Los Gatos Weekly-Times

Managed care manages to be pretty awful

By Carl Heintze

'Here," the nurse said to the new mother. "This is a thermometer to take the baby's temperature. I'll be back pretty soon."

And she disappeared. This happened in a hospital not so far from here. It wasn't that the nurse didn't care to take the baby's temperature. She didn't have time. She didn't have time to do the things nurses traditionally have done.

It's only a small example of what euphemistically is called "managed care," a term which, like HMO (Health Maintenance Organization), isn't self-defining.

For the certainty is that as we approach the millennium, medical care in the United States is in danger of becoming a national disgrace. It's not enough to cite those millions without medical insurance or to say there are too many specialists among physicians or to bemoan the likelihood that Medicare is going to run out of money or that it costs too much.

The truth is that we are not dealing with adequate medical care in the United States; we are not dealing with its problems, and we are in danger of losing the care we do have.

How did this happen? How did we, the most prosperous nation in the world, come to have such a paucity of patient care?

Well, there's blame enough to go around. Everyone, from physicians to the average patient, has contributed. For years doctors operated a cottage industry, each M.D. his or her own little company, financially inefficient, fiercely competing for patients from the patient pool.

For years the public agreed to an open-ended fee-for-service system, under which there was no real limit on what a doctor could order to care for his or her patients, and for years insurance companies paid such charges and passed the cost on to the insured or the insurers.

For years, too, the poor were cared for in government-operated hospitals, where interns and residents got substandard salaries and the patients upon whom they learned their profession got what taxpayers were willing to pay for.

For years doctors were treated with respect--they saved lives, after all; what nobler profession could there be? You could talk to the doctor, but you couldn't tell him much, not about medicine, not about economics and sometimes not much about anything else.

Doctors also were well paid. Most had six-figure incomes, even if they usually didn't have time to stop and enjoy much of what they earned. The doctor and his Mercedes or Lincoln or Cadillac became a cliché.

Well, that's all changed now. Medical care has become "managed," which seems to mean that it must turn a profit, although not so much for physicians as for those who have invested in the large corporations which own and operate HMOs and hospitals.

The solo practitioner is pretty much gone. Actually, he or she has been pretty much gone for some time. One doctor working alone in his own office is economically difficult, if not impossible.

HMOs, originally set up to maintain good health, have come to be big clinics and conglomerates designed to treat as many patients as possible in a kind of faceless, mechanical way. There's care, but there's not much left of the patient-doctor relationship.

Medicare, approved in 1965 because the elderly, whose care costs the most and who were spending their last years improperly cared for, has become the economic measuring rod for medical charges. Doctors can either accept what it will pay or do without. There's really no choice.

So where does that leave us all?

Frankly, in a mess. The nation, or at least its elected representatives rejected Bill Clinton's "managed care," an ill-conceived program at the least. The elderly rejected catastrophic medical care--a good deal, although they seem not to have understood it.

Insurance companies still control much of how charges are figured and doctors are paid.

Finally, and perhaps most importantly, everyone wants good personal medical care, but almost no one is willing to pay for it. For the truth is, there is no substitute for the one-doctor/one-patient relationship. And the truth is, such medical care costs money.

Anyone can get good medical care in the United States--if they are willing to pay for it.

The question is not whether it exists. The question is how much you are willing to pay.

Carl Heintze is a regular contributor to the Los Gatos Weekly-Times.

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