THE VIRGINIAN-PILOT
Copyright (c) 1997, Landmark Communications, Inc.
DATE: Tuesday, January 28, 1997 TAG: 9701280013
SECTION: FRONT PAGE: A14 EDITION: FINAL
TYPE: Editorial
LENGTH: 62 lines
The federal government has proposed new rules on health-maintenance organizations aimed at preventing insurers from practicing medicine without a license.
For many years, fee-for-service medicine and liberal reimbursement policies by Medicare and Medicaid contributed to spiraling health-care costs. Horror stories about waste and overprescribing were common.
HMOs have changed the way physicians are compensated, have imposed restraints on referrals and have streamlined purchasing. Costs have come down. But horror stories are now being heard concerning incentives to save money that have the unfortunate effect of diminishing the quality of care that some patients receive. The pendulum has swung in the other direction.
The Department of Health and Human Services has warned HMOs that provide service to Medicare patients that it won't countenance so-called gag clauses that try to restrict which treatments doctors can recommend to their patients. It's expected the federal rules will be widely adopted in the private market.
Much evidence is anecdotal, but many doctors have claimed that such clauses are common. Some internists say they've been penalized for recommending bone-marrow transplants for women with breast cancer. Some psychiatrists have been told not to counsel suicidal patients that they need more time in the hospital than the HMOs in question permit.
In a very questionable practice, some HMOs have been known to reimburse only for cheaper - and not necessarily comparable - medicines, refusing to pay for more-costly but more-effective prescriptions.
Ironically, physicians have been critical in the past of government health-care programs for telling them how to do their jobs, at least indirectly, by setting fee schedules and thus limiting the availability and quality of treatment.
But some now applaud HHS for trying to prevent HMOs from influencing medical decisions or intruding their own medical judgment between doctor and patient.
Unfortunately, recent reports suggest medical costs have begun to rise again. That could encourage a further squeezing of costs. In a perfect world, doctors and patients would decide in consultation on the best treatment, but it's not a perfect world. Funds are finite while miseries are numberless. Many patients need more medical care than they can afford. Society as a whole consumes more medical services than it is prepared to pay for. A de facto rationing takes place.
It's unfortunate that insurers and the government each have felt compelled to limit doctors from practicing medicine as they see fit for reasons of economy. It is also regrettable that some physicians have been known to gouge, hospitals to profiteer and HMOs to squeeze costs to the point of undermining care.
The society is going to have to draw some clear lines that can't be crossed. But it's a fiendishly complex subject. Early attempts to legislate solutions have often been unworkable, unwieldy or overly restrictive.
The federal ban on gag rules seems reasonable. But a proposed Virginia law to make it illegal to make drug selection on the basis of financial incentives appears to address a real issue in a clumsy manner. Cases would be hard to prove.
One thing is certain. The debate over how to regulate managed care needs to be conducted in public and taken seriously. Lives, health and billions of dollars are at stake.