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"DISINCENTIVES" THAT DISCOURAGE DOCTORS
FROM PROVIDING GOOD HEALTH CARE
Although HMO's (so-called "health maintenance organizations") and
"managed care" were originally sold to the public and to employers
as systems to encourage good health care, the facts show clearly
that the contrary is true. Every managed care plan is subtly but specifically structured
to discourage good health care.
Consider:
- Doctors are now paid such low Office Visit fees that they feel
overwhelming pressure to try to rush many more patients through
in a day. No doctor can do a good job when he's constantly feeling
pressure to get rid of each patient as quickly as possible; so he can get on to the next one. The absurdly low fee schedules
discourage doctors from spending any more than the bare minimum time possible with each patient.
- Doctors on "capitated" HMO plans receive a flat fee each month
whether they actually see a patient in their office or not; so
they are strongly motivated to try to treat everything over the
phone (usually via their staff) and are discouraged from having their patients come to the office for proper evaluation
when they are ill. By discouraging patient Office Visits, the
HMO plan also thus discourages any lab work that might have been
done in connection with the visit. Only if the patient "craters"
from lack of proper care are they finally allowed to come in to
see someone, often not even a "real" doctor (click), who will invariably be rushed.
- Managed Care tries to discourage doctors from doing thorough Physical Examinations because they
pay significantly less for thorough 40-minute Physical Exam on one patient than they pay the doctor for seeing four patients
for quick 10-minute Office Visits during that same period of time.
For instance, Prucare pays $27.14 for a 10-minute Office Visit (thus $108.56 for four
10-minute visits), but it only pays the doctor $92.85 if he spends
40 minutes with the same patient doing a thorough exam. Instead
of rewarding the doctor for being thorough, Prucare penalizes him $15.71! An even more egregious example is Aetna which pays $32 for an Office Visit but only $86.48 for a 40-minute
exam, a loss to the doctor of $41.52 every time he does a Physical Exam. Obviously the managed care companies don't want doctors doing
thorough exams. Doctors who do persist in doing thorough physicals are doing
so out of dedication and professionalism because they're losing
money on every one.
- Managed Care tries to discourage Primary Care doctors from referring patients to specialists by
requiring time-consuming paperwork to obtain authorization. What's
more, the best specialists, the ones to whom the Primary Care
doctor has been referring his patients for years, are often not
available because they refuse to participate in many of the plans
whose fees are too low.
- Managed Care tries to discourage doctors from doing lab work because doctors know that with many
of the health plans their office will receive little or no compensation whatsoever for the time their staff spends processing the samples and reports;
and the doctor knows he or she will receive no compensation for the time spent interpreting the test results, making decisions,
documenting those decisions, and then communicating them to the
patient.
The subliminal messages from Big Insurance (BI) to doctors on these bad health plans are:
- BI: "We will pay you only for Office Visit charges, not lab work
and time you spend thinking about your patients. So stop thinking and get those patients in and out as fast as
you can and don't waste your time (and BI's money) on thoroughness!
- BI: "Don't you go looking for problems that aren't absolutely jumping
out at you because any time you order a test or think too much
about a patient it will cost you time, and your time is money.
- BI: "Don't be aggressive about preventive medicine and trying to identify
and correct potential problems unless the patient is complaining loudly or starts getting really
sick from longtime neglect.
- BI: "If you turn up some sort of unexpected abnormality as a result
of a test you ordered you will then be ethically and legally bound to 'waste' more of your time (unpaid)
on this patient's case. If you have to study the patient's chart, look something up
in a medical book, consult with other doctors, telephone the patient
to discuss the meaning of the tests, instruct your nurse what
to do next, and then record all this in the patient's record,
you won't be paid anything for any of this time and effort. It's better that we not know about silent problems at all until
the patient starts to go sour."
- BI: "So you see, Doctor, you're much better off if you don't order
tests and can thus state honestly that you didn't know that the
problem existed. You're much better off not ordering any tests at all unless it would be obvious malpractice
not to do so. Don't worry about preventive medicine or trying to keep your
patients from getting into trouble -- you've got more important
things to worry about now, your own survival.
- BI: "FORGET YOUR OATH AND YOUR ETHICS, DOCTOR -- THINK ABOUT YOUR
BOTTOM LINE!"
These insurance company disincentives to good health care can only grow stronger as long as the insurance
companies are allowed to continue to reduce professional fees while maximizing their own profits.
Do you like your health care better now than you did five years
ago?
Probably not. Well, you ain't seen nuthin' yet - just wait five
more years if this malignancy is allowed to grow unchecked!
Please consider supporting your doctor's efforts on your behalf by becoming proactive on this issue before our
health care system is completely dismantled by the insurance companies.
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