Giving HMOs the Checkup They Deserve
* As a 40-year-old physician in my own private medical practice for 16 years (yes, I was young and idealistic when I started), I see idealism is still alive but maybe in need of reality testing. What Dr. Alan Zwerner fails to mention in his article (“The Corporate Physician Has Much More to Offer the Patient,” July 17) is that in virtually all HMOs, physicians are financially penalized (or as he states “at risk”) or may be terminated from a plan, for referring the “frail and catastrophically ill patients” for more advanced care.
If you are ill, do you want your physician (or “provider” as most HMOs refer to physicians) to choose between your health and his/her paycheck? You only need to look at several recent judgments against HMOs, including the infamous Health Net case, to see that it does occur with catastrophic results to the patient.
One must also remember that most HMOs are for profit corporations with executives who are ultimately responsible to the shareholders. How can you promise the utmost in care (even with “volume discounts”) when you must deliver ever-larger profits to the shareholders to justify the ever-increasing stock prices?
Finally and unfortunately, “quality” is increasingly being measured in terms of cost with reduction in cost being equated (in the corporate setting) with increasing “quality.” In a traditional doctor-patient relationship, if you feel you are not receiving quality care, you can easily “fire” your physician and find another. It’s not so easy to “fire” your HMO.
Medical care is like any other commodity in this world--there is no free lunch. But maybe with some reform we can at least afford a “diet plate” that affords the preservation of the traditional doctor-patient relationship.
MICHAEL D. MYERS, M.D.
Los Alamitos
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The Sunday Times printed several articles on health care that advocate managed care and HMOs as the solution to the health care cost problem and dismiss concerns about quality in a managed care system.
One article, by Alan Zwerner who apparently is a medical director/employee of an HMO group in Orange County, states that prepaid HMO doctors are superior in quality to private practice, fee for service doctors. He supports this premise by endorsing “practice guidelines,” which are rules for the treatment of various diseases derived from what is called “outcomes research.” He may be correct but the use of guidelines and outcomes research is in its infancy. Those of us who have been studying this subject for years know that outcomes research is just coming into use and is not yet a practical tool for monitoring quality of care on a large scale. It is a fact that the early use of this technique, back as far as 1977, showed that private practice, fee-for-service doctors responded rapidly to change their practices when outcomes research demonstrated a better way to do things.
It is also a fact that most HMOs do not have any systematic guidelines to standardize care of their patients. The most disturbing fact is that the Group Health Assn. of America, an HMO lobby, is fiercely opposed to any outside monitoring of quality in HMOs under health reform. The state of California is similarly opposed to outside quality monitoring in the Medi-Cal program. As a proponent, in spite of my independent private practice, of managed care and a board member of one of the Medicare Peer Review Organizations, which has spent years learning to monitor quality in the health care system we have, I am worried about the battle going on in Congress over the quality issue in the health reform debate.
To prevent serious errors, many who are concerned about health care quality (as opposed to cost) believe that only outside monitoring of HMOs will protect the public and the HMOs themselves from the pressure of economics on decisions about rationing. Every competitive sport I know of has some form of referee. The HMO industry, through the GHAA, fiercely opposes any outside review, but I believe that they are mistaken. We should not have to rely on the malpractice bar to monitor quality in health care.
The Clinton Plan is behind the curve of what is happening now in California with groups like Dr. Zwerner’s. They may, indeed, be as good as he says, but someone has to be the referee as the rules change in the health care business. Please make it someone other than the lawyers.
MICHAEL T. KENNEDY, M.D.
Mission Viejo
Michael Kennedy, a surgeon, is director and Data Committee chair for California Medical Review Inc.
