Managed Care: Another Biased, but Educated, Opinion

Dr. Charles Simpson ("The Truth about 'The Trouble Ahead'" in the 6/5/95 issue of "DC") raises several counterpoints to the series of articles on managed care written by Dr. Arnold Cianciulli. However, I think a recitation of the raw facts shows that Dr. Cianciulli has the better insights by far. I don't wish to offend Dr. Simpson, but perhaps by mentioning just a few salient points your readers will gain some understanding of what we are being sold.

Dr. Simpson cites, " ... the lack of comprehension of managed care." The truth is that those who comprehend it most, like managed care the least.

Dr. Simpson does, " ... not see himself as an apologist for managed care." But the whole substance of his article is apologist in nature and tone.

Dr. Simpson " ... participates in a number of managed care organizations, both as a provider and as a manager." Here lies one of the most important points overlooked by Dr. Simpson: it is the providers (and patients) who lose in managed care, and it is the managers who win. As a manager in some managed care plans, of course he likes them because he is getting financial remuneration from them. Every single doctor (MD, DC, DO) I've ever heard praise managed care plans (admittedly it is a small number because very few praise them) was not just a provider, but like Dr. Simpson, also either a salaried reviewer or other employee; a plan manager; an independent contractor being paid for nonclinical services to the plan; a paid consultant; an early supporter who helped market the plan; or an investor or shareholder in the plan. They have heavily profited by the plan, and are not simply providers of care like the rest of us. Given that scenario, do you think their treatment plans are reviewed like yours and mine? Do you think you'll get the same referral opportunities, etc., or do the managed care people give preferential treatment to their own?

Dr. Simpson states that " ... market forces are a far more powerful determinant of value." True enough, but the concept of managed care is diametrically opposed to the free play of market forces. Laissez-faire, free marketplace choices are antithetical to the forced control of managed care. "Managed care" and "managed competition" are contradictions in terms when discussing free market economics. Nothing can change the facts that the only ways for managers to "cut health care costs" are to either forcibly reduce provider fees, or to reduce/ration care to the patients.

The managed care plans smugly reduce the visits and services and doctors' fees, telling doctors to "make it up on volume." Even in the downsizing climate of the '90s, very few factory workers would accept this "work harder, make less" ultimatum. They also tell doctors that they will have access to a new base of patients who had no chiropractic coverage before. What they don't tell you is that they will also do their damnest to lure employer groups and "carve-out" the chiropractic benefits from existing indemnity plans so that your total patient base will become smaller and you will be forced to accept a fee much lower than free market, supply and demand, usual, customary, and reasonable.

Dr. Simpson says, "The growth of managed care proceeds not because of some sinister agenda on the part of the medical-industrial complex, but because customers search for ... and purchase ... value." This too misses the point because the "customers" who purchase managed care plans are not consumer-patients who are well-informed or who even had a choice, but rather employers looking to reduce the costs of their employees' health insurance fringe benefits. Anyway, no one ever blamed the "sinister agenda of the medical-industrial complex" for managed care; if there is a sinister agenda at all it is that of the insurance industry, notably the top five. Remember that it was hundreds of smaller insurance companies that fought the Clinton plan; the top five would have been granted a monopolistic concentration of powers. Can anyone call this a "free market economic choices"?

The actual impetus for growth of managed care proceeds from two simple facts:

1. The insurance industry has learned that it is much more profitable for them to sell managed care plans than the traditional major medical or indemnity plans.

    

2. The insurance industry has learned that it is very advantageous to become chartered under the federal HMO guidelines, thereby escaping the jurisdiction of state legislatures and the state insurance commissioner who formerly protected the public from abuses by the insurance companies.

I'm reminded of an ACA brochure a few years ago that headlined, "Get on the Managed Care Train or Be Run over by it!" Is that a free choice, or a threat against your right to practice? If managed care is so good, and there are no unequivocal studies that say so, then why must it be shoved down our throats as the only way to deliver care? No one is suggesting that we bemoan the past, but surely we will be unable to create other better delivery models if we are forced to accept managed care as the only model ever to be allowed again.

If managed care plans are such an ideal model, and so very advantageous for all, why are the providers contractually banned from saying anything negative or critical about plan administrative details or problems, and not allowed to even discuss fee schedules? Many doctors desperately try to join as many plans as they can and don't read the fine print. I suggest you look at yours closely because many do forbid any criticism and actually require you to surrender your constitutional right to free speech as a condition of being in the plan. Some doctors have been thrown out of plans for raising constructive criticisms or complaints, and they are then branded by plan managers for not being nice, quiet, obedient "team players." But their career track record often speaks otherwise. They were known as good team players on teams of their own choosing. Why did they have to be silenced? How can this veil of mandatory secrecy be good for the American public? If managed care is so good, why is it so afraid of honest public discussion and open disclosure?

I could go on, but for the sake of brevity will end on this final note. There are billions of dollars flowing in U.S. health care, which will not change much, but it can be shifted from group to group as Dr. Cianciulli observes. The myth of the rich, greedy doctors has been deliberately perpetuated. Who benefits? Did it originate from an element of jealousy or envy? Doctors make a lot less income, and I think do a lot more good for people than attorneys (can you imagine an outcry for managed legal services?), entertainers, media people, big business executives, politicians, professional athletes, insurance industry executives, and managed care plan administrators.

Who benefits when doctors' incomes, independence, judgment, autonomy, and financial motivations are greatly reduced?

Speaking directly from the patient's viewpoint, given that there is plenty of money flowing in the system, would you rather have the doctors be satisfied with their working conditions and professional incomes, or should the managed care plan and insurance industry seize control, keep most of the money, and manage your care their way instead of your doctor's way?

Rand Baird, DC, MPH, FICA, FICC
Torrance, California