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By Charles Atkins, M.D.
I am trying to hold my tongue. There are far too many diatribes against the evils of managed care. As a physician I must work with managed care companies, so I constantly remind myself of things that managed care has done well, such as cost containment, an increased emphasis on outcomes, improving efficiency, and so on.
The facts remain, however, that efficiency and cost containment have come at a high price. The actual amount of the health care dollar that gets spent on care shrinks as the administrative costs grow. About 50 cents of the behavioral health dollar is currently going to cover the overhead and profit of the parent company, carveout company, and local anchor groups.
I look around at how my colleagues are handling the situation. "We do more with less," one psychologist stated at a recent meeting, and around the table there were nods of agreement from the M.D.'s and Ph.D.'s. And our patients-what about them? This is where I have trouble keeping my peace.
I was on the phone recently with a medical director for one of the carveout companies. The company was insisting that the care being provided for a very symptomatic patient was excessive. We argued back and forth and engaged in the haggling that goes on in such interactions. As a flea market devotee, I am pretty good at this: "Could you do a little better? What's your best dealer's price?" But afterward I was left with a knot in my stomach.
The physician reviewer was somebody I knew and respected as a clinician. Yet in his new role, I felt embarrassed for him. He was attempting to restrict outpatient care to an older woman with recurrent depression, panic, and profound anxiety. If I were to take his advice, it would worsen my patient's condition; it would create unnecessary suffering. This is where I get stuck.
When one is faced with adversity, it is often useful to find ways to join with the adversary. Common bonds can do much to defuse a situation. But how far should we go?
Certainly the limits must be in keeping with professional ethics and with personal or corporate mission and philosophy. This reviewer, whom I respected, was coming close to that line. Recently, other physician reviewers have made clear attempts to have me cross the line-to deny inpatient hospitalization to a suicidal patient or to discharge to the street an adolescent in crisis whose parent had abandoned him in the emergency room. It is discouraging.
In the situations above, the patients needed admission for that most basic of reasons-safety. Of course we went ahead and admitted, but I have no doubt that when the bills are submitted, payment will be denied.
In earlier days the physician-to-physician review was a helpful second-step appeal, providing a clinically savvy listener to whom a case could be presented. Typically this had a reasonable outcome. But now these physician-to-physician reviews are leaving me even more bewildered than those I had with nurse reviewers.
So why would someone become a physician reviewer? It could, in an ideal world, provide a moral stopgap to a system where financial incentives are aligned counter to the direction of the patient seeking treatment. These jobs also allow physicians a look at the other side of the fence, an exercise that invariably educates-it doesn't hurt to be clear on level-of-severity criteria. The physician reviewer jobs pay well and often come with the title of medical director-a sure resumé booster.
The down side of physician reviewers is clear. They create obstacles to treatment, attempt to limit treatment, and make it necessary for physicians to waste valuable time haggling on the phone. They provide a veneer of credibility to the managed care company's medical decision making. And there is a risk that treating physicians will accept the reviewer's decision as final.
We must never forget that the burden for appropriate treatment still rests with the treating physician. Just because managed care denies an essential service does not mean we should withhold it from our patient. Once a service is denied, it is appropriate to inform the patient of this as well as of your treatment recommendations. I also suggest getting a copy of the denial faxed to your office. You might encourage the patient to contact the insurer, and it is reasonable to begin the appeals process with the insurance company or the appropriate insurance commissioner.
The financial reality of these physician-reviewer positions is that they add dollars to administrative costs. None of this money will ever go toward treating a patient. Indeed, this is money spent to curb the cost of treatment. This is the irony-that physicians are being paid to deny and limit treatment. All those years of training, the nights on call, the harried duty in emergency rooms are now at the service of a managed care company.
Well, I didn't hold my tongue. I suspect that none of us should. Just as there can be advantages to finding common ground with managed care, there is a real need to work to correct the problems with this system or to find alternatives. Just as we spend hours with managed care companies and physician reviewers, we should take the time to add our voices to the debate and to join forces with groups and individuals who reflect, far more accurately than managed care companies, the needs of our patients and our profession.