WHAT THE DOCTOR ORDERED

November 9, 1999
		Doctors will now have the final word in treating their patients, at least from one health insurer. Citing the high costs of reviewing denied claims and the fact they currently approve 99 percent of requests, UnitedHealth Group declared yesterday that they plan to defer to physicians for treatments. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

A Health Spotlight Report: Patients' Bill of Rights Nov. 1, 1999: Increased privacy for patients. Oct. 29, 1999: President Clinton proposes increased privacy for patients. Oct. 27, 1999: The House votes against assisted suicide. Oct. 7, 1999: Patients can now sue their HMO's. Oct. 6, 1999: Congress debates HMO reform legislation. Sept. 30, 1999: Patients vs. HMO's July 16, 1999: A Republican bill passes July 15, 1999: Senate votes against HMO suits. July 14, 1999: A partisan debate. July 13, 1999: Should patient's be able to sue HMO's? July 1998: Forum: Should the government manage care? July 9, 1998: Debating managed care The NewsHour's Health Spotlight. Browse the NewsHour's coverage of Health   UnitedHealth Group American College of Physicians-American Society of Internal Medicine White House	GWEN IFILL: In popular culture, in Congress, and for countless patients, HMO's have become the enemy. SPOKESPERSON: It looks like there's a possibility they're questioning pre-existing. GWEN IFILL: Anyone with a horror story to tell has found plenty of outlets in the media, and members of Congress have climbed on board as well. REP. CHARLES NORWOOD, (R) Georgia: What we've done in this country over the last 30 years is turn over the health care industry of this country to the insurance industries, and they are in total charge. GWEN IFILL: Polls show most Americans now believe they are being shortchanged by managed care, the very idea once considered a solution to soaring health care costs. In a Washington Post poll published this week, access to health insurance through HMO's was listed as the number one concern. ROBERT BLENDON, Harvard School of Public Health: Most of them actually haven't had experience. They say they've heard about it from a friend or family member or the media. But they are convinced the changes of the last five years, as everybody shifted into managed care, have put them at risk for personal safety when they're very, very sick. GWEN IFILL: Congress has grappled with the issue for two years. Last month, the House passed an HMO Reform bill that would give patients broad new rights, expanded access to care, and new avenues of appeal. But the Senate version is vastly different, with no middle ground in sight. Meanwhile, premiums are rising, due in part to increased use of drugs and changes in medical technology. HMO's, most of them now for-profit businesses, say some decisions to deny care often save consumers money and expand health care coverage. But HMO's also have made powerful enemies within the health care community, especially among doctors. They've argued that administrators, not physicians, have been making the ultimate decisions on medical issues, including access to specialists and coverage for experimental treatments. UnitedHealth Care, the nation's second largest HMO, is the latest insurer to shift strategies in the face of poisonous public opinion. United says administrators will not interfere with doctors' decisions on a case-by-case basis. Instead, doctors will be given greater say in deciding what medical treatment is necessary. In doing so, United has put other insurance companies on the spot, and set up the next big debate over managed care.
