(This is a copyrighted book - Ó C. Phillips, 2001) - Rewrite 4-9-01

Chapter 2

Managed care is really a combination of mangled care caused by managed cost. Promises were made to make better patient care available by the use of greater efficiency. But managed care has become an ethical brownout. Its techniques are as myriad as are the number of illnesses in a comprehensive medical book. The methods are designed to be just subtle enough to be below the radar of regulators and just above the understanding of patients. For example, neither will catch a slightly under-read cancer biopsy slide or cardiac stress test, each potentially lethal distortions of testing fact. And those who believe that they have escaped the dark gravity holes of the HMOs by joining a higher level Point of Service plan or Preferred Provider Plan – think again; HMO tactics, thinking, and outcomes are still woven into the fabric. No longer is it a matter of making a choice of which managed care plan is good or which is bad, but judging them all to be dangerous – unsafe at any premium.

* * *

The Man Who Died of A Pulled Muscle

"Ellen! How nice to see you. Won’t you come in?" the kindly old, gentleman said as he opened the door to his newly bereaved neighbor. He noted the haggard look in the once-bright shining eyes, and the wrinkles he had not seen before. Last year’s problems had taken their toll on Ellen Sanders.

"I was just about to make a cup of coffee. Won’t you have some with me?" he suggested as he motioned for Ellen to sit in a comfortable leather chair in the living room. Under her arm was a bulging Manila envelope. The gentlemanly old neighbor was Frank Marshall, M.D., retired some four years from his once-thriving practice, but glad to be away from it now that the Health Maintenance Organizations had taken over. In fact, in the last year of practice, the HMO told him his patients were only loaned ("assigned") to him. Even getting out took a full 90 days.

Because his neighbor had been so distressed when her husband died, he had suggested she let him look at her deceased husband’s medical file when she felt a little stronger, and he would see if he could help her make sense of it. Dr. Marshall even called the HMO once to remind them that Ellen had a right to a copy of the entire chart and that ten working days was the maximum amount of time allowed for duplication.

Ellen inhaled the aroma of the fresh, steaming coffee as she placed it carefully to her lips, handed the Manila envelope to Dr. Marshall, and began her story.

"My husband, John, first went to see the doctor a year ago in February. He’d been having some problems and the doctor gave him what he called a complete physical."

"Did the doctor order an X-ray?" the retired physician asked.

"No, but the doctor did give him a prostate exam, said he was concerned, and gave John appointments with a urologist and a colon specialist."

"How old was your husband?"

"Only 66-years-old," she answered, as she looked tentatively, tears coming to her eyes at the remembrance of a life cut short.

"And was he a smoker, or a drinker?" Dr. Marshall queried.

"Yes, he was a rather heavy smoker, but only a social drinker," she quickly assured her friend.

As Dr. Marshall read John’s medical file, it showed he had had a sigmoidoscopy done by the specialist and that six polyps were discovered in the colon. They were removed and sent to the pathologist, the results were negative. "Please go on," he urged.

"John was next sent to a urologist, who did a PSA and took note that it was 6.2. He asked to see John again in June, and at that time his PSA had jumped to 8.2, so the doctor performed a prostate biopsy. Luckily, the results were negative."

"By August, however, John had developed a severe pain in his back by his left shoulder blade. It became so painful!" Remembering her husband’s pain brought tears to her eyes. "We had to go back again to the HMO to get him some relief. There he saw a different doctor then had done the intake physical. The substitute doctor said the pain in the shoulder was stress related, and gave him a cortisone shot."

"Were any tests or x-rays suggested?" Dr. Marshall asked.

"No," she answered, angry fresh tears coming to her eyes. "But a couple weeks later the pain became so intense he had to see the doctor again. This time he saw the same substituting doctor. ‘You’re not giving the cortisone time to work,’ the physician said, and he did nothing else for him."

The retired physician thought to himself that cortisone doesn’t take two weeks to alleviate pain, but he said nothing as Ellen went on.

"The cortisone didn’t seem to work and John was in so much pain. It made my heart ache to see him like this, so we went back again to the HMO. And this time we saw another doctor, a Dr. Smith."

"So, if I understand what you’re saying, by September John had seen at least six different doctors, had had a complete physical, a sigmoidoscopy, a colonoscopy, a prostate biopsy, a cortisone shot, and ten separate visits to see doctors. Is this correct?" he asked shaking his head in amazement.

"Yes," Mrs. Sanders answered. "Dr. Smith gave John a rather brief exam, said the pain was not caused by stress as the former doctor had said, but by a pulled muscle. He said there was really nothing to be done, but wait for the muscle to heal on its own. So I took John home, and he ‘toughed it out’ again, until October when the pain was so bad we just had to have some relief. Again, we saw Dr. Smith who told us there was still nothing to be done for John’s back. I found this incredible to believe considering the amount of pain he was in."

