Mismanaged Care

by Suzanne Gordon

The Nation magazine, December 7, 1998

Last summer, Democratic efforts to establish a so-called Bill of Rights for patients in health maintenance organizations died in the House of Representatives. With the Democrats' gain of five House seats-the same number they would have needed to pass the measure-the issue of regulating HMOs is alive again, with dueling Democratic and Republican bills likely to emerge soon. So now is a good time to reflect on the wisdom of addressing our healthcare crisis through a narrow strategy of grafting a "bill of rights" onto a corporatized healthcare system. How can we have a patients' bill of rights without a healthcare constitution?

None of the current proposals address the problem that has plagued our healthcare system for decades-access to healthcare services. Just a few months ago, the number of uninsured Americans commonly cited was 42 million. But that figure is now yesterday's news. The Census Bureau recently announced that in 1997 alone, the number of uninsured Americans jumped to 43.4 million-that's 16 percent of the total population and substantially higher when people over 65, who are usually covered by Medicare, are not counted in the total.

Not only do HMOs fail to alleviate this problem. They are making it worse. Over the summer, a number of for-profit and nonprofit HMOs revealed that they were dropping Medicaid patients, and in October many announced that they were cutting off tens of thousands of elderly citizens covered by Medicare. No state or Congressional bill of rights restricts HMOs from dumping the patients they thought would be lucrative but who prove unprofitable. (Big surprise: They're sick and/or poor.)

The proposed legislative remedies promote the notion that streamlined appeals procedures will inhibit HMOs from denying patients needed care. But design flaws in an increasingly profit-driven system cannot be corrected by more efficient appeals systems. These procedures embrace the barbarous practice of asking sick people-and their families-to fight for care when they are most vulnerable. They also reinforce the managed-cost (for God's sake, let's start calling it what it is) conception of sick patients as irresponsible healthcare over-consumers whose nasty habits must be regulated.

As for the "consumer information" these bills supposedly guarantee, much of it is either useless or unusable. Supposedly, by allowing patients to find out how their providers are paid, the new provisions will protect them from HMOs' "full risk capitation" arrangements, which reward doctors, clinicians and healthcare organizations financially for denying care. But revealing how providers are paid doesn't eliminate this pernicious practice. And say you manage to wrest needed treatment from a doctor whose first question about the horrible headache you've had for two weeks is, "What's your insurance?" Despite the temporary victory, something crucial has been sacrificed. That's trust-the trust that patients should have in doctors, nurses, psychologists, social workers and others in healthcare.

Finally, legislators say they want all patients to be able to choose their primary care doctor and to be reimbursed for necessary emergency room visits and specialist consultations. Important as these provisions are, they still leave us saddled with one of the main abuses of managed care. To cut costs, HMOs are shifting the burden of caring for the sick from their staff end provider networks to patients themselves and their often ill-prepared family members. HMOs do this by reducing the length of time patients are permitted to stay in hospitals and forcing them to undergo many complex medical treatments in clinics, outpatient surgery centers or at home. Even the Democrats' effort to allow patients having mastectomies and breast reconstruction surgery to stay in the hospital, or to give other patients the right to appeal HMO denials of medically necessary care, will do little to stem the increasing dehospitalization of the acutely and chronically ill.

Because we are stuck with mismanaged care, it is important to try to regulate the industry, but all regulatory efforts should be strategically linked to the goal of universal healthcare. Some regulatory proposals rightly target the ERISA loophole, which allows insurers to evade any legal and financial consequences of the medical decisions they impose on patients and clinicians and prevents states from experimenting with new methods of financing care for all. But legislation should also halt the conversion of nonprofit healthcare institutions to for-profit status, ban any capitation arrangements that reward clinicians for denying care and mandate that all decisions about admissions to hospitals (or other healthcare facilities) and length of stay be made by doctors, nurses and patients-not mismanaged-care bureaucrats.

It is time to turn the struggle for healthcare reform away from pseudo-rights and to reinvigorate the battle for the healthcare constitution this country has lacked for so long. There are currently a number of different proposals for setting up a tax-supported universal healthcare system-including expanding Medicare for all, establishing a Canadian-style single-payer system and pooling all revenue from multiple payers and using it to entitle and cover everyone. What we should be discussing is how a universal system would be financed, how care would be delivered, how clinicians would be paid and educated and how true collaboration, coordination and evaluation of care could be achieved. And until we get our healthcare constitution, let's drop the pretense that we have any meaningful "rights" in this market-driven, managed-cost system.

Suzanne Gordon writes about healthcare. Her most recent book is Life Support: Three Nurses on the Front Lines (Little, Brown).

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