	A changing HMO
	GWEN IFILL: Joining me now from all sides of the HMO debate, Judith Feder, Dean of Policy Studies at Georgetown University and the Institute for Health - in the Institute for Health Care Research & Policy: Dr. Whitney Addington, president of the American College of Physicians; Robert Laszewski, president of Health Policy & Strategy Associates, a consulting firm; and Dr. Lee Newcomer - the senior vice president for health policy at UnitedHealth Group, the parent company of UnitedHealth Care, together; they provide HMO coverage for millions of people. Dr. Newcomer, why has United reached the decision to offer this? DR. LEE NEWCOMER, UnitedHealth Group: We were listening to our customers. It was a matter of people saying to us they thought we had too much control over the decisions, and whether we actually did or didn't was irrelevant. The thought, the perception was there. So what we decided to do was find a way to bring control back to them so that the doctors and patients could make their decisions together, and we would support that decision rather than try and get in the middle of it. GWEN IFILL: But isn't what was medically necessary yesterday still going to be medically necessary tomorrow? What changes really? LEE NEWCOMER: Well, what changes is how we actually react to that decision. We're no longer going to say to a physician, "we want to second guess what you're doing." What we're going to say is, "How can we get that decision executed faster? How can we get it done better?" So, we're going to spend our time, our doctors and nurse -- we never had administrators reviewing cases -- our doctors and nurses are going to instead walk by the patient as they go through the hospital and help them get those services quicker. GWEN IFILL: As you know, HMO's have become the big bogeyman. What... is this a matter of your trying to get out of the way of the oncoming train -- the change was going to happen anyhow, and you just got there first? LEE NEWCOMER: Well, we actually started this three years ago. The reason that we can make this change comfortably is because three years ago we started pilot studies, and we know from those studies that changing the way we did this didn't raise costs. So what's happened is physician have made changes. They've adapted. Fifteen years ago we had to have these things in place because costs were rising at 20 percent. Doctors weren't doing anything about it, including me when I was in practice. That's changed. They're being conscientious about their decisions, and now we can get rid of the old processes we used 15 years ago. We don't need them. GWEN IFILL: Mr. Laszewski, you advise other health care companies. Will there be a bandwagon effect? Will we see other companies following suit? ROBERT LASZEWSKI, Health Policy & Strategy Associates: Well, it's interesting. I talked to a number of HMO'S and health insurance companies today on their reaction. And I think it comes in two forms: Some of it is cynical, some of it is very positive. On the cynical side, what I hear insurance companies talk about and HMO's talk about is that this is not been an area that UnitedHealth Care has stressed to the same degree others have had over the years. And in large part, many HMO's and insurance companies focus on fee schedules and on putting providers, doctors at risk. For example, it's not uncommon to see a PPO, which is probably the preferred provider organization, the least managed kind of managed care, getting a fee schedule of 150 percent of the standard Medicare schedule, where some of the tougher HMO's may be more around 100 percent of that index. GWEN IFILL: What does that mean? ROBERT LASZEWSKI: That means there's as much as a 50 percent difference in what a less-managed plan is paying a doctor versus a tightly managed plan. So, much of what's gone on in managed care in recent years has been about screwing down the costs in terms of what's being paid, both in terms of captivation and fee-schedule kinds of reimbursements. I recall the first time I saw pre-certification used was in 1983. So, it's sort of a 16-year-old system. And it's more the fee schedule that's being keeping costs down. Also on the cynical side, people are saying, well, UnitedHealth Care's stock dropped by about a third when it was announced that a number of trial lawyer organizations were going to start going in after the HMO industry. And there's a concern about litigation. And this is a way to some degree preempt that. GWEN IFILL: So is this a heroic move on United's part or is it a risky move on their part? ROBERT LASZEWSKI: Well, it depends again whether you're looking at it cynically or optimistically. What I hear on the optimistic side or the positive side from people, what I hear is this is more an indication what we're going to see is evidence-based medicine, in other words, collecting data, knowing more about what works and doesn't work, and using that information to improve cost and quality. Pre-certification, what they stopped doing today, is circa 1983. What they're talking about doing more of is evidence-based medicine, more education, working with doctors and hospitals in the best way to do something. And that is fairly consistent with what's going on in the industry. And I think they made a bold move today. I think it was a good public relations move. I think they've invested a lot in evidence-based medicine over the years, and they've taken the initiative. And they need to be applauded for that.
	A plan good for doctors and patients?