"Then, a month later, just before Thanksgiving . . ." Mrs. Sanders’ tears flowed freely again remembering their last holiday together, and her neighbor offered her a glass of water. She sipped slowly, still dabbing at her eyes, and tried to regain her composure.

"Thank you," she said. "It was close to the holiday when John’s left arm started swelling so badly that he lost the use of his arm and hand. He couldn’t even dress himself, or cut up his food; I even had to help him button his shirt. It was so pitiful," she stated, the pain reflected in her eyes at having to see her husband in that helpless condition. "Again we went back to the HMO hospital. I remember it was November 24. This time Dr. Smith diagnosed John as having a pinched nerve, and said he would schedule some neurological tests to be done. The doctor gave him a prescription for Motrin to help with the pain. But we couldn’t get an appointment to have the neurological tests done until January 15 of the next year, 1998! I felt that was an awful long time for a person in his condition to wait, but what could we do? Our HMO was in control – we were not."

Dr. Marshall nodded. The HMO probably thought it had spent enough on John that year already, he thought to himself sadly.

"Thanksgiving was not as happy that year as it usually has been. John was in so much pain he was popping the Motrin like it was candy. And believe me, my husband was no baby when it came to pain. He had a high tolerance for it. I felt so frustrated that there was nothing I could do to help him.

"Just before Christmas – December 21st to be exact – I noticed John’s speech was slurred and he had difficulty walking. By now, he couldn’t hold anything in his right hand. I thought he must have had a stroke! So I rushed him to the Emergency Room at the hospital and they discovered he’d taken a huge amount of Motrin in just three days, 30 pills I think; so they took him right into the hospital and started running tests. At last, I felt they would really find out what the problem was – why John was in so much pain! But even before the results of the tests were in, the doctor in charge of his emergency care decided that John didn’t have a stroke after all. Looking at his medical records, the doctor focused on the fact that John drank and arbitrarily decided that the whole problem had to do with alcoholic neuropathy. I couldn’t believe what I was hearing!"

"How can you make this assumption without any test results?" I screamed at the doctor in charge. ‘Well, based on his medical history, it sounds like a logical diagnosis,’ John’s doctor answered. "My mouth just fell open when I heard this!"

It took Ellen Sanders several minutes to recover from having to relive the emotions of that scene at the hospital. Her neighbor marveled at the fact that through all these visits, having been seen by all these different physicians, that not once had an arm or chest x-ray even been suggested.

When Ellen continued, she stated, "The first test results showed John’s kidneys were failing; he was in renal failure probably as a result of the Motrin overdose, and an IV was started immediately."

"The next test he was given was a CAT Scan. They finally admitted that ‘Yes’ John had had a stroke. The Scan showed two lesions in his brain, an old stroke and a new one. When the doctor told me this, I was surprised and told him that John never had a stroke that we knew of. The doctor said it was probably so mild we never noticed it. At this point, they decided to do a chest x-ray, and to admit John to the hospital because of renal failure."

"Poor John," Mrs. Sanders said. "Fortunately, he slept through all this. Now, the same doctor came back, told me that he didn’t think it was a stroke after all, and that he needed to recheck the CAT Scan. Within ten minutes the doctor was back, and this time he told me to sit down. I knew it was going to be something bad even before he said it," Mrs. Sanders said, her head hanging down as she re-experienced the pain of the moment.

"The doctor in charge said, ’The chest x-ray showed a large mass in John’s left lung.

Probably the lesions we saw in his brain were actually metastases, or cancer cells that traveled from the lung cancer and grew in the brain. We’ll know more when we do an MRI, but right now,’ he added gently, ‘You need to be prepared for bad news.’

"I sat there dumbfounded! Why, with all the visits and all the doctors John had seen, had not one found this earlier? Why, when John was begging them to stop the pain, had not one of them thought to order an x-ray? The medical chart must have also shown he was a heavy smoker, if it showed he drank. Why didn’t they focus any attention on that? Why?" Her shoulders slumped and Mrs. Sanders’ hands lay limply in her lap.

There was nothing anyone could say for this inexcusable breach of medical treatment. The man had certainly come in often enough to have had this problem detected. He had complained of severe pain often, too. Why would no one listen to the patient? Another sheer case of neglect, the neighbor knew the pattern all too well!

"The results of the MRI," Ellen Sanders continued, "came in the next day. They showed a tumor measuring 11 X 11 X 9 centimeters! About the size of a very large apple! It was in John’s upper left lung and it was wrapped around the nerves of his neck, causing pain and swelling. The workup soon showed that the cancer had spread from his lung to his brain, liver and ribs. No wonder the poor man had been in such severe pain! Next, they did a lung biopsy and, of course, it was no surprise that it proved the now obvious malignancy."

