to authorize services on the basis of cost effectiveness rather than medical necessity.

It also delays the timely approval of needed services.

One of my patients, who has years of experience in the insurance industry, gave me a rather distasteful explanation of why insurers can dominate the medical decision-making process.

He said it’s a result of the “golden rule.” They who have the gold make the rules--in this case, the insurance industry. It not only makes the rules but also controls where the patients go. Its actions grow bolder as its power increases.

A couple of years ago the Prudential insurance company took 175 of my patients--without notice to the patients, and only a few days notice to me--and reassigned them to another doctor.

I called to ask why. Was I doing something wrong? No, was the reply, in fact a poll had shown that most of my patients were very happy with me (many later changed insurance to return to me). I was told only that it was “a business decision.” Did another doctor offer to work for less? Was the company simplifying its paperwork? I couldn’t find out.

I’ve always been opposed to buying and selling patients. Patients should be allowed to go to whomever they wish. But that’s not the way managed care works. You pay your premium, (or your employer does) for the privilege of having managed care control your medical destiny.

Insurance companies treat patients like chattel. They are interested only in how many they can service at the lowest possible cost and highest possible profit.

President Clinton has stated that between 25% and 40% of the health care dollar goes to administrative costs before one cent is spent on patient care. In a recent article promoting his single-payer national health plan, Rep. Jim McDermott (D-Wash.) said Medicare has an administrative overhead of only 2.5%.

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A few years ago, the government decided to try to save money by encouraging patients to join HMOs and other managed care systems. A study showed that Medicare lost money by doing this.

The time has come to get rid of the insurance companies, their enormous executive salaries, obscene profits, constant interference with the patient/doctor relationship, huge marketing budgets and “fine print” manipulation of medical care.

The billions of premium dollars saved would be better spent on patient care and universal medical coverage.