The HMO (Attrition) Plan: It’s Doctor vs. Bureaucracy

In the old days, the doctor decided why, when and how to treat patients. Nobody asked questions or challenged medical decisions. The interaction between doctor and patient was almost holy. A treatment plan was determined in the privacy of the doctor’s office, and nobody could interfere with its execution. Those days are over.

The advent of managed care has made every treatment decision subject to negotiation. There is pre-approval for hospital admissions and surgical interventions. There are limits on length of stay in the hospital. There are constraints on which medicines may be prescribed. There are restrictions on when and why to obtain specialist consultation.

Some constraints are overt: If you do not get pre-approval from the managed-care plan, the patient may not be admitted to the hospital and you may not undertake treatment. Other limitations are more subtle. Managed-care plans often put doctors’ income at risk for the treatments they provide. More treatments lead to less income; fewer treatments lead to more income.

A colleague of mine is a neurosurgeon. He once did a complicated surgery to remove a brain tumor. The patient’s managed-care plan approved one day in the intensive-care unit following the surgery. That day came and went. The patient still had uneven breathing. Her blood pressure and heart rate continued to fluctuate dangerously, as is often the case after the brain is manipulated in surgery. The doctor decided she needed another day in the ICU: She still needed minute-by-minute monitoring and physiologic fine-tuning.

The doctor phoned her HMO to obtain approval for the extra day of ICU care. The HMO’s utilization-review nurse consulted a guide book that outlined the HMO’s policies for allowable treatments. It stated only one day was allowed in the ICU. So she denied the extra day. The doctor felt that it would be medically unacceptable to transfer the patient out of the ICU. He kept her there. The next day he was called by another utilization-review nurse from the HMO. She explained that since the second day of ICU care had not been approved, its cost would be deducted from his surgeon’s fee. “You’d better transfer the patient out today,” she warned. Then she made a joke: “If these ICU costs keep adding up, the deductions will surpass your fee. Not only won’t you get paid for caring for the patient, you could wind up owing us money.”

As a resident training to become a plastic surgeon, I treat many patients who have had disfiguring operations to remove cancer. One of the most common procedures is breast reconstruction following mastectomy. Reconstruction is a two-step procedure. First, a sphere of tissue is created to form the new breast’s mass and shape. Once this has healed, another operation recreates the nipple.

I once had a patient who underwent mastectomy and desired reconstruction. The surgery team performed the first step. But then the patient’s HMO said it would only cover one operation for reconstruction, insisting the second step of the procedure was “cosmetic.” The patient eventually did have the reconstruction completed, but only after a six-week delay during which her doctors fought the HMO’s bureaucracy in a long appeal process.

This demonstrates the most subtle method by which managed care limits care: It wages a battle of attrition. In this case, to get approval for the second part demanded hours of effort on the part of doctors and office staff. It required routing through the HMO appeal system, asking whom to appeal to next, making more and more phone calls, enduring seeming eternities placed on hold, writing and rewriting letters, filling out specialized treatment request forms. In all, a treatment request or appeal might require 10 or more hours on the part of the doctor and far more time from his or her office staff. The limited number of hours in the day demands that doctors pick their battles--not every treatment is worth such extraordinary effort. So managed care limits care by simply making it logistically difficult to obtain permission. Doctors fight for the truly important cases. But many times when there are smaller--though still real--benefits for the patient, doctors concede defeat.

Many doctors are demoralized. They feel like they have taken a beating in recent years. Their incomes are down. They are no longer self-employed. Medicine is no longer the prestige occupation it once was. Some physicians are opting to retire early or switch professions. Others have taken to whining.

But the current malaise afflicting doctors is not really the result of shrinking incomes or declining prestige. Physicians train years to learn how to practice medicine. They work long hours practicing their field. Under the new health-care system, that training and hard work often seem irrelevant. A bureaucrat dictates how doctors are allowed to treat their patients.

This is not to say that no good has come from the managed-care revolution. Health-care costs are down. Had they been allowed to continue spiraling out of control, the resulting strain on resources may have resulted in far worse constraints on patients and doctors. Managed-care plans are demanding and sometimes generate hard data on costs and outcomes. This increases efficiency and has helped doctors determine which procedures are most effective and how best to perform them. HMO’s are able to collate data from many different doctors across hospitals and geographic areas. This allows doctors to compare their work to that of others, so they can improve the care they give their patients.

But the price for the new efficiency has been high. It is paid in the declining trust between me and my patients. When I recommend conservative treatment, or tell someone he is fit to leave the hospital after an operation, I am often given an accusing stare. Sometimes my patients ask: Is that what you really think, or are you caving into HMO pressure to cut corners on care?

There are signs that things are improving. Some states have created an ombudsman to provide speedy reviews when HMO’s deny treatments. Laws against drive-through deliveries and mastectomies have been passed. My patients who need breast reconstruction are more likely to get it, as many states now mandate coverage for the procedure. Perhaps most important, the managed-care market is now maturing. Competition among HMO’s has forced them to provide care their patients demand, and their doctors feel is necessary. Some HMO’s are allowing patients easier access to specialists, while others are streamlining their approval and review processes.

While some older doctors may be demoralized, many young doctors like me go to work each day with enthusiasm. The excitement of the job’s clinical challenges offsets the bureaucratic hurdles imposed by managed-care plans.

Perhaps we are witnessing the swinging of a medical pendulum. In the past, doctors called all the shots. Everyone got an abundance of care, some excessive or even unnecessary. When HMO’s came onto the scene, the pendulum swung too far in the direction of limitations and restrictions. Now legislative action and market pressures appear to be pulling the pendulum toward a balance of cost control and good care.

Though the transition is difficult, there is reason for hope the managed-care revolution will result in better care at lower costs. But the interaction between doctor and patient will never again be a completely private and noncommercial one, free of outside interference. Adjusting to this change will remain the greatest and most painful challenge for doctors and patients alike.