dr. solomon's dilemma


solomon profile
financial incentives
cost v. care

a hospital scene

In the 1990s, as America's HMOs cut costs by controlling patients' care, they were reviled as the enemy of doctors and patients. Now, after fighting to regain control of the medical process, doctors are assuming responsibility for treatment decisions.

But, there's a catch. Taking control means financial risk. The more care doctors give, the more it can cost them directly. So the sickest patients can become money losers for doctors like Martin Solomon, a respected primary care physician at Beth Israel Deaconess Medical Center in Boston.

In "Dr. Solomon's Dilemma" FRONTLINE correspondent Hedrick Smith goes behind the scenes for a candid examination of this new frontier in managed care. The cameras follows Dr. Solomon and his colleagues as they are forced to weigh cost vs. care, patient by patient. That's because they're in what's called a capitated plan with a lid -- each doctor gets just so much per year per patient. As a result, part of their own salaries are at stake if they go over.

This report looks at how thousands of doctors are part of this new trend in managed care. In 1998, Dr. Solomon sold his practice to a company called CareGroup, a network of seven hospitals, 3,000 doctors and 400,000 patients. In 1999, CareGroup lost $100 million.

In an effort to change that, CareGroup's doctors, working under thse capitated plans, have been made responsible for containing treatment costs and turning their practices into profit centers. CareGroup--and other national health care systems--have organized doctors into small mutual-review groups known as "Pods." Each pod must balance its own books.

FRONTLINE's cameras follow Dr. Solomon into one of his Pod meetings where the doctors are shown cost charts itemizing how much each spends on everything from X-rays to prescriptions to surgical costs. The doctors see which members of their Pod are spending more on patient care--thereby decreasing the group's profits.

"Dr. Solomon's Dilemma" also interviews corporate cost cutters who argue that doctors should have a more direct role in monitoring costs; hospital administrators who are fighting red ink every year; and patients who in this new culture of medicine, are called "units."

Several stories of patients are interwoven throughout the report: patients who have become financial liabilities for their doctors, or whose hospital stays are being shortened, or who are told they have to stay within a certain team of doctors even though an outside doctor may have more experience in treating their illness.

As Dr. Solomon confesses, this new cost consciousness not only affects a doctor's decisions in treating his own patients, it also ultimately tears apart the trust between doctors and patients.

"One patient said to me, 'So, you're not letting me do this because of money?'" Solomon tells FRONTLINE. "My response was, 'Of course--if it was just medical care, I'd let you go wherever you want. But this is a contract. I'm not in the business of subsidizing your care.'"

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