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QUALITY OF CARE
APRIL 11, 1996
TRANSCRIPT
An estimated 100 million Americans now receive medical treatment through managed care plans. Arizona has a particularly high rate of participation. Elizabeth Farnsworth interviews a panel of doctors at the Good Samaritan Regional Medical Center in Phoenix on how the changing system is affecting them. For the Tom Bearden lead-in piece, click here.
ELIZABETH FARNSWORTH: 80 percent of the patients who come to Good Samaritan are in some sort of managed care program. Whether they're treated here in the emergency room or somewhere else in the hospital, their relationship to their physician is quite different than before. We turn to six doctors, all of whom see patients in HMO's, health maintenance organizations, or other managed care plans. Joining us are General Surgeon Robert Stephens, who's in private practice; Pediatrician Mark Morales, a staff physician at CIGNA Health Care; Obstetrician/Gynecologist Marilyn Laughead, president of the Arizona Medical Association; Michael Gray, a rural primary care physician now in private practice who previously spent time working on staff at an HMO; Debra Jamison, an internist who also used to work on staff at an HMO; and Todd Taylor, an emergency physician here at Good Samaritan. Thank you all for taking time from your busy practices to be with us. You heard what Mindy Edwards, the patient in that piece, said, and you all have been trained to give the best care possible to your patient. Can you do this in this new managed care world, Dr. Stephens?
DR. ROBERT STEPHENS, General Surgeon: I don't think there's any doubt we do. Notice Mindy did get seen. Unfortunately, you know, there are different insurance policies out there, and the buyer beware. There are some which are very good. There are some which are very inadequate. And that's the problem. It's choosing which ones where they have the better coverage.
ELIZABETH FARNSWORTH: But you're not worried that your ability to, to treat your patient as well as possible is compromised by an HMO?
DR. ROBERT STEPHENS: No. Once that patient gets in my office, I have no guidelines that's any different taking care of that HMO managed patient than anybody else. Once they get in the office, the treatment's equal.
ELIZABETH FARNSWORTH: Dr. Taylor, what do you think?
DR. TODD TAYLOR, Emergency Room Physician: I think Mindy's concern really speaks to the heart of managed care, and that is that there is some loss of control once you join a managed care plan. And so perceptions may be different. If you have ultimate control over what--selecting your physician or your hospital or your treatment, you feel better about it, versus in a managed care plan, where maybe somebody else is making a lot of those decisions. And whether it's different or not, you may feel that it is different.
ELIZABETH FARNSWORTH: Well, I would think that control issue would be especially hard because you were all trained to think that you had to make these decisions. Is this an issue for you, Dr. Laughead?
DR. MARILYN LAUGHEAD, Obstetrician/Gynecologist: One of the problems in my practice in order to get the appropriate testing done for a patient, for example, the mammograms as I see of patients that are women is that it has to be pre- certified, and sometimes it may slow down the process in terms of trying to get patient care done.
DR. MICHAEL GRAY, Internist: Right. I think that the operative clause in Dr. Stephens' comment was once the patient gets to your office. In our situation as primary care physicians, we fight the battle to try to get the authorization to get that patient to your office, and certainly many times it goes smoothly, but at other times there are significant delays, there can be hours spent on the telephone for our staff in our office, trying to get through to the proper person to get authorization and so on and so forth. I mean, I've had to put a person on full-time, doing nothing but getting prior authorization for, for needed patient care.
DR. MARK MORALES, CIGNA Staff Pediatrician: But this speaks, I think of the benefit of a staff model, which we are networked ahead of time. I do not have a problem.
ELIZABETH FARNSWORTH: Explain what you mean there.
DR. MARK MORALES: Well, basically, we are self-contained. We are staff model--
ELIZABETH FARNSWORTH: This is your pediatric practice?
DR. MARK MORALES: Pediatric practice.
ELIZABETH FARNSWORTH: Uh-huh.
DR. MARK MORALES: And I have exclusive rights in determining where the care is delivered. I like to look at my relationship with the family as a partnership, and we, together, will decide what their child needs. And I've had no barriers, and, in fact, I'm encouraged to practice the standard of care which is not only here locally but nationally.
