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Quality Issue Still Paramount in Debate Over Managed Care Health Plans With PM-Managed Care

June 1, 1993

Quality Issue Still Paramount in Debate Over Managed Care Health Plans With PM-Managed Care Glossary

WASHINGTON (AP) _ Dr. Richard Robinson sees a basic conflict between the way he practices medicine and the way managed care health insurance programs work: He spares no expense; they pinch every penny.

″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,″ says Robinson, a pulmonary specialist in Woodbridge, Va. He said he regularly turns down the opportunity to join managed care provider lists.

Robinson’s beliefs are echoed by other doctors who long have practiced traditional fee-for-service medicine, and who stand to lose patients and income as managed care programs become more popular.

But other physicians feel differently.

″I don’t have to agonize every time I order a test or a referral because I know the patients will probably follow through because they don’t have to take it out of their pocketbooks,″ says Dr. Judith Ratner, a pediatrician specializing in adolescent medicine at the George Washington University Health Plan in Washington.

Pressure on doctors to join managed care programs seems likely to intensify as more and more patients abandon costlier fee-for-service medicine.

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

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

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.

″If I don’t participate, I am excluding a tremendous portion of the population,″ said Dr. David Plotsky, a pediatric ophthalmologist in Washington.

Plotsky said the 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 are very inflexible about covering certain treatments, and paperwork for doctors can be a hassle.

Even though Ratner likes her health maintenance organization, or HMO, she is nervous about the future. ″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?″

Dr. Peter Rappo, a pediatrician, participates in several managed care programs near Boston. ″Although they might put restrictions on doctors and patients, they give patients the better bang for their buck,″ he said.

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 cost should not be the only issue in health care.

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.″

Doctors have their own set of concerns; patients have others.

After an unpleasant experience with an HMO 13 years ago, Linda Jacobson won’t enroll in managed care even though it would save her money. She doesn’t want her choice of doctors restricted.

″I know I could cut my costs and the government’s costs, but I would rather pay out the money as it is,″ said Ms. Jacobson, who as a federal worker can choose from a wide choice of health plans.

Marie-Helene Gugenheim, who arrived in Washington from France in 1988, said, ″HMOs are the most affordable way to get health care.″

Also, she said, ″When you get into a new city, it’s difficult to get a network of doctors you can have confidence in.″

Ladd Biro, the National Association of Manufacturers’ vice president for marketing in Washington, says the managed care referral requirement doesn’t bother him.

″I trust my primary care physician to give good advice and good direction,″ Biro said.

But Bill Martin, NAM’s treasurer, said he stuck with NAM’s catastrophic insurance plan.

″It’s a quality of care issue,″ he said. ″I want to be assured of that quality of care.″

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