The retired doctor silently shook his head. "Your physician," Dr. Marshall began, "is supposed to be your advocate against pain and death. Seems as if your HMO considered even the basic chest X-ray a rationed luxury."

Ellen sipped more coffee and continued. "After a week in the hospital, the HMO wanted to discharge him, now that his kidney had started functioning again. They told me there was nothing more they could do for my husband but make him as comfortable as possible, that he only had four to six months left to live. Also, his mental status was decreasing daily. So a Hospice was called." Ellen’s eyes brightening for the first time since beginning this tale.

"Finally, someone listened to me, someone realized what I was trying to cope with. But unfortunately, no beds were available at the moment at the Hospice. So after much fighting with the HMO, they finally agreed to pay for a nursing home for a couple of weeks until a bed would be open at the Hospice.

"Obviously, the HMO had more or less washed their hands of him now that he was so deathly ill, undoubtedly due to their delayed diagnosis and wrong treatment! But the Hospice stepped right in and gave us a hospital bed and a commode, and all the medication we needed to keep John comfortable. And thankfully, they were there, too, with the emotional support I needed."

"Yes," the kindly old neighbor said. "It costs the HMO next to nothing to find an illness at the terminal stage. New Medicare monies kick in as the patient is declared likely to die within six months. And it is the kindness of the Hospice that keeps families from exploding with grief and anger that their loved ones have been treated so shabbily to end up there."

"That’s right!" she agreed. "Everyone is used. And yet you can’t even sue!"

The HMO is our nation’s most protected industry, Dr. Marshall thought, as he paused in reflection recalling why he retired early from the medical nightmare. Congress protects these supposed "Health Plans" as if they are foreign diplomats.

"Two weeks later," Ellen continued, "on January 20, 1998 John died."

"It was less than one year from the time he first went in to see the doctor at the HMO. All this while – up to December 21 – we thought he just had a back problem. Then, four weeks later, he was dead of cancer. It makes no sense to me, no sense at all!" she said dejectedly.

But more was yet to come. Mrs. Sanders related how the phone rang the morning of January 21, 1998, and she answered it. Surprisingly, it was Dr. Smith.

"Mrs. Sanders, I’m sorry to bother you at this time, but as John’s Physician of Record I need to fill out his death certificate. Can you tell me what the actual diagnosis was? What did he die of?"

In disbelief, Mrs. Sanders held the phone away from her ear and looked at it. Had she heard correctly? Had John’s primary doctor actually asked her what the cause of death was of her poor husband? Did he not have even the time and decency to look at the test results of the MRI and the X-rays first? What had the HMO done with them?

Ellen Sanders clenched her fists remembering that fateful morning as she described to her neighbor what she said to Dr. Smith when he called. "I just screamed at him. What! How dare you call me! How dare you have the nerve to ask me what my poor husband died of! You were his doctor! You were supposed to help him! He was in terrible pain! You ignored his symptoms until it was too late. You of all people should know what he died of!" Disgustedly she spat out. "He died of a pulled muscle!"


* * *

Quality medicine starts with good listening. Unfortunately, the art of listening is the first to go. When a patient first starts complaining of increased constipation, loss of appetite, a cough that won’t go away, or a headache that awakens the patient from a sound sleep, that ‘s the time the physician must care enough to be curious and have sufficient time to be thorough, in order to make an accurate diagnosis.

"That’s why we weigh the elderly at monthly intervals, looking for suspicious weight loss, " Dr. George Degnan, a popular medical teacher used to tell his residents in Martinez, California. "Every time a cancer is diagnosed, early or late, you should go back and quiz the patient as to their very first symptom. Reread the chart to find that initial clue. As a primary physician your job is about the discovery of that same type of cancer earlier in the next patient."

By coercing physicians to see inappropriate numbers of patients per hour, control of the quality of medical care is compromised. Yet these new masters of the physician’s time are never present in the same room to see how little get done in eight minutes. Those physicians who have drifted upward for their cleverness until the stethoscope in the pocket is replaced by a piece of chalk have forgotten – if they ever first knew – what is like to listen carefully to a patient.

One would assume that the discovery of a cancer early on would be in the best interest of a managed care budget, but that is not necessarily so. It is sometimes cheaper for the Health Plan to let a few patients develop cancer than to routinely test thousands for vague symptoms. This is particularly true if the managed care system intends to initiate only a brief attack on the cancer, before moving the affected patient early into a situation of hopelessness and, eventually, hospice.

This type of reasoning is reminiscent of some auto makers in the 1970’s who calculated that a few auto deaths were an expendable legal risk in moving a new model car quickly to market. Bottom line analyses often do not pause for ethical diversions. This appears particularly true when you are in the only suit-protected industry in America.

