Physiatry Practice Management Resources

"I think the anti-HMO movement will grow because the press and politicians have done an excellent job of vilifying HMOs," says David Lack, president of the Council for Affordable Health Insurance, a nonprofit consortium in Alexandria, Va., of independent insurers and employers.

In January, The New York Times reported that half of all physicians at one New York hospital have whittled down the plans they accept. And 10% of doctors at that hospital completely dropped out of managed care plans last year.

Medical management consultants see these actions as a blip. "We've always had doctors who have said, 'HMO, hell no,'" says Robert Bohlmann, a consultant with the Medical Group Management Association, in Englewood, Colo. "They are cavalier. If it's not an HMO, it's going to be something else like it that they don't like."

What is irrefutable is that managed care has long suffered a barrage of criticism and some of the criticism is justified. Physicians complain about their lack of freedom and reduced compensation. Patients, of course, are angry if care is denied, delayed, or inappropriate. Yet, despite its failings, managed care has won the support of employers that buy health care for their workers.

In an effort to counter this backlash against managed care, health plans are countering with advertising, spending million in one 1998 campaign alone, "The Truth About Managed Care." That campaign, with the tag line, "The Health Care You Want at a Price You Can Afford," was supported by the Coalition for Affordable Quality Healthcare, a political action group, funded by managed care insurers and employers.

Even physicians who support managed care believe HMOs must change. "Doctors are mad and frustrated; but HMOs are not to blame," says Bill Williams, MD, a family practitioner and senior vice president for the National Association of Managed Care Physicians, an organization in Richmond, Va., that has 3,500 members. "Employers are driving the HMOs. Doctors should stop complaining and sit down at the table with CEO purchasers of health care and resolve the problems."

HMOs were designed to help employers solve the problem of rising health care costs brought on by fee-for-service insurance. Physicians who practice HMO avoidance contend costs are not held down by HMOs but driven up by what they believe are large amounts of administrative waste.

When Allan Weisshar, MD, a pediatrician in Torrance, Calif., reviewed his per-patient revenue, he was surprised at the findings. He learned that 35% of 2,200 patients were enrolled in an HMO, but they represented 65% of his office work and only 19% of his income. At that point, he began disenrolling from all his HMOs last year.

Quality vs. Quality

"It was a big gamble but I was having to compromise my practice principles," Weisshar says. His breaking point came when his IPA suggested that when dealing with patients in capitated plans he should take his own x-rays and remove any foreign bodies from his patients' eyes. Otherwise, he would lose income by referring these patients to specialists.

Weisshar has worked with 30 health plans, 15 HMOs, and 15 PPOs. He dropped all the HMOs. The result? "Most of my HMO patients changed their insurance plans to a PPO plan I would accept," he says. "I transferred out only 100 patient records." Over the course of a year, his income declined only ,000. "The patients love it because I'm not beaten up and I'm not cranky when I talk to them on the phone," says Weisshar, 50.

A frequent accusation leveled against managed care plans is that the fees are discounted so much that physicians need to make patients wait for months for appointments and they see large numbers of patients daily. "Because of the sheer volume of patients you are forced to see, patients may not get the quality of care they deserve," says Arnold Ison, MD, 60, a dermatologist in St. Petersburg, Fla., who is president of DocTra, a group of physicians who oppose HMOs.

Payers deny this charge. In a fact sheet issued last year, "Dispelling Managed Care Myths," the AAHP said its statistical analysis showed that physicians spent more time on direct patient care activities in 1996 (26.9 minutes) than they did in 1985 (24.3 minutes).

Pepe Granat, MD, a family practitioner in Miami, says that even if physicians spend more time with patients, "HMO doctors are subtly pressured to do things in a certain way." Granat refuses to accept HMO patients, in part because he believes managed care creates irreconcilable conflicts of interest.

"Even good doctors can't give the best possible and timely advice under this system," says Mark Heipler, an attorney in Oxnard, Calif., who has become famous for winning large judgments against managed care insurers for denials and delays in treatment. Heipler and his family see only physicians who do not take HMO patients.

Of course, managed care critics say denials, delays, and limits to care are common. The AAHP refutes these complaints, however, citing a study of more than 2,000 physicians that appeared in the fall 1997 issue of Inquiry which showed that physicians using managed care techniques denied care only 3% of the time.

That has not been the experience of anti-HMO doctors who sometimes provide on-call coverage for HMO physicians. Granat has gone so far as to personally guarantee payment of hospital bills for HMO patients she sees who are told to wait for hospital authorization.

Concern About Cost

Those who prefer managed care fear that if enough physicians oppose HMOs, the movement will spur a return to high-cost fee-for-service medicine. "My suspicion is that fee-for-service physicians who tend not to behave in a cost-conscious way will revert to premanaged care days with uncontrolled utilization," says Rosalie Phillips, executive director of the Tufts Managed Care Institute, a collaborative formed in 1995 between the Tufts University School of Medicine and the Tufts Health Plan. Its goal is to help health care professionals learn to practice high-quality medicine in a managed care environment.

Physicians who oppose HMOs believe health care costs can be controlled under fee-for-service medicine if all patients have medical savings accounts and control their own medical costs.

"Insurance should be decoupled from the place of employment," says Miguel Faria, MD, 45, a neurologist who is a member of AAPS. "As long as you have this, patients will spend medical care dollars as if it's someone else's money."

Beyond the health policy implications, physicians who oppose HMOs believe the most significant benefit from disenrolling from managed care plans is an increase in job and career satisfaction. "It's possible to do the job right and have happy patients and a happy doctor," says Marilyn Marcus, 50, a DO in Miami who signs no HMO or PPO contracts.

For new doctors fresh out of residency and trying to build practices, or for doctors working in towns where a single employer or health plan dominates, however, dealing with HMOs may be inescapable. What's more, for doctors who rely on referrals, such as anesthesiologists and surgeons, relinquishing managed care plans must start with primary care doctors and trickle down.

Written by: Maureen Glabman