It's Access, Stupid

E. Rawson Griffin, III, M.D.,
President of Clay County Medical Society

 
Everybody now complains about managed care. Doctors and patients alike are frustrated and fed up with the problems created by managed care. However, to talk to physicians and patients alike, you would think that the main problem with managed care is their refusal to pay and the economic disincentive that they provide to render care. Many physicians feel that basically managed care does not want to pay for quality care. This is done sometimes by putting the doctor at financial risk. Physicians in the past have not been knowledgeable about what the patients could really afford or what health care cost. So when they agree to take financial risk, they were doing so with less than the best information. However, in my judgment the real problem with managed care is that managed care has devised a method in which they refuse or limit access for medical care, so it's really the access that is the issue.

One of the biggest problems primary care offices have is in providing referrals to the patients to receive specialty care, durable medical equipment, and hospitalizations. Primary care physicians primarily provide an administrative function in doing this. They are required to call the insurance company and go through a myriad of administrative paperwork in order to notify the insurance company that a patient requires specialty care. Almost never is the care actually refused as recently evidenced by United Health Care's recent decisions to not require pre-authorizations for specialty care, as in the long run, the patients eventually needed the care.

In my judgment, the main reason that manage care companies require referrals is two fold. They are able to get the data that a patient is going to see over to specialist long before the patient sees the specialist; therefore, they can project their financial data, their financial costs, weeks or months ahead of time, which to their mind gives them some type of competitive advantage in the marketplace when they bid on contracts and try to get increased market share. By having some concept to what the total cost are in advance, they can manipulate the premium to employers and hopefully get more business. The second reason that they place these burdensome administrative requirements on a primary physician is to basically limit the access of the care of the patient. If the patient has to wait, sometimes the problems go away. The patient would not want a referral or would not use the referral, and the more hassle there is in getting a referral is a great disincentive for the primary care physician that actually provided the care for the patient. The government is also restricting access in a similar fashion by restricting the amount of physicians that are trained by reducing funding for medical education. A recent medical economics article stated that one of the easiest ways to reduce the cost of medical care was to limit access. If there are fewer physicians then fewer patients will have access to physicians and will utilize fewer medical resources. The government feels that having too many physicians actually increased utilization.

The fact is, however, that I have never seen a primary care physician who was not overwhelmed with sick people. There are plenty of ill people in the world. As an additional evidence of this, the recent billion-dollar deficit created in the Medicaid system during the last fiscal year for the State of Florida was to a large degree precipitated by the Healthy Kids Program. When the counselors went out to sign up all of the eligible children for Healthy Kids, they identified thousands of patients who are in fact eligible for Medicaid who did not know they were eligible for Medicaid, and then signed those patients up for Medicaid and got them in to see physicians. These patients, of course, had many problems such as hypertension and diabetes, and when they started being seen, it caused the cost to go up substantially. We all know that the amount of illness that is caused by tobacco, alcohol, and drugs is staggering. The fact is that the patients go to doctors because they are sick, they have medical problems, and when they have real diseases. More patients should actually go to physicians to receive preventive health care; however, the date the government and managed care still does not actively cover preventive health care. If we provided all the preventive health care and the patients need in addition to the one that are sick, the actual utilization and cost of medical care would clearly go up even more than it has.

In the long run, if the patients receive preventive care and they change their lifestyles, it is well known that the actual cost of health care in the future would go down. Unfortunately, managed care and the government can only see the next 30 days, and they generally do not have the insight to do what is necessary to provide the preventive care today. In my opinion, the manage care industry in general has pervasive methods in which they try to reduce the ability of the patients to seek and receive medical care. In fact, there are times when the access is denied or reduced. In addition, because of the manner in which health care is reimbursed at this point in time, there has been increase in the amount of uninsured, which have no access to health care. The government has reduced the amount of public health dollars that are available to fund public health clinics to provide care for the uninsured or emergent, and this only exacerbates the problem. Our society has obviously decided through its elective representatives and its insurance industry, the patients are not supposed to seek medical care. Until that basic attitude is changed, we as physicians are forced to deal with the system that we are living with.

June/July, 2001/ Jacksonville Medicine

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