Realizing that patients tend to change Health Plans every few years, managed care saw that disease prevention did not really pay off, so the Health Plans felt free to simply speed up patient "care," delay testing, and otherwise slow down or dilute patient-physician interaction. Interference with this trust created a mangling of the profession and the art of medicine, hurting both patients and doctors, and enriching all the wrong people. The result has become a mangled mess.

Patient Enrollment

The patient usually enters into managed care as a series of choices connected with a job or through attainment by age with Medicare. For most workers the choices come up in the Fall. Three types of options are usually presented: an HMO - as the cheapest - offering to pay for all medications; a modified Health Plan with a wider choice of physicians but less help with medications called Point of Service; or a high-choice/high-cost Health Plan called Preferred Provider. Each step upward in choice ensures that more financial risk will fall to the patient. Often these are simply three "tiers" offered by the same insurance company, e.g. Aetna.

Comparison of benefits is often quite difficult for the worker. How many people have time to read through their insurance company’s hundred-page document of the official explanation of benefits, let alone try to determine how their own health will progress or decline in the future? Often the patient’s trust depends upon the presumed integrity of the insurance broker’s discussion with management. Changes are announced as the manager tells everyone about the trusting agent with the new plan choices at a general meeting. No one reads anything else.

Advertisements hit the media as deadlines for a choice of Health Plan approach. But eighty-three percent of United States companies that provide health care insurance benefits to employees, cannot -- or do not -- offer their employees a choice between two or more Health Plans ... rather only one option. And since by a strange federal law they must offer an HMO option, the employer’s favorite due to low cost to the company is often the single HMO choice.

Choosing a Doctor

Soon after the Health Plan is chosen, the employee is presented with a list of approved physicians working with that Plan. Most patients feel they have no idea how to choose a good physician from such a list. Many would first like to meet a prospective physician, find out about his/her medical competence, the physician’s philosophy, friendliness, etc. Some would think to ask how many patients are already on the panel – Medicare trying to limit one physician to 2500 and HMOs trying to boost the number to 3500. But patients learn that brief interviews are simply not available and the waiting time for an appointment is quite long for those physicians who are even taking new patients.

In the Spring of 2001 PacifiCare suddenly decided to save money by moving all of its HMO patients to a new group of physicians and a less desirable hospital. Suddenly 60,000 patients had only weeks to chose from a physician list sent to them. The list was actually two years old and very inaccurate. But the anguish of patients thus set adrift was of little concern to the HMO.

For those that do set up an appointment with the new physician, the patient has to decide whether this doctor will truly be an advocate for those enrolled in the practice. In the managed care system, however, the Health Plan attempts to shift the risk of a patient’s problems onto the doctor, by means of a system called capitation. The physician with the Health Plan is often on a fixed, per-patient capitated fee – perhaps $20 a month. Usually, the time allowed for an examination remains the same. So, when treating patients who are mostly healthy, the doctor at risk for cost will come out ahead. But with patients who have complex or major illnesses such as diabetes and hypertension, under the capitation system, the doctor will suffer a loss.

Changing Physicians

While in the past, a patient was often given thirty days to make an adjustment, the patient-physician relationship can now be abruptly severed. We are presently in an era of minimal caring, and a letter from a doctor to a patient being so dismissed can be as cold as this recent following example:

"Effective ten days from the date you receive this letter, I will no longer be available to provide you with medical care. This period should give you ample time to find another physician."

Ten days is hardly enough time to arrange for a visit with a new physician let alone schedule a physical exam with that doctor. Such a letter simply sends the patient into a panic. The patient might have a Managed Care Plan but certainly no friend or advocate within it. Perhaps ninety percent of the time, when a physician has moved out of a Health Plan, the administrators will simply pretend that provider has just disappeared. The Health Plan wishes ownership of the patient and considers

providers to be of as little importance as ink cartridges in a printer, easily replaceable parts. Patient loyalty to a provider is to be discouraged; loyalty to the Plan is key.

Now, back to the patient who is losing his physician. The letter quoted earlier went on to say:

"When you have selected another physician, I will, upon your written authorization, provide a copy of your chart or a written summary of it to the new physician."

One is left to wonder why the patient cannot have a copy of their summary sent with the letter? Unfortunately, patients are usually unaware they are half owners of their charts and have every right to have a copy of any of their records. Armed with their records, they could be prepared immediately to see any new physician. There is no requirement that records move only from physician to physician – this is a myth that is further perpetuated by such letters. In fact, patients carrying copies of their own records to the next appointment have the best chance of insuring a smooth transition of care.

And – at least in California – if a patient asks for his or her record, the physician has a maximum of two weeks, or ten working days, to produce the summary. Managed care companies ignore the two-week rule because patients do not know about it. It can take up to four months for them to transfer some records. Oddly enough, the choice of material to be copied is often made by a clerk rather than a physician. Often key records are simply not copied at all.

