by Alan Lindemann, M.D.
Whenever I see or hear the term managed care, I cringe. Health maintenance organizations (HMOs), insurance companies, Accountable Care Organizations (ACOs), and Medicaid are all examples of this type of health care delivery. These managed care entities exist to make money by controlling what you get as patient care and dictating who will be your health care provider. The intended public relations implication is that there are so many excellent health care providers locked into one of these managed care organizations, why would anybody want to seek healthcare from someone outside the organization? So much for choice.
Patient Choice has Disappeared from Health Care
Let’s face it. Informed consent has been transformed into “managed care.” There are six ethical principles involved in informed consent. Two of them rely upon choice, patient choice, the ability to choose your health care provider and to choose your treatment.
A 55-year old female presented with chest pain and severe aortic valve stenosis. She is on Medicaid. Recently Medicaid changed insurance plans without asking or even telling this patient. She had had a run-in with two surgeons at Clinic B, so we made an appointment for her at Clinic A. The patient then got a letter from Clinic B telling her she couldn’t go to Clinic A. In addition, she was told in this letter that she could only go to Clinic B.
The patient went to Clinic B, where she was assigned to the two surgeons she didn’t want to see. These two surgeons told her they would think about doing her surgery and give her an answer in one month. Or they may decide to not do the surgery at all, in which case their suggestion was that she simply go home to die. Delay and denial is a widely recognized cause of unnecessary deaths.
This patient is essentially enrolled in an HMO even though she is on Medicaid. HMOs will prevent patients from seeing any doctor outside the HMO for any reason. These two surgeons should have found her a surgeon for referral, even if that surgeon was outside the HMO. Furthermore, the patient can seek a surgeon outside the HMO on her own, but she is not advised of this by the surgeons or Medicaid. Medicaid would still have to approve the surgery, but if the surgery was not available within their HMO, Medicaid could approve the procedure with different surgeons.
As I discussed in “What Ever Happened to Informed Consent,” there are six ethical principles comprising informed consent. Two belong to the patient:
1. Comprehension, which the patient had, and
2. Voluntariness, which was lacking in her situation.
The last four ethical elements belong to the physician:
1. Beneficence, the desire to do good for the patient, in this case the obligation to help the patient,
2. Non-maleficence, the desire to do no harm to the patient is missing,
3. Justice, the act of balancing the competing interests of patient versus hospital or insurance,
is missing, and
4. Autonomy, the provider’s task of allowing the patient to choose her own care, is missing.
Certainly the two ethical principles which apply to the patient’s choice are missing, so there is the moral dilemma where these actions are legal but certainly not ethical. So everybody except the patient gets what they want.
Physician Choice has Disappeared Along with Patient Choice
This loss of informed consent is not a new problem. Thirty years ago I wrote about what happens to patient care when it becomes “managed” for them. This is one of the narratives I wrote for Modern Medicine: What You’re Dying to Know. The medical costs will seem low compared to today’s prices, but these numbers are from 30 years ago. What hasn’t changed, but in fact has simply gotten much worse, is the inability of the patient to make decisions about their own health care.
Story: “Managing” the Overuse of Technology
The overuse of technology is proffered repeatedly as a major reason for the high cost of our medical care. Instead of dealing with preventing every street corner clinic from buying CAT scanners or preventing expensive tests from being repeated every time a patient goes from one physician referral to the next, the powers that be have declared war on preventive tests like Pap smears and PSAs. It’s considered cost effective to deny women a PAP smear every year instead of controlling the number of MRI machines in a square mile radius. This does not save money, but it surely degrades the quality of the health care of every one of us.
The husband of one of my patients has no high school diploma and no GED diploma because he believes he cannot do the required math. He works irregularly at various minimum-wage jobs and hence has no opportunity to enroll in any health insurance program. His wife, my patient, also works for minimum wage as a cashier in a convenience store which offers its employees no health insurance benefits (often the case with minimum wage, part-time jobs).
Since she has a progressive, hereditary degenerative disease of the connective tissue, she would have difficulty getting health insurance under any circumstances. She and her husband make too much money to be eligible for Medicaid, and even if her state offers high-risk health insurance for people ineligible for regular insurance, she could not afford it.
This couple is typical of the over 35 million people in this country that have no health insurance. Since they have no regular doctor and no insurance, like many people in their situation, they rely upon the emergency room for their medical care, and resort to it only when they cannot avoid the problem any longer.
Not long ago the husband had severe abdominal pain and went to the emergency room. He was sent home and told to take Mylanta. Two days later he returned to the emergency room with the same complaint, and was again sent home and told to take Mylanta.
Finally, on the third visit, he was referred to a surgeon. The surgeon performed two CAT scans at a cost of $612 each (we find ourselves wondering why two were needed, or even one). The surgeon diagnosed this man’s problem as an umbilical hernia, a fairly common and generally non-life-threatening condition. A condition that hardly requires two CAT scans to diagnose. A condition that can very simply and adequately be diagnosed with a manual examination.
This family now has a $6000 medical bill which they have little if any hope of ever paying. A large part of that medical bill is not their fault, since the emergency room staff sent the man away without being able to diagnose his problem, but nonetheless felt free to charge him emergency room fees every time he came back. For some reason, he has also been given two CAT scans for a condition that should have been diagnosed without even a single scan.
The surgeon was probably a member of the clinic staff, and hence would be paid by the clinic regardless of whether the clinic got paid. The hospital and clinic, however, are now hounding these people to pay a bill they cannot afford. The collection office has now started calling this woman at work and harassing her about payment of her husband’s bill.
What are this family’s options? Well, the woman could get herself fired and go on welfare, which she is too proud and too honest to do. She and her husband have no way of knowing that they were subjected to a lot of unnecessary charges by the doctor and hospital, and have no means of negotiating the bill down for the expensive and unnecessary care they received. This family’s only apparent alternative is to literally disappear, pull up stakes, and move on to another area and start over.
Time to Remove the Middle Managers From the Physician-Patient Relationship
After all these years, the story for my current patient is little different from my patient 30 years ago. Since my current patient is on Medicaid, we have county, state legislators, and social service standing by condoning the lack of informed consent and the patient has no recourse.