"Torture by HMO" is the title of a March 18 column by Bob Herbert in The New York Times. Herbert tells the story of a North Carolina family with a baby suffering from leukemia. Their health maintenance organization insisted that the child undergo treatment in another state, at great cost and inconvenience. Herbert condemns the HMO's "inflexible and thoroughly inhumane" policies, adding that "humanitarian concerns are not what corporate care is about. In the competition with profits, patients must always lose."
This portrait of HMOs as soulless money-making machines has become increasingly popular in recent years, as skyrocketing health care costs have driven a shift from fee-for-service medicine to managed care. Critics such as Harvard Medical School professor David Himmelstein contend that HMOs reward doctors for providing less care, trapping them in a conflict between their incomes and their patients' welfare, and impose "gag clauses" that forbid them to discuss this conflict with patients. "The bottom line is superseding the Hippocratic oath," write Jeff Cohen and Norman Solomon in their syndicated column. "Cost-cutting edicts from HMO managements put doctors in a box....Faced with directives to help maximize profits, many physicians are under constant pressure to shift their allegiance from patients to company stockholders."
From my perspective as both a physician and a patient in the same HMO, these charges do not ring true. I do not doubt that HMOs, like any other business, sometimes serve their customers poorly. But there is no reason to believe that managed care systematically undermines patient welfare because of the imperative to cut costs. To the contrary, I have found that efficiency is perfectly compatible with compassionate, effective health care. (Since this article was written, I have myself become a cancer patient. Thus far, my care has been unsurpassed. I have the option of being treated outside my HMO, but would not think of going anywhere else. I expect from my plan the same level of care as a patient that I have provided as a physician.)
My plan delivers care at several neighborhood health centers. Each member chooses a "home" center and a primary care physician at that center. Surgical, pediatric, obstetrical, and mental health services, as well as radiology, laboratory, pharmacy, and physical therapy, are all provided under one roof. While our "staff model" HMO does not offer as extensive a choice of physicians as many "network" HMOs, our arrangement does offer economies of scale and strict control of physician quality. Surveys consistently show that patients rate quality of care above greater choice of providers.
I am paid a straight salary and modest bonuses tied to both the plan's profitability and a patient satisfaction index. Frequent advisory audits help me and my patients sort out health care they need from health care they want. My goal is healthy, satisfied patients and a financially sound business. Every day, I put my professional reputation on the line. So does my HMO. Our challenge is to cut costs without cutting quality. Fortunately, there are many ways to do this.
Changing the venue of medical care from hospital to outpatient center, office, or home is the most important factor driving health care costs down and quality up. Hospitals are very expensive pieces of architecture. They are also complex places and therefore potentially hazardous to your health. Despite rigorous safeguards, medication and treatment errors can and do occur. As many as 15 percent of hospitalized patients go home with a hospital-acquired infection, often caused by antibiotic-resistant organisms. Furthermore, most patients do not wish to be in a hospital. In the last three years, my HMO has reduced hospital use by 25 percent.
Inguinal hernia repair is one of the most frequently performed operations. Just a few years ago, the cost of this operation included a preoperative night in the hospital, one to two hours in the operating room under general anesthesia, and up to five postoperative days in the hospital. The patient had to take four to six weeks off work, and the recurrence rate was 10 percent. In 1996, at my HMO, this operation requires 40 minutes of surgery in a free-standing, outpatient surgical center under local anesthesia using a $100 plastic-mesh plug. Patients have less discomfort, return to unrestricted work in one week, and enjoy a recurrence rate of less than 1 per 1,000. This approach to hernia repair has been technically feasible for several years but was usually employed sporadically, at the discretion of the surgeon or the patient. In the era of cost containment, it has rapidly become the standard in the profession, regardless of reimbursement mode.
Thanks to the innovation of laparoscopic surgery, 80 percent of my patients who need their gallbladder removed can undergo the operation as outpatients and return to work in a week. The original inspiration for this procedure was the development of miniature video cameras, and the early reports were dismissed as mere technical wizardry. But as it became clear that laparoscopic gallbladder removal was not only safe but much less expensive than conventional surgery, surgeons quickly adopted the procedure as the standard approach, and patients demanded it.
The challenge of providing better care at lower cost has spurred not only the development of new procedures but the resurrection of old ones. Pilonidal abscess, a chronic and painful anorectal condition, used to be treated with radical surgery in the hospital. Recovery was frequently prolonged and painful. I now treat this problem with a 20-minute office procedure. Patients can return to work in two days, and the recurrence rate is less than 2 percent. This procedure was first described 15 years ago but languished until managed care created the incentive to implement it on a wider scale.
Open-heart surgery is expensive. Traditionally, the payer is billed separately by the hospital, the surgeon, and the anesthesiologist. My HMO recently negotiated a contract in which we pay a flat fee per operation that is about half our previous cost. As for concerns that surgeons might offer less surgery for less money, our studies show no change in mortality or morbidity since this contract went into effect. Beyond the question of ethics, no reputable provider group would risk a lucrative contract with a large HMO by delivering less than first-class care. Based on this experience, we are exploring package pricing for other high-cost procedures, such as organ transplantations.
Childhood asthma is a distressing and sometimes frightening problem for parents and children. Our studies showed that repeated visits to the emergency room were not only unnerving for families but accounted for a substantial portion of the cost of treating asthma. Through an aggressive program of family education, we are teaching our patients how to handle most asthma attacks at home, even how to give adrenaline injections. A nurse practitioner is available by telephone 24 hours a day to advise families whether a visit to the hospital may be necessary. Emergency room visits are down 40 percent in the last two years. So far, we have noted no adverse effects on patient care, and the response from families has been almost entirely positive.
Treatment of minor lacerations used to involve a trip to the hospital emergency room and frequently entailed a long wait. On nights and weekends our health centers are now staffed with specially trained physician assistants who repair 90 percent of all minor lacerations. In the first year this program has saved more than $100,000 in hospital emergency room charges while taking care of our patients better and more quickly.
For many of our patients with chronic wounds, such as bedsores and diabetic ulcers, treatment has often involved lengthy stays in rehabilitation hospitals or prolonged, expensive home visits by nurses. Under our wound-care program, most patients with chronic wounds can be treated directly at our health centers under the supervision of a physician. In most cases, patients and their families can be trained to do the daily wound care at home. In the first year, this program saved more than $70,000 in outside utilization costs.
Patients needing hip replacement surgery are often elderly and suffering from other medical problems. We now begin physical therapy evaluation in the patient's home prior to surgery. By knowing the level of family support and the location of stairs and bathrooms, we can much better prepare the patient for recuperation and rehabilitation. The new approach has cut the average hospital stay in half, eliminated the need for intermediate rehab hospital care in many cases, and accelerated recuperation.
For the past three years, my HMO has followed a policy of early discharge after childbirth. The childbirth program includes comprehensive prenatal education, post-partum home visits, and individual screening. A 16-year-old first-time mother with no family support and no telephone at home is not sent home in 24 hours. But 70 percent of women with uncomplicated vaginal deliveries are discharged in 24 to 36 hours. And despite the recent brouhaha over "drive-thru" deliveries, a recent survey documents that 90 percent of our patients are satisfied with their care--the same percentage as before the early discharge policy was adopted. There is no evidence that the health of mother or infant has been compromised. Most mothers and their babies belong at home with an attentive family, rather than in a potentially dangerous hospital.
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"High-quality medical care at an affordable price is not only possible under managed care; it is a reality." We sure hope so.