The physician’s letter finishes by explaining that the various options for coming to the office "may result in more than one visit annually." Actually, this will shift the time frame back onto the patient to come in for each separate problem, one visit at a time. The time off work, cost of transportation, etc., will fall to the patient. The managed Health Plan will simply save itself money as the patient (and sometimes the employer) loses time and value. Was this the vision of managed care Congress was in such a rush to protect?

The "Physical"

But let’s assume the patient has made an appointment, and has arrived for an initial, thorough exam. Managed care has altered the search for an illness that used to be called by the patient "my yearly physical." This medical event has proven much too expensive for most Health Plans. It takes too much time to complete, and when open-ended, tends to lead to a search for hidden illnesses that may end in costly referrals to specialists.

So not only has the time allocated for the physical exam been drastically shortened, the history taking has also been abbreviated. Many Health Plans use up the patient’s time rather than the doctor’s by having them fill out long history questionnaires while waiting to be seen. Few of these are read carefully. The old skill of developing a personal history as the professional art of progressive, probing inquiry by the physician has been all but set aside. The standard "review of systems" taught to every medical student, as a means to search for problems, has no value in mangled care.

In a form letter sent to patients in May of 1998, one physician went so far as to issue new rules for an office visit, which reads as follows:

"Routine Office Visit: For chronic condition – one or two problems per visit maximum" [message – don’t bring in a list of problems];

"Comprehensive Physical Exam: This type of visit is generally not covered by health care plans and I will no longer be offering them."

"Preventive Medicine Exam": Includes "a brief interview to look for obvious new problems" plus "age-appropriate studies . . . like pap smears," etc.

This letter is a cold summary of the new attitude forced by managed care. How much of a search is it to look for "obvious new problems?" Where is the interest in a subtle cancer invading from within a safe tissue boundary to a regional zone – a death march? How is the patient supposed to be trained well enough to decide when a nagging change in symptoms is worth triggering an "acute office visit?" Perhaps in the future, managed care will have to fit in a course in Self-Diagnosis somewhere in the high school curriculum.

Commonly during the "preventive medicine exam" there is no particular search for records; such an effort would result in the physician spending unpaid time reading. When the occasional outside record does arrive, often it is simply put in the patient’s chart and not read. So the patient’s forgotten penicillin allergy may well get buried and missed, or the test for a slowly rising cancer may never be seen until it is too late to be of value. Hopefully, the patient will remember all the important details and write them on the questionnaires. Since switching Health Plans should not be encouraged anyway, the most callus believe; it is hoped the patient will have learned a lesson by having to start over.

As the goal of the "physical" shifts in managed care to merely catching a handful of audit-sensitive cancers, there is no interest or time left to create the most important document of the yearly exam: a detailed summary of findings and problems. Following is a high quality sample summary now abandoned in managed care. It is reduced in size:

Health Summary Chart


While the writing of this type of summary is still taught residents in medical school, it is slowly disappearing. Such a summary used to be the goal of a physical: to redefine the many unique issues about a patient, perhaps one of which is the beginning symptom of a lurking new cancer.

The so-called "health" Plans no longer cover the comprehensive exam; Medicare and MediCal (the California form of Medicaid) does not even cover the preventive exam. Medicare has even taken the silly position that Pap smears in senior women are only needed every three years. The de-emphasis on health care comes from the top – from the planners of these Plans. The physician, trying to maintain a practice sole business, can now only follow the rules for which they are being paid.

The Patient Perceives a Medical Problem

Now, let’s suppose the patient has selected a personal physician as their supposed advocate – renamed in the business sense as a "primary provider" – and then one day an illness occurs. The patient experiences pain in the upper abdomen, vomiting, weakness, and inability to function. Luckily, the patient is in a Health Care Plan that has been prepaid, and can now call for the help.

However, calling for an appointment commonly gets patients a tape-recorded voice, a lot of music, a few ads about how great the Plan is, and a lot of waiting; perhaps even as long as an hour. Eventually the patient does get through. In the past, the person at the other end of the phone used to be a nurse, but an appointment clerk

now handles this duty. The advice nurse may be sitting nearby, but already has ten calls to return. An appointment may be suggested for five days later; however, the ill patient explains he needs to be seen today.

"Well, your doctor is booked," the appointment clerk says. "But if you can’t wait, I suppose you can come in to Urgent Care."

"Who will I see?" the patient asks.

"You’ll see whoever is available. Probably it will be a physician’s assistant."

"But my doctor just did my yearly exam and knows me."

"Your doctor is currently doing preventative exams these days and following up on a few chronic problems. He’s booked for days ahead and no longer sees hardly any acute visits."

At times like this one wonders what the goal was of having one’s own physician only to have to be seen by someone else when trouble occurs? And who is the best qualified to see a sudden problem – a physician’s assistant or a physician? The whole system is being turned upside down. The physician is used first during intake to get more Medicare money rather than being saved as a resource for urgent problems.

