Managed Health Care for Elderly and Poor

* The prospects for the elderly and poor in Los Angeles are even worse than your Oct. 3 editorial, “Lost in the HMO Maze,” states. With scant preparation, ridiculously low reimbursement rates and utilizing some of the most marginal HMOs, the state is forcing more than 1 million Los Angeles County Medi-Cal beneficiaries into managed care at the end of this year. What will happen to them?

For one thing, their health will suffer, as the study published in the Journal of the American Medical Assn. and cited in your editorial says. In fact, physicians, through the medical association, have been warning of such an impending disaster since the state announced its intentions three years ago. Another thing that will happen is that the health plans involved will post impressive profits, pleasing their investors and fueling more gigantic health care mergers.

You suggest that HMOs “encourage their physicians to balance cost-cutting objectives with serving the people least able to advocate for themselves.” Physicians already do this but do not have the power to implement such a balance. In far too many HMOs physicians are not only ignored, they are threatened if they shout too loudly. There are HMOs where physicians can do what’s right for patients, striking a reasonable balance between economy and quality health care. Employers, and the state, should recognize that such HMOs are not always the low bidders on contracts.

BRIAN D. JOHNSTON MD

President

L.A. County Medical Assn.

* Re “Ill Elderly and Poor Fare Worse in HMOs, Study Says,” Oct. 2: The study found that elderly and poor chronically ill patients enrolled in HMOs were more likely to report that their health status declined than similar patients in traditional fee-for-service medicine. The trend in self-reported health status is a powerful predictor of future health care costs. Therefore, if these results are valid, the message to HMOs is that they may have shot themselves in the foot by creating new demands on their resources and profits.

As an HMO member, I take some comfort in this. In fee-for-service medicine, such errors increase profits. Worse yet, before HMOs, there was little demand for this kind of patient outcome-oriented research.

JEFF McCOMBS PhD

Associate Professor, Dept. of

Pharmaceutical Economics and Policy, USC School of Pharmacy