ELIZABETH FARNSWORTH: You think that you can give actually better care this way?
DR. MARK MORALES: Through this networking, I have statistics to prove it, our asthma education program has prevented days lost from school, has decreased emergency room visits, has decreased hospitalization. Our immunization rate now is 90 percent for children under 35 months of age. It's increased 20 percent for children under two years of age.
ELIZABETH FARNSWORTH: So the prevent aspects are working in your case.
DR. MARK MORALES: Again, it's really encouraged, I think, and our founding fathers based this whole concept on looking at populations based on a budget, finding out where people need their care, how they get sick, and to proactively work with it.
ELIZABETH FARNSWORTH: Uh-huh. Dr. Jamison, you've done both. What do you think? You've been both in the managed care situation and now you're in private practice.
DR. DEBRA JAMISON, Internist: Right. Umm, that's all I know. I started working for a managed care right out of residency, and I worked for a big HMO here in Arizona for the first five years. After five years, myself and two of my colleagues who also worked at an HMO decided to start our own private practice. So HMO, managed care is all I know. I really don't have a problem with providing adequate care for my patients. I have a problem with getting those procedures done in a timely fashion, and all the other things that all the other physicians have mentioned here. Umm, I think that one of the problems is the ton of paper work. Like my colleague here has said, I've had to hire a person who actually--I mean, I just can't pick up the phone and say I want this test done, I have to get that authorized. I just can't pick up the phone and schedule a patient to see one of my colleagues that's a specialist. I have to get that authorized. Plus, I have to hire a person to do that, I have to work more hours so I can pay that person, so I have to spend less time with my patient.
ELIZABETH FARNSWORTH: Do some of the plans that you work with give you a bonus if you don't refer to specialists, or if you don't put somebody in the hospital? I mean, does any of that affect you?
DR. DEBRA JAMISON: Now that I'm in private practice, no.
ELIZABETH FARNSWORTH: Uh-huh. How about any of the rest of you?
DR. MICHAEL GRAY: Yes, it does. There are incentives that are operative in many of the contracts. It depends which managed care program you're talking about, but there certainly are incentives that relate to your profile, the physician profile, which is maintained by the managed care systems in terms of the percentage of patients who refer to specialists, the, the cost of in-patient care, and so on. And it's not always clear to the provider really what it is that the parameters are that are being looked at. You often don't have any access to the data. You just know that you did or didn't get the bonus and so on and so forth.
DR. MARK MORALES: And then ironically, though, using that same information, we as a department set our goal, and we as a department are judged on how efficiently we work at it, but, again, we are encouraged for quality of care, and, in fact, when statistics are gathered for us, we look at it as an opportunity to improve care, specifically kind of basically standardizing care. Though the art of medicine is wonderful and individual style practices, for certain disease entities, sometimes you can get a wide range on how you approach that, and to really affect a good outcome, usually a standardization or a bringing in of the mean on how you approach a particular problem is most helpful in primary care and pediatrics.
ELIZABETH FARNSWORTH: And you're a specialist. Are people referring their patients to you in the same way that they used to?
DR. ROBERT STEPHENS: I think always, and I don't think there's any--been delay in transfer to a requested general surgeon to see a patient, but I want to pick up on something that Mark said earlier. We also in the private practice mode have the same requirements for the testing, annual exams, mammograms, that the private or the staff model uses.
ELIZABETH FARNSWORTH: By requirements, you mean you have to convince the--
DR. ROBERT STEPHENS: Patient care, our charts are audited, we must provide the same follow-up that they do in their staff model, and so I don't think that the care is rendered differently but maybe we have a bigger paper work mountain that we have to go through. But the patients are getting the same care.
ELIZABETH FARNSWORTH: But would you go--you would not want to go back to the way that it used to be, right, the way it was say 15 years ago, or would you?
DR. ROBERT STEPHENS: I'd love to, but that's not--that's not a fact of life. I mean, there's been--
ELIZABETH FARNSWORTH: This is inevitable, you think?
