President's Message
Managed Care And The Future Of Medicine
N.H. Tucker, III, M.D., President
From this physician's perspective, capitation has conflicting incentives. A physician is given economic incentives to give less care, and the unscrupulous might fall into this trap. Fortunately, most physicians are ethical, give good appropriate medical care, and as a result tend to "bail out" a bad system. I predict capitation is not a permanent fixture.
Managed care discounted fee-for-service has its problems. It can be intrusive, arbitrary, and promulgate poor medical care. The various patients' rights bills before the U.S. Congress are attempting to address some of these problems by prohibiting "gag" clauses, by allowing better patient access to emergency care services using a prudent layperson definition, by setting up an external appeals process, by making health plans legally accountable, and by requiring health plans to fully disclose what they do and do not cover as well as provide comparative information so that patients can make informed decisions. It also makes sense for physicians to have a due process procedure before they can be terminated from a managed care panel.
Paul Ellwood, generally felt to be the father of the managed care movement, has recently been quoted as saying that he is disappointed with managed care. It has not lived up to his expectations. He felt that quality would be the primary market force determining which plans were successful. However, as we all know it is cost, not quality, that usually drives the managed care industry.
Physician concern in dealing with managed care has resulted in the strength-in-numbers approach. We have seen a proliferation of physician-physician and physician-hospital organizations as manifested by MSOs, IPAs, IDOs, PHOs, and enlarging physician groups. We have also seen hospitals and physician practice management companies (PPMs) acquiring physician practices, but this trend seems to be waning.
Frustration with managed care has led to some support for physician unions. Unfortunately, unless a physician is employed by a non-physician corporate entity and is in a non-supervisory capacity (i.e. in residency training or possibly those employed by the state), a physician union is no better equipped to "bargain" with managed care entities than any other physician organization including the DCMS, FMA, FPA, and the various IPAs, MSOs, etc. All of these organizations can bargain on quality but none can directly bargain on monetary issues. All can bargain monetarily using a messenger model. In this model, a third-party messenger speaks individually with each and every independent physician or independent physician group belonging to whatever organization the messenger represents. The messenger then relays this information to the managed care organization which can then accept, reject, or counterpropose. At no time while the bargaining is taking place are the independent physicians allowed to directly talk to each other about the actual fees being discussed. This process is cumbersome and usually ineffective. To rectify this, a number of medical organizations, including the DCMS, FMA, and AMA, have been seeking legislative relief from the antitrust laws and a bill has been proposed in the U.S. Congress (Campbell) that would allow the formation of "collective bargaining units". These bargaining units would allow independent physicians to collectively and directly negotiate on all issues with managed care and insurance entities.
Some have suggested that once patients, physicians, and the American public tire of managed care, the next step is a government single payor universal health care system—i.e. national health insurance similar to the Canadian Health Care System. In the past, at least one of our medical organizations has endorsed this approach but at present all are quiet on the issue.
We need a better mousetrap. It would seem that the perfect health care system would please patients, providers, and payors. I certainly don't have the solution but would tend to favorably evaluate a universal health care system (multipayor as opposed to single payor) in which patients had freedom of choice. Funding sources would include employers, government, and individuals. Regardless of the funding source, patients would 1) choose which high deductible catastrophic health insurance policy they would purchase, and 2) would have vouchers to spend on the health care they determined best for their health needs. The value of the vouchers each patient received would be disease and severity stratified. Patients would manage their own care and the redtape mountain would shrink.
I welcome all comments from the DCMS membership as to what that "better mousetrap" might be. Who knows? Jacksonville might be the incubator for the next health care revolution.