Not What The Doctor Ordered
(Page 3 of 6)
Like so many doctors, Dr. B. was not at all worried when patients began asking him to join their HMOs and PPOs in the mid-eighties. He was happy to oblige. “I didn’t want to lose my patients,” he says simply. Back then, it was easy to join managed-care organizations: The doctor requested an application from an insurance company, filled it out, and mailed it back. Though insurance companies went to great lengths to convince their clients that they painstakingly selected the doctors for their plans, this was not exactly the case. In those days they were building their networks of physicians, so they were willing to take almost any doctor in good standing. And because of the shrinking pool of desirable patients—those on reimbursement plans—most doctors were more than happy to join up. Once accepted into a plan, doctors signed a contract, their names appeared in the network directory, and the phones began to ring.
Whether through ignorance or arrogance, Dr. B., like many physicians, did not read the contracts carefully. He did not note the clause that stated he could be fired at any time for no reason. He paid even less mind to phrases like “Physician shall provide only that level of care which is Medically Necessary,” which, besides its ambiguity, might be considered at odds with the Hippocratic oath, as he understood it, to do all that is medically necessary. Like many physicians, Dr. B. saw the contracts as bureaucratese that didn’t apply to him. The idea that an insurance company would dare tell him how to practice medicine never crossed him mind.
The Gatekeeper
IN THE BEGINNING, the insurance companies had wanted him to feel important. They had given Dr. B. a new title: gatekeeper. It made the corners of his mouth tighten every time he heard it. The age of the specialist had drawn to an expensive close, he was told. No longer would family practitioners be sneered at as medicine’s poor cousins; now they were needed to bring order and common sense to a chaotic system. Under managed care, the primary-care physician—the companies’ term, not his—is restored to primacy. This does not mean a return to the Norman Rockwell-style family doc who knew his patients so well he could sense whether they were really sick or simply in need of a sympathetic ear. In the new era of managed care, general practitioners, internists, pediatricians, and the like are the first line of defense in the war on cost. It is the gatekeeper’s mission to prevent what the insurance companies consider unnecessary care. This might mean discouraging access to specialists, tests (“Are the tests ordered needed,” posits one set of Aetna guidelines, “or are they a response to our legal friends?”), and sometimes the gatekeeper himself. It would take a while before Dr. B. understood his new role: He was no longer a healer; he was a traffic cop.
At first he had only a few patients on such plans, so his practice didn’t change much. The funny thing was, one of the first differences he noticed was in his wastebasket. It was always full. Every plan had a different system of procedures and a different set of hospital and lab affiliations, all of which seemed to generate a constant and ever-increasing paper flow—memos, forms, reminders, reports. Dr.B. found he needed more and more shelves and files to accommodate the change. Before, there had hardly been enough paperwork to occupy a receptionist-secretary. Now he had to hire a full-time administrator with more expertise in managed care than patient care. In five years his overhead doubled from 30 percent to 60 percent of his income. This is not cost savings, he joked to himself, but redistribution of wealth.
As he joined more and more plans, he began getting visits from insurance company “referral specialists,” who were paid to show him how to run his office according to the companies’ needs. They left little to chance. One company, for instance, went so far as to provide checklists for items that should be on hand in his office (as if he needed to be told to keep thermometers around) and ways to make office work easier (putting stickers on a patient’s chart when allergy symptoms are present). One handout even suggested what questions to ask a patient during a physical exam and how often to check blood pressure and cholesterol. “A high school student could do this,” Dr. B. thought to himself. “What do they need me for?”
Over the same period, he also began to notice a change in the patients who came to him. Before, his practice depended on his reputation; his patients had always been referred by another doctor or another patient. Now patients found him through “the book,” the provider directory they received at work. In cases where patients failed to choose a doctor themselves, companies often assigned one. This change in doctor selection was small but profound. The emotional power of the doctor-patient relationship was being diluted. If you didn’t know your doctor—and your doctor didn’t know you—one physician certainly would be as good as another.
Dr. B.’s patients were becoming strangers to him. Around midnight one Saturday, for instance, he received a call from a woman he had never met. Yet she insisted that he was her physician. The insurance company, she told him, had assigned him to be her doctor. She complained of dizziness. What should she do? Dr. B. listened and asked a few questions. He stared at the phone and sighed. “I think you should go to you nearest emergency room,” he told her. She could have had anything from the flu to a stroke—if he had been familiar with her medical history, he might have been able to make arrangements that would have been less costly and less time-consuming for the patient. As he hung up the phone, the woman’s voice returned to him. “What should I do? What should I do?”
“How the hell should I know?” he wanted to scream.
By 1990 the needs of employers to hold down health care costs had radically changed his practice: Three quarters of his patients were now affiliated with managed-care plans. It might as well have been 100 percent—like it or not, he had become an employee of the insurance companies. Dr. B.’s practice, once a mixture of science, art, and simple good sense, had become more and more standardized. After each patient visit, he submitted a bill to the company, showing what he had done. Long ago the forms had been formatted for the convenience of the insurance companies; every possible condition had a code that had no medical significance (460 was for the common cold; v65.5 was to be used to identify a “patient with feared complaint in whom no diagnosis was made”). More and more, a sense of paralysis would come over Dr. B. whenever he had to fill out the forms.
Ever so gradually he was beginning to weigh the needs of his patients against the money he was getting from the insurance companies. Dr. B. received a fixed amount per patient for those in some plans or a fixed amount per visit for patients in others. In either case, he was rewarded for what he didn’t do. Say he got $30 a month for a given patient. If the patient needed a gynecological referral or a complete blood workup, those costs were charged to Dr. B.’s “account” and were subtracted from the pool of money he was to receive at the end of the year. The less he saw a patient—and the less he did for him—the more of the original pool of money he received. In essence, the most valuable patient was the one who never showed up. Dr. B. practiced conservative medicine—he discouraged the use of antibiotics in his patients and was never afraid to prescribe old-fashioned home remedies—but what happened when a patient got AIDS or cancer? What was he supposed to do with the patients who had come to him in middle age and were now facing the more costly problems of the elderly? Giving too much attention to any of these people could result in what Dr. B. called “a bad report card”—monthly mailing that rated his economic status according to the insurance company’s expectations. If he was branded a “high utilizer”—insurance company parlance for “too expensive”—he risked being dropped from a plan. Did he do good work or bad work? Were his patients on the road to recovery after seeing him? There was no code for that at all.
Money was not the only problem. There was, for instance, privacy. One patient came in complaining of allergies, but in talking with her, Dr. B. could see that she was troubled. He probed a little and unleashed a flood of emotion. Sobbing, the woman explained that she was despondent over her breakup with a lover. She also hinted at a history of child abuse. Dr. B. knew the woman needed help for more than a runny nose, but to refer her to a psychiatrist meant not only that he might be penalized for a referral but also that Dr. B. would have to get on the phone and describe the woman’s past in detail to an insurance company clerk, who would then decide whether the insurance company would pay for the woman’s psychiatric help. Information that was once sacrosanct would then become part of some corporation’s records. Why was she depressed? The clerk would want to know. What was her sexual history? Her sexual preference? Dr. B. could not bring himself to make the call.
He billed the insurance company for a $29 office visit. Though he advised her to see a specialist, he did not give her a formal referral, and he did not code her bill for mental health care. He had to cover his tracks.
