Why I don't take Managed Care
In January 2000, I decided to stop seeing Managed Care patients in my practice. This was a difficult and painful decision for me, and one that did not come easily. I realized that I would no longer be able to continue taking care of a great deal of my established patients, many of whom had become good friends. I was concerned that I would not be able to continue to provide the high quality of Orthopaedic Surgery services to my patients that I was used to, given the restraints of the Managed Care system. I also felt that I was unwilling to provide anything less than my best efforts at delivering health care. Therefore, I determined that I could not continue to provide services for these patients.
Managed Care developed as a way to control health care costs, by making the physicians more responsible for cost containment. There are certainly admirable aspects to that goal. Unfortunately, what has happened is that we, the physicians, find ourselves under severe economic pressure to provide less than our best efforts, or to deliver a lesser quality of health care. Managed Care, in essence, rewards physicians for delivering less care, i.e. saving money. In its most extreme form (ie. capitation), physicians are actually penalized for delivering care, by making the cost of the care the physician’s responsibility, to the point that taking care of our patients may cost us to lose money!
In my opinion, the concept of Managed Care is illogical, as health care is not a basic commodity, like most of our other goods and services. We are certainly used to a variable degree of quality for all of our commodities and household goods, dependent on what we are willing to pay. The concept of ‘you get what you pay for’ holds true for most things. We understand that a nicer house, nicer car, or nicer bottle of wine, all cost more than less expensive versions. This is our choice as consumers; we can decide what we want to pay for something, depending on the level of quality. Managed Care is slowly creating the same marketplace. Managed Care is creating different levels of quality in Health Care delivery, which is antithetical to how we were trained to practice.
For years we, as physicians, have resisted this: We are not trained to deliver less than our best level of care. There is no “in the middle “ in Medicine. In my own practice, I believe I am cost efficient, and conservative in my care. I have not found room for any substantial reduction of services, without risking patient care. We are expected to deliver the same highest standard of care, regardless of insurance, regardless of payment, regardless of cost. All of the physicians I know have tired to do this. Yet we are treating patients with a wide variety of levels of reimbursement, with Managed Care at the very bottom. What has happened is that our non-Managed Care insured patients are subsidizing our Managed Care patients. Now it has reached the point that we may even lose money when we take care of a Managed Care patient. While I certainly feel a responsibility to take care of my share of indigent and uninsured patients, patients with Managed Care usually hold good jobs.
Our choice, as physicians, is clear. We can continue on the road we are on; we can continue to treat Managed Care patients with the same level of care as the rest of our patients, for far less reimbursement. We will continue to lose money with these patients. More Doctors will leave, or get burned out. Another unpleasant possibility is that we will learn to grow used to delivering a lower level of care.
For me, both of the above options are unacceptable. I spent many years in training at some of the finest medical institutions in the world, in order to be the best physician I can be. I am trained to take the best care of my patients as possible. When a patient comes to me, I take an extensive history, perform a thorough physical examination, and order appropriate tests to make a diagnosis. Then, and perhaps most important, I have to explain the condition or injury to my patient, in terms they understand, so that they can make rational choices regarding the care that they want for their bodies. This takes time, and in my opinion, cannot be shortcut or streamlined. I do not believe my care is extravagant or wasteful at all. I am, in fact, extremely efficient. I believe my care is my best effort, and I am unwilling to provide anything less.
All of us spent many years training to be physicians, and we give heavily of ourselves to our patients, at the expense of our own free time, and our families. This is our choice, and our calling. I am proud of what I do, and I am proud of the quality of my efforts. I feel that I honestly give my patients my best efforts, with their care in mind. This is what keeps me going, and I love what I do. I enjoy what I do because I feel I am an able advocate for my patients. While I am very cost conscious, I do not believe I can give my patients the same high quality level of care when I am given financial incentives to minimally treat them. It is getting harder and harder to find joy and satisfaction in what we do, with the continued onslaught of extraneous interference in our practices. Maybe I am being foolishly idealistic, but at some point this has got to stop. For me, this is the point.
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