PBS- Healthcare Crisis: Manage care

The Gilberts' daughter, Mara, is 13 years old and is finishing a 2 and 1/2-year protocol for the successful treatment of leukemia. The insurer paid most of the bills but refused some when prior authorizations weren't properly secured. The family argues that many times during her treatment they couldn't take the time sometimes hours to wait for pre-authorization, especially when Mara was rushed to the hospital suffering from a high fever, or other emergencies and complications. In addition, even for procedures that they did approve in advance, the insurer has delayed payments to the hospital, in some instances for more than a year. As a result, the Gilberts have been harassed by debt collection agencies and their once-respectable credit rating has been ruined.

”Now it’s all HMOs because that’s what everybody can afford. You can’t afford total coverage, no matter where you go.” Charlie Nielsen

Richard is the owner of the B & M Machine Company. To provide health insurance for his employees, he has joined a leasing program but still has difficulty offering the coverage and remaining competitive. Charlie has worked at B &M Machine Company for 42 years and has seen a lot of change in the way employers provide health care coverage.

Ninety-one percent of employees with health insurance were enrolled in managed care plans in 1999. Managed care plans range from Health Maintenance Organizations (HMOs), which require enrollees to select from a network of doctors, to Preferred Provider Organizations (PPOs), which are more specifically designed to meet a patient’s individual needs (but at a higher cost). Managed care emerged as a response to the skyrocketing costs of the virtually unrestricted fee-for-service plans popular in the1980s, but many Americans express dissatisfaction with the limitations imposed by managed care.

Patients are concerned about the effects of cost-containment measures, such as pre-certifications and specialist referrals, and about losing access to services they believe they need. And from the physicians’ perspective, the requirements and policies of many managed care plans can sometimes undermine the traditional doctor-patient relationship make the doctors question their role as patient advocate. There are also gaps and differences in state law protections which have prompted many to feel that greater federal regulation of the managed care industry is necessary.

“HMOs have the promise of both controlling costs and improving quality. Now as it's happened in the last several years, there have in fact developed some HMOs that appear to be as interested in profit as they are in delivering care. At this point we need to recognize that there is an extremely wide variation in HMOs. Many of them are not-for-profit. They don't make a cent of profit. So their incentive is to deliver the best care possible within the budget that people are willing to pay. At the other end of the spectrum we do have some companies that do seem to be motivated by profit. I would very much like to see the profit incentives decreasing or at least becoming much more reasonable and having the primary motivation from HMOs to be the real motivation that got us excited about them as a country in the first place, which is improved quality and controlled costs.” -- David Eddy, MD, PhD, Senior Advisor, Kaiser Permanente

“In 1993 and 1994, when the Clinton Administration was creating its plan for health care reform, managed care was already a large train hurtling down the track. Because the plan was defeated, many Americans, I think, now attribute the things that they dislike, in some case intensely about managed care, to the large companies, particularly the for-profit companies, that own the plans.” --Tom Murray, PhD, President, The Hastings Center.

“Managed care isn't a thing; it's just a whole lot of different efforts to bring rationality and a bit of fiscal conservatism to our health care system. But in the process I think some of the deeper issues that we're up against have to do with the best interest of each individual versus the best interest of populations of people. And we really do have clashes of, in a certain instance, some very wonderful, but extremely expensive, treatment that really does work for somebody” -- Haavi Morreim, PhD, Professor of Human Values & Ethics, University of Tennessee