DR. ROBERT STEPHENS: And I think for the most part the change has been good. I think the patients are getting better care, they're being better followed up, lab works are being appropriately followed up. They're getting appropriate testing. They're getting to the specialists in a timely fashion. The preventive medicine especially, I mean, mammogram rates have gone from 38 to almost 80 percent. Our asthma program, which is the same as the private mode, we've got programs now trying to identify the male between 20 and 40 who doesn't access this system, trying to get them in to the doctor so we can pick up hypertension, obesity, all these other hidden things which before were never looked at.
DR. TODD TAYLOR: I'm going to take a little different aspect here, because in the emergency room where I work, I many times see the failures of managed care. In other words, once they weren't able to get to see their doctor, many times they come to me for help that they were not able to receive, uh, elsewhere, many times after hours, on weekends. I think the promises of the HMO, which was initially health maintenance organization, has been lost. It's been lost and become a health management organization or a health cost containment organization, and, umm, Dr. Morales, I think his points are well taken. In certain types of managed care, the health maintenance is still a major factor; however, as time goes along, many other organizations have seen opportunity really to save money rather than maintain health and have taken that to the extreme. And that's where sometimes legislation or regulation needs to rein these plans back in to get back to our original premise, and that is to maintain health and keep people healthy.
ELIZABETH FARNSWORTH: But do you think maybe we're just in a certain stage here, where the cost containment aspects were foremost and now we have to move to some, to much more concern with quality?
DR. TODD TAYLOR: Certainly it's an evolutionary process, and in Arizona, we've had in our Medicaid system managed care for sixteen or seventeen years. In the early years, it was terrible, and then it over the years became better and better, and now I believe in Arizona, we probably have the best Medicaid system bar none in the whole United States primarily due to managed care.
ELIZABETH FARNSWORTH: Because are Medicaid patients--go ahead, sorry, Dr. Gray.
DR. MICHAEL GRAY: I think we have the best plan for those who qualify and get into the plan. The fact is the state of Arizona is not a leading state in terms of the number of patients that are covered in relation to the poverty level. There are about--you know, if you're at 30 percent of the poverty level or above, or maybe 35 percent, you don't qualify for that plan, $400 a month, you're not in it. Your concept of the staff model is really not at issue from our perspective. I certainly had no problem practicing the staff model setting. The problem is that there is more and more incentive for managed care programs to get away from staff models. Everything is showing us that the economics is pushing them away from the staff model, even though the staff model might well work better for primary care purposes.
DR. MARK MORALES: But that's all part of our societal evolution. The bottom line is there is a bottom line. The bottom line is there is a budget at some point. We don't have a bottomless pit of finances for health care, and who pays for that as part of this evolution and how that's affected is part of our responsibility too. As Todd pointed out, there are plenty of glitches, but part of the positive changes that have happened have been the hard work that he's put in, his staff, in terms of alerting certain payers, what is right and what's wrong. And as long as we continue that evolution--
ELIZABETH FARNSWORTH: Dr. Laughead, do you feel like your relationship with your patient has changed? I mean, you, you have been in medicine long enough to have been through this transition. Do you feel like your--the fundamental relationship has changed?
DR. MARILYN LAUGHEAD: It's definitely changed in some circumstances. What happens is, is that now the employers will go from one plan and next year to another plan. And so consequently, there's no continuity of care. And this greatly interferes with the relationship that I as a physician have with my particular patients. And you can't really follow through. Now, if it's an obstetrical patient because we're caring for them for nine months, that's a little bit different situation. We do have the rapport and the continuity of care with obstetrical patients. But with the gynecological patients, we've lost that, because now next year they have to go see another physician.
ELIZABETH FARNSWORTH: Do you think this is the way it's going to be, or do you think there are still changes that will come that will allow you to stay with somebody longer?
DR. MARILYN LAUGHEAD: What we're hoping is that the managed care associations, that the health plans realize that it's important that there is some way of maintaining continuity of care because that really makes care better for the patient, not only for the so important physician-patient relationship but just in terms of getting general care for the patient. And so hopefully, they will be able to see some way of being able to maintain that. I'm not sure how they're going to do this, but there should be some way so that patients don't have to, to every year to see a new physician.
ELIZABETH FARNSWORTH: Dr. Gray.