	GWEN IFILL: Dr. Addington, is this PR, or is this good for doctors? DR. WHITNEY ADDINGTON, American College of Physicians: Well, I don't know if it's PR or not, and I can't comment whether it's cynical or opportunistic, but I can comment that it's welcome. Physicians in general in our organization in particular have always pointed out that patients are only interested in the quality of care that they provide, physicians are only interested in the quality of care they provide their patients. And physicians should be allowed to practice within the scope of their practice. And I think this goes a long way of removing what first in terms of second opinions and now pre-certification being removed were barriers to the realization of that quality care. GWEN IFILL: In your experience in your practice, as well as with other doctors you know, is this something that's going to change the way you do business? DR. WHITNEY ADDINGTON: Oh, absolutely. It will remove large hassle factors which can be risky. Let me tell you a story. I'm caring for a patient now that I've cared for for 20 years, a young man with chronic lung disease awaiting a lung transplant. And six months ago because there was a change in case managers, he was denied oxygen therapy. He receives continuous oxygen therapy at home. And this was not just -- caused me to lose and afternoon, and more importantly put him at risk. And with the removing of these hassles, we can get on to true quality control. And I suspect that while the... heretofore, the insurance companies have been concentrating on over-utilization, there's dangerous under-utilization, which I'm sure they didn't look at. Now let's use good peer review and look at some of those outliners. GWEN IFILL: So Ms. Feder, should consumers be breathing a huge sigh of relief over all of this? JUDITH FEDER, Georgetown University: I think consumers need to be cautious here. First, I think that the action confirms consumer's concern that managed care plans have not within so much managing care as putting barriers in the way of giving and getting good care. So I see some pretty good confirmation of what we've been worried about right along. Second, I think we have to watch what comes in place of this review. We can hope for true management of care, people, doctors and patients looking together at the evidence and deciding what makes most sense to do, but we've also heard United say that they are going to continue to be concerned about what physicians do and oversee how they choose physicians. GWEN IFILL: After the fact? JUDITH FEDER: Who they take in and who they let go. And we do know of experience already where there is a concern that a physician, for example, who sees a lot of high-cost patients, a lot of patients with AIDS or disabilities, a patient (physician) who believes that a particular practice is necessary for his patients and it's a more expensive approach, that kind of physician can see themselves dropped in the plan. And as consumers, we won't be able to see that as clearly as we would see a denial that would be in our face. GWEN IFILL: So they're saving money by cutting doctors instead of cutting care. JUDITH FEDER: No, it's the same thing. They're cutting doctors who deliver care, but it's harder to see. GWEN IFILL: Dr. Newcomer, I know you want to respond. LEE NEWCOMER: Well, I think we need to check those facts, because our track record shows last year out of 300,000 physician, we only terminated 150, and they had lost their licenses for disciplinary action. So when we talk about terminating physicians for high utilization, that's bunk. It doesn't happen. JUDITH FEDER: Dr. Newcomer... LEE NEWCOMER: The other thing I'd make a point about is we've been evolving to make our plans user friendly for a long time. We didn't have gatekeepers as far back as 1984, so you didn't need permission to go see a specialist. In 1992, we released the first public report cards, and we've, in fact, been documenting under-utilization by physicians for the last three years as a industry leader, helping doctors learn where they weren't practicing against standards and helping them do more care. In fact, we made the front page of the Wall Street Journal with that a year-and-a-half ago. So one of the things I'd point out to you is our consumer orientation is how do we improve health care? And I would say to the skeptics about this is a public relations move, this was part of an evolutionary process for us that started three years ago -- long before trial lawyers, long before the patient bill of rights. GWEN IFILL: Ms. Fader, you wanted to respond. JUDITH FEDER: Yes. I wanted to clarify that I was not referring to your past practices in terms of terminating physicians. I'm responding to the report that was put forward by your company that said you were going to look more at profiling. And what I'm describing are the risks of profiling. Profiling can be used as you've put forward to, encouraging all physicians to do better care; that's what managed care was supposed to be about. It can also be about identifying physicians who are costing money, and what we need to do is watch it.
