Government must help make managed care work

THE BALTIMORE SUN

ACROSS THE country, there is a surge in complaints by physicians against health maintenance organizations, and increasing numbers of doctors are quitting managed care altogether. Meanwhile, patients seem equally perturbed, fretting about everything from restrictions on medical coverage to the actual denial of care. Everyone, it seems, has a complaint. Yet no one is leading the charge to find a solution to the crisis in managed care. The question is why.

Though it may come as a shock to the hordes currently besieging the managed care industry, the truth is that much of our predicament is not the fault of monopolistic HMO executives. Rather, it's the result of a grim reality: There's only so much we can spend on health care without driving the nation to insolvency. It's a simple principle of economics, but it's something the public has yet to accept. Regrettably, until this occurs, little is likely to change.

As someone who has seen our health care system at work as both a patient and a physician, I can attest to the troubled state of medical care in the '90s. As a doctor, I've seen indigent patients faced with limited choices and, all-too-often, mediocre care. I've seen mistakes made that could threaten the life of the undiscerning patient. And I've seen how shortages of qualified staff can compromise even the most prestigious medical institutions.

Patient's problems

As a patient, I've fought heated battles to obtain health insurance at any price. I've spent countless hours on the phone and waited as long as a year to receive reimbursement for medical expenses. And I've seen how physicians expected to cope with ever-increasing patient loads have less and less time to provide thorough, conscientious care.

For the average healthy patient, this may merely be an inconvenience. But for patients with chronic diseases, it can be deadly. Take diabetes, for example, a condition I've lived with for 16 years. It affects millions of Americans and is a leading cause of devastating complications, including blindness, kidney failure and amputations. It's the seventh-leading cause of death in the nation. It's also one of the most time-consuming diseases known to man, requiring constant intervention by both patients and doctors.

Fortunately, as a physician, I am not entirely dependent on our flawed health care system to ensure my long-term survival. However, most diabetes patients must rely on health professionals to monitor the results of dozens of blood tests to manage their disease, and their fate is in the hands of these providers.

Managing disease

But what if the harried doctor doesn't have the time to teach the patient how to manage his disease? What if the patient is left largely on his own? Managed care, with its finite resources, can have a huge impact on whether these people live or die, and the harsh truth is that diabetes will kill or maim countless Americans because of inadequate medical care.

I've already seen it happen. Indeed, while working at a California HMO, I saw how a patient can slip through cracks large enough to swallow a whole bevy of the infirm. In one case, I saw a diabetic patient with severe ulcerations on his lower legs -- clear evidence of diabetes complications. I examined him for further complications and promptly discovered "cotton wool spots" in his eyes, a sign of potentially serious retinal disease that can lead to blindness. To my surprise, none of his other doctors noted this physical sign, despite the fact that it was clearly visible.

Sadly, this kind of incident is not an isolated event. And it may become even more common in the future, as insurers encroach more aggressively into the practice of medicine. But HMO officials aren't looking over the shoulders of physicians because they like arousing the ire of doctors and their patients.

They're doing it because they have a thankless responsibility: to reduce the spiraling medical costs that have been consuming an ever-greater share of the nation's economic output. If the HMOs weren't doing it, someone else -- like the government -- would be.

The real problem is not managed care. It's the fact that the managed care revolution is occurring in a vacuum, with no national leadership and no coordination of the forces that run our medical establishment. In this chaotic environment, disparate special interests are battling one another in parochial turf wars, and no one is guarding the public interest. The result has been an unmitigated disaster for the nation's health.

Leadership needed

By now, it seems clear that the medical establishment is woefully ill-prepared to provide the kind of leadership needed to salvage our health care system.

Government leaders urgently need to fill the void, but they cannot do so until the public comes to grips with the fact that we cannot afford unlimited health care. Only then can political leaders make the tough choices needed to finally reform our system of medical care, creating an infrastructure in which the risks, costs and benefits are shared equitably by the nation as a whole.

Dr. Stephen L. Cohen writes on health care issues for the Los Angeles Times.

Pub Date: 3/26/99

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