CIGNA Health Care of California has just issued a notice that Pap smears are not needed over age 65. Yet, 25% of all cases and 41% of all deaths come from this age group. Others allow only one test for every three years. But the standard of the American College of OB/Gyn is to keep doing Pap smears for life.

Preventative care has been designed around managed care audit criteria rather than patient need. Patients who are sick experience this as a terrible frustration. Picture a mother holding a screaming child who has a painful earache. Is she supposed to listen to taped music for over forty-five minutes while waiting to get an Urgent Care appointment at the end of the day? Immunizations may have gone up in managed care, but the outcome for the care of acute disease deteriorated.

The Emergency Room

Eventually the patient may in frustration end up going to the local HMO Emergency Room. But there too, more serious cases may experience a six-hour wait. Staffing is no longer volume sensitive. "Therapeutic waiting" is considered a deterrent to over-utilization of the Plan.

"We find that seventy-five percent of our patients are happy with managed care," is often the Plan’s reply to complaints. However, one is not told where the survey was done: in the mall or in the ER waiting room perhaps? Usually, surveys are taken back in the workplace where the happy seventy-five percent are the ones who never get sick and like low premiums.

At any given time, approximately only one-percent of the people in a community is very sick. (The typical emergency department experiences about one visit per day for every hundred people in the community). Therefore, if ninety-nine percent are happy with the care given that day, the system may still be failing completely the one who is sick. Try taking a poll of satisfaction in the HMO Urgent Care area. Better yet, try polling the ones who turn around and walk out of the area when they view the crowd waiting to be seen, and simply go pay privately elsewhere for care with dignity. A six-hour wait to see a strange doctor is uncalled for and unsafe medicine.

Tests Are Delayed

But for now, let’s follow the patient who is finally seen at Urgent Care. Once a problem is defined (often one look/one guess), some tests may be ordered. Managed care has learned early on to delay testing. The more expensive the test, the longer the line. A good example is the MRI.

The principle of a Magnetic Resonance Imager is that magnetic fields passed through tissues of different densities can create very accurate images. An MRI can pick up such subtleties as the tear of cartilage in the shoulder or the knee that even a CT Scan will miss entirely.

To delay the ordering of MRI’s a medical Plan need only have:

  1. rules as to who gets an MRI -- for example a patient with knee pain cannot have an MRI until at least one month after an X-ray has been done. This is because of a MediCal (California’s form of Medicaid) mandate;
  2. rules as to who can order an MRI – such as the physical medicine physician only ordering an MRI of the back.
  3. "If a significant trial of conservative treatment, such as supervised physical therapy and medications the patients has received, fails or is not clinically appropriate to continue, a referral to an Orthopedic surgeon or Neurosurgeon is usually appropriate prior to imaging." (Blue Shield Letter of 9/3/99)

  4. a contract with just one MRI provider, who they know closes at 5 p.m., aware that such an approach will force a line to develop for the volume of patients waiting (but let us again remember: the accountant is not practicing medicine);
  5. physicians graded according to the amount of MRIs ordered – and attempt to get rid of physicians who have supposedly ordered too many.

The sad fact is at many HMO’s meet all four of the above obstacles to care.

The Patient Gets Worse

In some cases patients get worse – often as a result of managed care policies and subsequent health loss -- and these patients resort to going to emergency rooms. Managed care has now tried to judge the necessity of the emergency room visit after the visit and testing is done. If the problem turns out to be simply stomach acid going up into the esophagus and causing chest pain, the Health Plans do not like to pay. Somehow the patient was supposed to "know" that this particular pain was not a heart attack.

Congress has had so many angry questions about this that they are busy, even as this book is being written, in forcing managed care to accept the "prudent layperson" standard as a new point of law. If the patient believes that the chest pain might be a heart attack, the patient has a right to emergency care.

Meanwhile, a number of states including Washington, Florida, and Ohio have not only required Health Plans to follow the "prudent layperson" approach but have imposed fines. QualMed, for example, was fined $250,000 by the State of Washington for denying one of every six emergency visit after the fact. When these denials were rechecked, state auditors said that half of the denials were legitimate reasons to go to the emergency room. Patients in the QualMed Health Plan became hesitant to seek care, fearing their claims would be denied. The emergency physicians turned Health Plan in to the state.

"Under the settlement, QualMed is required to pay the $250,000 fine to the Insurance Commission; pay all valid emergency department claims identified during the investigation; establish an emergency care claims quality improvement process; and change its contracts so that the health plan no longer has sole discretion to decide whether to pay for a claim."

EM 9/8/99 – a publication of the American College of Emergency Physicians

Luckily some physicians are willing to turn in those wishing to profit from greed.

