Flaw in Managed-Care Concept: ‘Gatekeepers’ Are Already Passe
Dr. Lloyd Krieger’s interesting “What Managed Care Needs Most Is Someone Who Truly Manages” (June 18) has an important flaw: It describes a managed-care concept that is already passe. Health care systems (at least in California) are fast moving beyond the “gatekeeper” concept for an important reason: As with supermarkets, quality and customer satisfaction are as important as price in maintaining market competitiveness.
The health plans I deal with monitor underutilization as well as over-utilization. In my own practice, most referrals no longer require pre-authorization: (1), because the process was slowing things up, and (2), relatively few referrals were being denied. Many specialists may soon be “capitated,” i.e., handle all referrals for a set monthly fee. This will eliminate disincentives for referral.
Krieger proposes a “manager” concept to solve the putative problem, yet he gives only a vague job description for this functionary. It is hard to understand how such a manager would be successful in the very example Krieger gives us--back pain. One must understand that back pain is one of the most common complaints among patients. Very few need MRIs; almost none needs surgery. When considering expensive tests, the doctor always takes a calculated risk, based on a careful interview and examination. Only the doctor can make that important initial decision.
Even in the present era, as it has been for millennia, the best medicine requires an artful physician who knows the patient well. Curiously, this also makes economic sense.
GERARD W. FRANK, M.D.
Los Angeles
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Dr. Krieger is correct when he states that “managed care has fallen short of its potential as a means of improving patient care or creating cost savings,” but his suggestion of adding another layer of management, especially a manager that “need not be a physician,” could not possibly improve patient care.
Instead, the primary care doctors should be given more authority to give their patients the care they need and less incentive to keep a patient at the gate.
Health care cannot be handled as “any other industry.” If we are to remain a healthy nation, we need a health care system that is concerned with the health of its patients, not the dollar sign.
DOROTHY MARSH
Fullerton
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I fail to see any advantage to adding still another position to the administrative bureaucracy currently controlling medical care within the HMO system.
How will the role of this “manager” differ from the role of the very highly paid executive currently running the system? With 30% or more of the medical premium dollar now going to “administration,” including multimillion-dollar executive salaries and stockholder dividends, do we have to add even more layers of expensive bureaucracy?
I am sure Dr. Krieger is very astute in business, having received an MBA. He certainly realizes that the monetary rewards in medicine now go to the administrators and not to those actually caring for patients. Perhaps he is defining a new position for himself.
No, Dr. Krieger, the American people are already being managed to death in every aspect of their daily lives. Hopefully, the future of American medicine does not lie in managed health care.
It is the patient rather than an HMO who should be determining how much primary and specialist care he needs. Perhaps the medical savings account proposal now being introduced in Congress will be the ultimate solution to the problem of financing health care in this country.
BRIAN H. HEWINS, M.D.
Arcadia
