'Gatekeepers' May Be Hazardous to Your Health : Medicine: Financial incentives and restraints are tilting precipitously toward patient undertreatment.

Marla, a 55-year-old woman, had a malignant melanoma removed from her arm several years ago. Later, a red-brown discoloration appeared around the scar. She went to her health maintenance organization physician, who performed biopsies on the site himself rather than send her to a dermatologist because to do so would have cost money from his own pocket. The lab that he used called the biopsy samples "atypical," but the physician's advice to Marla was only that she "might consider having the lesion removed."

She then switched insurers and became a patient in a different HMO, where the doctors were salaried. The new doctor asked me, a dermatologist, to evaluate the lesion. The melanoma had indeed recurred, and was removed right away.

In other cases, I've seen patients badly undertreated for severe itching and patients with communicable skin diseases that went undiagnosed for long periods.

This is a result of a continuing reversal of the basic way that medicine is practiced, from the traditional open-ended "fee-for-service" to a cost-cutter's invention that coerces doctors in certain types of health maintenance organizations to undertreat patients. In most people's minds, HMOs are staffed by doctors on salary, freed of competitive pressures and able to concentrate on what's best for patients. That model is becoming rare as physicians are increasingly put at personal risk for the cost of treating their patients' illnesses.

To understand this new model requires a descent into jargon. Many doctors who maintain their own offices but participate in an HMO network are known as "at-risk capitated gatekeeper" primary-care physicians. Some definitions:

* A gatekeeper physician manages the patient's care by deciding when a test should be obtained and when a specialist should be consulted. A patient who overrules the doctor or seeks a second opinion may get no insurance reimbursement for outside care.

* Capitated, literally per head, means the doctor is paid a set amount per patient per year, no matter what care is necessary or requested.

* The physician is at risk because if the patient requires specialist consultations or other outside care, the physician in one way or another can lose money. Various plans use various disincentives against use of specialists.

These plans "work" to hold down costs because the primary-care physician has a strong personal financial incentive to restrict care. Employers are increasingly offering only this sort of plan to employees and, more slowly, Medicare is embracing capitated plans. In my community, almost every primary-care physician in private practice and involved in managed care plans is "at risk" to some degree.

A conflict of interest is established between the physician's role as the patient's advocate and the physician's drive to make a profit.

HMO plans with "at-risk capitated gatekeepers" are unethical because they conflict with physicians' inherent responsiblity to represent the interests of their patients. They are also unethical because patients are not told that medical decisions may be influenced by outside financial pressures on the physician.

It has been clear for a long time that physicians should not make money from referring patients to other doctors or clinical laboratories. Anti-kickback legislation prohibits doctors from receiving referral payments. The American Medical Assn. says that physician self-referrals are generally unethical and Medicare will not pay when a physician refers a patient to clinical laboratories in which the physician has a financial interest.

It is a newer issue, but equally clear, that physicians should not withhold patient referrals to make money. Referrals to specialists should be financially neutral. They should be based on the medical needs of the patient.

In the reformed health-care system, physicians should compete by the quality and the appropriateness of the care delivered. As the Clinton Administration and Congress attempt to provide universal health-care coverage and control health-care costs, they must also protect the physician's role as the patient's advocate. The Administration and Congress should also guarantee the consumer's right to know what they are buying. Companies and individuals deserve clear and complete disclosures regarding physician financial incentives before they sign up for insurance plans. Patients enrolled in capitated gatekeeper HMOs have a right to understand the monetary forces that may drive medical decisions. Both the financial incentives to undertreat and withhold care in some types of HMOs and the incentives to overtreat in traditional fee-for-service medicine should be clearly outlined.

Financial incentives, in either direction, are dangerous in medicine and do not promote good patient care.

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