Treatment is Downgraded

Perhaps the mid-level practitioner – physician’s assistant or nurse practitioner – can proceed with treatment without testing, or while waiting for testing to be done. However, treatment often opens up medication problems inherent in managed care.

For example, one physician in a managed care facility has noted that pharmacy costs for certain age groups are often far more than physician costs: "As a family doctor, I know that my prescription costs almost fifty percent more than I do," he stated.

This physician was part of a group in the State of Washington who contracted with an HMO to accept a certain amount of money every month with which to keep their

patients’ pharmacy costs. If the cost for the patients’ medicine was lower than predicted, the physicians could then keep the difference. If the cost was higher than predicted, the physicians would lose money. Within this arrangement patients with

high utilization of medication are called "pharmacy risk-patients."

The Admission Step

Once the emergency physician decides a patient should come into the hospital, that physician sometimes has a problem in convincing the admitting physician that admission is needed. Often, an admitting Internist, far removed from the scene, will try to talk the emergency physician into avoiding an admission by saying: "Can’t you just give him intravenous fluids all night in the ER and send him to my office in the morning?"

The fact that the admitting Internist has a full office schedule the next day to attend to without having had sleep that night might make him more reluctant to incur any additional work. Perhaps it might make a difference in his attitude if the managed care accountant who insisted on that overburdening schedule spent a night himself on a emergency room gurney and saw how little sleep occurs on such a duty.

Emergency physicians learn about the paramedic’s world by riding out with ambulances. Accountants might wish to do follow the HMO internist for a night to see what their tight scheduling creates. Triage is supposed to be the sorting skill in disasters. But every night HMOs force triage decisions on their staffs simply by understaffing all areas.

Critical Care Shortened – The Hospital Intensivist

The most expensive care given in a hospital is an admission to critical care. Even there in the Intensive Care Unit, managed care games are to be played. First of all, the HMO system tries to turn the hospital ICU physicians – now called "intensivists" - into employees without benefits. Intensivists were first paid a fee for each activity. But as budgets tightened, the intensivist was pressured to avoid the all-night struggles with life and death cases. The physician is supposed to be ready for clinic the next day, or at least by early afternoon. Those who are not salaried are "capped’ by tight budgets into the same time expectations. As most decisions come from above, the physician feels like he or she is working for a boss but getting no benefits. Thus the arrival of a patient with high acuity (multiple problems) equates to no sleep, and furthermore, 24-hour shifts of coverage ensure that fatigue alone will downgrade their decisions.

Additionally, HMO’s encourage these physicians into medical staff management jobs so they can be wedded with hospital administration, the latter knowing that each diagnosis has a preset, government reimbursement rate. The shorter the time spent in ICU the better the hospital does against a predetermined income for that case. Bonuses to physicians are illegal, but "sweetheart" reimbursements for uninsured patients are easily arranged in yearly contracts. Thus, the managed care pressures as well as hospital pressures act in synchrony to keep the intensivist focused on quick care.

Often the intensivist finds the solution to be in convincing the patient and/or family to believe that critical care is inherently painful. Then the patient’s right to abbreviate his or her own care is brought up. The intensivist does not directly influence the decision – that would be against federal law – but will often present ICU care as dehumanizing. The patient, worried about being a vegetable with tubes in all directions, or worse being in a state of pain without the ability to get pain medication, will sometimes opt for no critical care at all.

Critical care can also be abbreviated by lowering the skill level of entry nurses. For example, there was a case in a managed care ICU where the nurses tipped the patient the exact opposite from the medical order causing the patient to turn blue and be in need of resuscitation.

Nursing fatigue is also used as a weapon. Because of the sheer number of orders coming to them, and the amount of critically ill patients in the ICU for too few nurses, at times nurses almost feel ready to give up on a case simply because it has become overwhelming. The HMO nurse can herself or himself almost hoping for death of a patient because there are simply too many orders written to ever complete in the shift.

The Path to the Hospice is Accelerated

Hospices were originally developed primarily as a way to try to give cancer patients and their families a caring focus in the final days. Those attracted to work at hospices have been unusually caring people who understand that death is the next adventure, that pain control is the key, and that these are people with cancers not just cancer cases.

But managed care has found that an early referral of a sick patient to hospice saves money. The cost of a day on chemotherapy might be five times the cost of a day interacting with hospice. One emergency physician working in an HMO called the Oncologist (a specialist who focuses on cancer care) at the same facility and the conversation went like this:

"Dr. Olsen, I’m Dr. Jason in the emergency room. We just checked a blood count on one of your patients receiving chemotherapy. His white blood count is so low from the chemo that he should probably be admitted to protect him from infection."

"Don’t bother admitting him. He’s at the end of the line with chemo anyway. Tell the family that it did not work and that they should contact hospice."

The ER doctor thought that was a strange decision. The easy answer to chemotherapy causing a low white blood count is to simply reduce the dose of the medication. It was hardly a reason for giving up.

