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Quality and Cost: The Debate Over Managed Care Health Plans

June 1, 1993

WASHINGTON (AP) _ Dr. Richard Robinson regularly turns down the opportunity to join managed care health plans. Dr. David Plotsky enrolls in every one that asks.

Robinson, a pulmonary specialist in Woodbridge, Va., says he sees it as a quality-of-care issue. ″Their objective is to provide care at the cheapest or least expensive manner, where I try to provide the best quality care I can provide regardless of cost,″ he said.

Plotsky, a pediatric ophthalmologist in Washington, says it is an access issue. ″If I don’t participate, I am excluding a tremendous portion of the population,″ he said.

Pressure on doctors to join managed care programs seems likely to intensify as more and more companies and their employees abandon costlier fee-for- service medicine. Doctors who don’t participate could face the loss of patients and income.

President Clinton’s emerging plan for overhauling health care is expected to rely heavily on the managed care concept, with millions of people led to join large health care groups and with doctors required to accept generally lower fees to treat them.

Managed care plans seek to hold down costs by requiring participants to choose within a network of doctors who have agreed to certain fees, and by closely monitoring the delivery of medical services.

They are gaining in membership.

Foster Higgins, an employee benefits consulting firm, surveyed 2,448 businesses last summer and found that for the first time more than half - 51 percent - of the 12 million employees and dependents covered under the companies’ health plans were in managed care. Seventy-seven percent of the companies offered managed care options.

Dr. Sheila Palevsky, a pediatrician with the George Washington University Health Plan, said the Washington-based health maintenance organization allows her to concentrate on patient care, rather than the business end of medicine.

″Over time we develop a good rapport with our patients,″ she said. ″The strength of this practice is the quality of care.″

Plotsky, a managed care supporter, said such plans can create hurdles for patients, including requirements that they see primary care physicians before they can be treated by specialists such as himself. He said they also can be very inflexible about covering certain treatments, and paperwork for doctors can be a hassle.

But, he said, ″I would rather see more patients then sit around and wait for a full-paying patient.″

Dr. Peter Rappo, a pediatrician who participates in several managed care programs near Boston, said managed care plans ″give patients the better bang for their buck,″ despite the restrictions.

Doctors opposed to managed care contend that they will have to increase volume - and decrease the amount of time they spend with each patient - to compensate for the loss of income.

Robinson said a lot of people don’t really understand the realities of managed care, that the plan might require them to stop seeing a doctor with whom they have ″a rapport and confidence and trust.″

He said some of his patients who tried managed care programs come back and ″tell me they don’t have the opportunity to see specialists, that they’re limited in terms of access to care.″

Cost should not be the only issue in health care, Robinson said.

″Most doctors don’t look at cost,″ he said. ″They look at what’s best for the patient, and if you’re that patient, that’s what’s important.″

Dr. Judith Ratner, a pediatrician specializing in adolescent medicine at the George Washington University Health Plan, fears that moves to trim costs may have a detrimental impact on the way she practices medicine.

″Our health plan is under pressures to make it a little less costly to take care of patients. ... How do you cut down on the time you spend with a patient without cutting down on the quality?″

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