	The rising cost of health care
	GWEN IFILL: Dr. Addington, what is to stop doctors now from prescribing more expensive and unnecessary treatments now that they are not going to be monitored on the front end? DR. WHITNEY ADDINGTON: Well, I think you'll find that the vast majority of physicians take appropriate care and properly... and use appropriate, both amount of prescribing medicines, as well as the amount of diagnostic tests. I'd very much like to underscore the point about the case mix in this profiling process. But I think you'll find, and every study that I've seen, is that most physicians really are only interested in the quality of care they deliver their patients, that most will not be outliers in judging against best practices and peer review guidelines. And they are really... we are physicians who are only interested in the care of our patients, and we'll do the best we can for them. We're not interested in running up bills. And I think there have been some good outcomes from the managed care era in that I think that the runaway inflation of increases in cost in the past have been curtailed. I think it's swung too far. And I think when physicians are given the opportunity to practice as they think best without this burden of pre-certification, second opinions and other things, when outcomes are looked at, patients, as they are now, will be delighted with their physicians. GWEN IFILL: Mr. Laszewski, Dr. Addington obviously feels very optimistic about the chance that costs won't take off again. What's your take on that? ROBERT LASZEWSKI: Well, I think what he's saying is that people operate in the system in good faith generally. And I think that's true of physicians, I think that's true of everyone who is participating. I think one of the key components of what UnitedHealth Care is talking about is providing more information so we have a better set of decisions made that balance cost and quality. But we can't be naive about it either. My sense is that while evidence-based medicine understanding about what works and what doesn't and educating people better is the direction to go, the fact of the matter is, we're still in our infancy in our ability to do that. If I were a consumer, I would be very concerned about having a conversation with my physician, understanding how that physician is compensated, understanding the degree to which that physician is using the kinds of materials, the systems, the protocols and so forth that are available now to tell the physician what the best options are -- because in the final analysis, this is going to be about both balancing costs and quality. Health care costs are less... are rising at a rate less than they have, but they're starting to take off again. It's not uncommon to see HMO costs rising 8 to 10 percent a year. UnitedHealth Care is a shareholder-owned company. It has to make a profit. This sounds good, but in the final analysis, they're going to have to balance the books, and they're going to have to control costs. GWEN IFILL: Ms. Feder. DR. WHITNEY ADDINGTON: May I take up that challenge? GWEN IFILL: Just one moment. Ms. Fader. JUDITH FEDER: What Mr. Laszewski is saying is that it's important and useful for a company to be saying it's going to work on using evidence to educate its doc's. But we have to be careful that it's not at the same time setting up a reward and a penalty system that makes doctors internalize the incentive to under serve. That's what we have to worry about. GWEN IFILL: Dr. Addington? DR. WHITNEY ADDINGTON: I'd like to accept that challenge, as president of an organization of 137,000 internists, this is the way the vast majority, in fact, all internists I know within our organizations practice. A continuous education program is part of all our lives. And I think we would welcome these opportunities. GWEN IFILL: Dr. Newcomer, you get the final word.
	Predicting congressional reaction
	LEE NEWCOMER: Great. Well, Gwen, what I would say to you, we have the same trust in physicians Dr. Addington is talking about because experience shows it. We've done seven pilot sites. And when we worked side by side with the doctors and our members, what happened is costs stayed flat or they went down. The kinds of things we do are actually advocating for the patients. Let's say, in fact, a true story -- on Thursday night, a woman with chest main needed to have a heart catheterization - a dye test of her arteries. And it was scheduled for not Friday morning, but Monday, because the cath labs were full and nobody works on the weekend. Well, we called for that lady to find someone who would come in and do the catheterization Friday morning so she would-be have to wait three days to find out whether she had had a heart attack. That's better care, and that's also less expensive care because we were by her side fighting for her to get what she needed right away. That's what all of this is about. It's about helping our customers get the health care that their doctors ordered in a way that really makes sense. GWEN IFILL: I know I said you have the final word, but I have to ask one more question on the other side of the table. What's the chance there's going to be any change in Congress as a result of what's happened here? ROBERT LASZEWSKI: I don't think it will slow things down in Congress a bit. First of all, I don't think we're going to get a patients right bill next year because it doesn't seem that Democrats or Republicans really want to do it. I think they want a campaign issue. So this doesn't affect that. But when the day is done, I think consumers are going to say, "It sounds good. This is what we want to hear." But in the end, I think they're going to want that bill, want that law to be sure they're protected. JUDITH FEDER: They need it. DR. WHITNEY ADDINGTON: And I'd offer that the market offers them a choice, that we responded to consumers two years ahead of the law, and more importantly, the law might take away the flexibility we need to continue serving customers. So I think a law will actually be a problem instead of a good thing. GWEN IFILL: So you get the final word after all. DR. WHITNEY ADDINGTON: I did. GWEN IFILL: Thank you, lady, thank you, gentlemen.