Second Opinions
"Cost-Conscious Care" (June) by David Jacobsen, a physician employed by Harvard Pilgrim Health Care in Boston, strikes me in the same light as a fox's affirmation of his qualification to guard the henhouse would. Dr. Jacobsen spends quite a bit of time noting how much money his HMO has saved in medical care costs. But the cost savings that he alludes to are by no means unique to managed care and, in fact, are being achieved by nearly all surgeons and physicians in the United States. In the same way that he takes umbrage that someone might accuse him of being unethical, we in the fee-for-service community take particular umbrage at the suggestion that we are absolutely insensitive to providing more care for less money.
Dr. Jacobsen then goes on to cite examples of how his HMO has economized in care and still maintained quality. He notes that he has cancer and says he would not go anywhere else for treatment. Having been a physician in an HMO, I can tell you that it is quite easy to "game" the system and that most physicians who are covered by, as well as employed by, HMOs very carefully choose to whom they would like to be referred, a privilege that does not accrue to the lay person enrolled in the same medical plan. Further, I believe that cost-cutting maneuvers such as employing a nurse to take asthma calls instead of a doctor and then stating that you have noted no decline in quality begs the question of whether one was trying to note a decline in quality in the first place.
Dr. Jacobsen then uses the recent example in Time to suggest that bone marrow transplantation is not appropriate for certain advanced diseases. I would refer Dr. Jacobsen to Tom Hazlett's article at the back of the same issue of REASON, "Risky Behavior." While it is true that bone marrow transplantation is being tried in a number of situations where it is not proven therapy, the essence of advancement in American medicine is that therapy must be tried against desperate illnesses to discover whether it will be useful. Under Dr. Jacobsen's plan for American medicine-- complete managed care--I fear that innovation would stop cold in its tracks. Dr. Jacobsen is correct that medicine is not immune from the laws of economics and if no one is paid for trying anything innovative, eventually no one will try anything innovative.
Dr. Jacobsen's assertions that studies have consistently shown HMO patients are as satisfied as their fee-for-service counterparts is merely a case of picking one's favorite studies to quote. Quite a few studies show great patient dissatisfaction with HMOs, as Dr. Jacobsen knows. Furthermore, it again begs the question to obtain quotes from "HMO experts" as to whether or not patients are satisfied with HMO care.
Finally, we should return to Dr. Jacobsen's statement, "wishing that medicine could be exempt from the laws of economics does not make it so." The corollary rule in economics is that one serves he who pays. Dr. Jacobsen is paid by and is serving his HMO, whether or not he wishes to soothe his conscience by claiming to be a patient advocate. Until he looks to his customer, the patient, for payment, his caterwauling about quality, cost efficiency, and compassion will not sway me.
Readers of REASON would do well to consider the philosophic underpinnings of managed care, compare them with those of fee-for-service medicine, and decide whether a fee-for-service world will eventually give better medicine to the individual than a socialistic, monopolistic managed care world where the plan will choose what care is best for you.
Michael Schlitt, M.D.
Renton, WA
David Jacobsen defends HMOs from accusations of being "soulless" and says he "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."
HMOs are no different from other forms of socialism in that the care that Dr. Jacobsen delivers and receives is centrally planned. If Dr. Jacobsen is on the HMO pharmaceutical committee and is outvoted for the drug he prefers, what does he tell his patients when they ask, "Is this the best treatment?" If he answers "no," then he could be fired for criticizing his employer. If he answers "yes," then he deserves to lose the trust of his patients.
Is there a place for HMOs in health care? I don't know, but I do know that the government should not encourage them. Our current tax code does this in two ways. First, tax subsidies encourage workers to choose job-based health insurance. Second, the income tax is anti-savings, and savings gives patients the money to pay for and thus control their own health care choices. The easiest way to level the playing field of health care is to return to the vision of our founders: Repeal the 16th Amendment and replace the anti-savings income tax with the pro-savings national sales tax. After this is done, Americans can rationally choose if they prefer corporate socialized medicine or patient-directed health care.
Bert A. Loftman, M.D.
Director of Health Care Reform
Citizens for an Alternative Tax System
Atlanta, GA
I'll bet Dr. Jacobsen is a physician I would be glad to call my own and that the utopia he describes in his HMO might occasionally be possible. I'll also bet it doesn't happen very often. Medical care abuses occur because the patient is not spending his or her own money, and the managed care organization must find a way to restrain the patient's desires. This allows the organization to retain as much as 30 percent for distribution to stockholders and executives. (Recall that the money they spend on patient care is referred to as the "loss ratio.") This encourages veterinary medicine ethics in which the patient is handled like Rover--someone besides Rover decides on the care dispensed. It should also be noted that at least Rover has a loving master making the decision, while the hapless patient has a doctor whose bottom line depends on how little he spends on the patient.
Medicine should consist of exchanges between the interested and consenting parties: patient and doctor. This can be realized when insurers sell true insurance against catastrophe and patients, in concert with their doctors, decide how much of their own money to spend. Also, the government shouldn't compound the problem by pouring fuel (money) on the flames. Finally, the medical advances Dr. Jacobsen cites came about in spite of, not because of, managed care.
Gerald E. Sullivan, M.D.
Bowling Green, KY
Dr. Jacobsen replies: I regret that some readers may have interpreted my article as a blanket endorsement of all HMOs. The intent of my article, as stated in the title, was to show that cost control and quality are not contradictory concepts in health care. I offered my HMO as an example of an organization which, in my experience, is doing a superb job of providing quality, personal health care at lower cost.
"Managed care" is an unfortunate phrase to the extent that it implies that health care choices are being made by someone other than the patient and his health care provider. I have no "plan" for health care in the United States. I believe in a market system of evolutionary development in which consumers must be the ultimate arbiters. The challenge is to determine, to the best of our imperfect ability, what constitutes optimal health care for each of us; how much of this health care we want; and finally, how much we can afford. To the extent that government regulations, licensure requirements, and tax policies thwart this challenge, they ought to be abolished. The choice is not between HMOs and fee-for-service--these may well be just way stations in the evolution of health care delivery.
The question of innovation is an important and complex one. Certainly, the innovations I outlined are not unique to HMOs. No responsible health care delivery system can simply offer its patients or its providers a blank check to foray into the unknown and unproven at whim. Science demands evidence before it can embrace innovation as a standard of care. My HMO endows a large research fund to help us define such evidence. Innovation and cost-consciousness are certainly not incompatible.
Why do medical costs increase with improved technology? Not all do. The inguinal hernia repair is much cheaper now than it was 20 years ago. Before the development of the artificial hip joint, the cost of this procedure was zero. The current cost of hip replacement is a welcome increase. In between these examples is a muddle in which new procedures and new technology have added to medical costs without always improving medical care. Getting out of this muddle will require that consumers and providers inform themselves of the costs and benefits of medical care and make their own decisions.