DR. MICHAEL GRAY: The issue of bottom line, I agree with you, is very important but it also has to be looked at from a national perspective. The United States spends 15 percent of its Gross National Product for health care services and are not providing services to almost 63 million or 1/4 of our population. There are terrible contradictions here, and the question of whether or not managed care is going to provide the model that will take care of these problems is very much at issue because currently your managed care programs, unlike Kaiser when it was first established which basically was a health maintenance organization that encouraged utilization, encouraged preventive services--
ELIZABETH FARNSWORTH: And was non-profit.
DR. MICHAEL GRAY: And was non-profit--we are now dealing with profit, insurance carriers that are for profit, that are driven totally by the profit motive. You and I and all of us sitting at this conference are committed to providing care and serving as advocates for our patients. Service is our primary concern, and I think we should take a perspective that says that health care is a right and not a privilege.
DR. MARK MORALES: But let's not bad-mouth the idea of profit. Let us say that none of us are here truly as altruists; that there at some level there is a, an area of profit that needs to be addressed. It can be a positive incentive. If you do it better, more efficiently, you do it well, why should you not be rewarded for it? The questions that you're bringing up are grander societal issues.
DR. DEBRA JAMISON: Right.
DR. MARK MORALES: That we are not going to necessarily--or look at managed care--the consumer needs to be more active in this as well.
ELIZABETH FARNSWORTH: Dr. Jamison, would you go into medicine today knowing everything you know about how the practice has changed?
DR. DEBRA JAMISON: Quite honestly, probably not. You know, I grew up in a time where we were looking at TV stations, you watched programs on Marcus Welby, you'd say, oh, great, I wish I can practice medicine like that, and, and you begin to believe that that's what you'll be able to do, but now that I'm in the real world, it's not fun. If I can just take care of patients, that would be great, but I'd say 30 to 40 to 50 percent of my time is not with patients.
ELIZABETH FARNSWORTH: Anybody else on whether they would go into medicine now?
DR. MARK MORALES: There was a time where I would have answered the same way as Debra did, but I'm having way fun now. Umm, I'm having fun--
ELIZABETH FARNSWORTH: What's made the difference?
DR. MARK MORALES: Umm, I must say that it's actually the organization that I'm presently involved with, plus the fact my close ties and encouragement with close ties in the community, the medical community that is, the opportunity to network, the opportunity to practice the way I was trained. It can be fun. There are those moments, and there are those moments I wish I was selling cars, I guess, but nonetheless, I am having fun.
DR. ROBERT STEPHENS: I love what I do. I would do it for nothing if somebody would take care of my bad investments, my kids in college, hold up my house that's too big, but I don't know anything else that I would do. I enjoy what I do. I think I do it well, and I love my relationship with the patients, and that's what drives me every morning when I get up--and have fun with my patients.
ELIZABETH FARNSWORTH: But I do know doctors who have left the practice because of having to deal with the insurance companies just did 'em in.
DR. ROBERT STEPHENS: There's been a tremendous downsizing in reimbursements. Who would have thought four years ago that we would love to work for what Medicare pays? Now Medicare has become the gold standard, and now all these contracts are coming Medicare minus.
ELIZABETH FARNSWORTH: I don't want to embarrass you, but has your income actually gone down?
DR. ROBERT STEPHENS: Oh, I'm down a third, as I think most physicians, the specialists that I know.
ELIZABETH FARNSWORTH: Are you all down?
DR. MARK MORALES: No, I'm up.
ELIZABETH FARNSWORTH: You're up.
DR. MICHAEL GRAY: I'm at a par.
DR. DEBRA JAMISON: I'm down.
DR. TODD TAYLOR: Down.
DR. MARILYN LAUGHEAD: Talking to physicians around the state, it appears that income pretty well generally is down. We're talking about as much as 40 percent.
DR. TODD TAYLOR: Let's not lose sight of what we're talking about, though, get off on to physician pay. In the emergency room every day, I fight for patients' rights under their health plan, and at the worst possible time all, of all time, when they are ill, many times their health plan fails them.
DR. MARK MORALES: I accept the situation in the community that there are situations like that. I tend to look at it, though, again, as an evolutionary process, and we just need to be continually involved in that.
ELIZABETH FARNSWORTH: I'm sorry, that's all we have time for. Thank you all very much for being with us.
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