But should public anger fall to the HMO oncologist? Typically the physician is often assigned a large pool of patients, numbers set by accountants. Since each cancer patient usually has four to five separate illnesses going on at the same time, they do require a great deal of care. The overworked Oncologist soon begins to feel trapped and wonders if he or she will ever get home again to see his or her own family. The pathway for the Oncologist to get out of this dilemma is to give aggressive chemotherapy, and then channel patients into hospice when medication complications become too time-consuming. In the managed care system, the physician is then rewarded for supposedly being "productive."

Hospices will welcome the new patient regardless of the diagnosis. It is not the job of hospice to review the medical chart to determine if all treatments were tried. It is only for the hospice to ease the burdens of all involved, patient and family, also unwittingly easing the burden of the health Plan fiscal officer as well. The case will never go for medical review. The very caring nature of hospice makes the family’s transition into defeat seamless.

Net Savings Are Sent to the Top

The original gleam in the eye of Dr. Ellwood, who coined the term HMO in 1973, was that the various savings would be redistributed among the patients. Immunizations would take off under managed care. Efficiency would create more care. That was also the false dream of Communism – from each according to his ability and to each according to his need. But in managed care as in Communism the transition phase – the dictatorship of the proletariat – never ends. In the Kremlin, the monies saved go to buy fancy cars and vacation dachas for the Communist elite. In managed care, riches flow up not down.

The salaries of the managed care executives at the top of the "food chain" have made both patients and physicians angry. The numbers are displayed in the chart next following these comments. Note that the top executive made almost $5 million in 1998.

Actually, the top eight executives in many of the same companies found this to be a drop from the 1997 compensations – nine exceeding the $5 million mark (AMA News October 5 1998 – page 34).

Source – Court, Jamie, and Smith, Francis – Making a Killing – page 105, Common Courage Press 1999


Meanwhile physician net incomes were reported to be dropping – the median income going from $166,000 in 1996 to $164,000 in 1997. Doctors experienced the losses often as unpaid time spent on the telephone trying to battle with some distant pharmacy technician over the necessity of a medication. As often happens in managed care, time is used as a weapon against a caring physician.

Interestingly, HMO Chief Medical Officer compensations were going the other direction and topping $200,000. The AMA took note that many of them were making management decisions for patients in states in which they were not licensed. Another appropriate goal of the AMA is to insist that a managed care medical director is licensed in every state in which he or she makes decisions.

Not uncommonly the managed care systems promote executives even in the face of losses. Just as Kaiser was publicly rending its garments over a $266 million loss for 1997 and a $127 million loss for the first nine months of 1998, it promoted four senior managers to newly created executive vice presidential posts. One would think that losing money at the bottom - too many bonuses perhaps – would translate to pruning at the top.

The Denial Letter

The biggest loss to a patient is when an admission to a hospital is denied while the patient is lying in the hospital bed. Here is a typical letter that arrived from PacifiCare to a patient who is about 88-years-old. Could this be an age-biopsy report?

"Dear Patient:

The purpose of this letter is to inform you that Priority Health Services has determined that the care proposed for you at ________ District Hospital Skilled Nursing Facility does not meet PacifiCare guidelines for skilled nursing facility care. This determination was based upon our understanding and interpretation of PacifiCare coverage, policies, and guidelines. We recommend you discuss with your attending physician other arrangements for any further health care you may require.

If you choose to be admitted, [the patient had already been admitted after a stroke and was still confused, working with physical therapy to regain her ability to walk] you will be financially responsible for all services provided to you by this facility beginning (date). [The author of the letter did not even have the intelligence to write in the date.] If you believe the determination is not correct, you have the right to request a reconsideration"

A panicked family, as well as a non-profit small town hospital, is now facing fiscal disaster. The whole process enters appeal. Interestingly, "… the highest incidence of [complaint] referrals per 10,000 customers during 1998 was PacifiCare with 1.7461, nearly double the overall average."

(According to the Department of Insurance of California as reported in the Fresno Bee 8/30/99.)

So, is the letter of denial really about this patient, or is it about warring accountants from Washington, DC to California’s Orange County to Fresno trying to squeeze a buck out of a senior citizen. Managed care like multiple sclerosis just strikes one patient at a time. But nevertheless managed care can be a vector for health care damage. And for many families it is the beginning of financial ruin. In fact, about 50% of current bankruptcies are triggered by health problems, the latter often combined with health care plans that do not pay up promised benefits.


Managed care is mangled care. Patients start into managed care with dreams of being cared for compassionately. They find themselves listening to music, talking to machines, forced into inadequate physicals, seeing mid-level practitioners when they get an acute illness, seeing total strangers when they are hospitalized, being encouraged to avoid intensive care, invited into giving up through hospice, and all around devalued. It is a serf versus castle feeling. And the anger is growing.