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Sunday, May 31, 2020  Spokane, Washington  Est. May 19, 1883
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News >  Spokane

Hmos Maintain Profit, Not Care

By Tommy Denton Fort Worth Star-Telegram

Despite all the glowing promises in the last decade of a new age of affordable, compassionate medical services, the managed health care industry has been taking some tough knocks from disillusioned consumers and lawmakers. Let’s hear it for tough knocks.

Suspicious critics all along have argued that HMOs were offering a deal too good to be true. Once the profit motive is introduced into any equation, they warned, human nature will tend to concentrate on the financial inducements at the expense of other, less pressing motives, such as adhering faithfully to the Hippocratic oath.

In response to protests that such concerns were unfounded, the marketing gurus of the managed-care networks issued assurances that the new age of high-quality, low-cost health services would dawn, if they could just be spared the onerous burdens of regulation.

Then came the spasms of complaints, most founded on the management principle that cost-controlling administrative decisions should take precedence over doctors’ priorities in delivery of medical services. According to the complaints, accountants’ judgments began to overrule physicians’ judgments.

“Gag orders” instructed doctors not to reveal medical options to patients. Concerns about “excessive” hospital stays led to “drive-by” deliveries of babies, turning the new mommies out of their rooms within 48 hours. Soon, complaints emerged over “drive-by” surgeries, especially for hysterectomies, which posed health hazards to recovering patients shoved out of protective care prematurely.

Enough of these complaints led eventually to political responses, and legislatures found themselves confronting new “diseases of the week,” afflictions that many patients and their advocates said reflected a devil-may-care attitude that overemphasized cash flow and minimized threats to patients’ well-being.

Throughout the barrage of public criticism, the managed-care networks insisted that they must remain free of the fetters of regulation. In Texas this year, the protests failed to sway the regulation-averse Legislature, which enacted a law to allow patients to file malpractice lawsuits against the networks if they had been medically harmed by HMOs’ administrative decisions to limit their care.

Lawsuits, unfortunately, are an extreme remedy that no one but lawyers would prefer. Better to prevent the circumstances that lead to unpleasant consequences, that is, establish uniform standards that hold all health care providers accountable for the quality of their services.

The idea is hardly new. Since 1917, U.S. hospitals have subjected themselves to accrediting standards, primarily to improve their care but also to gain public confidence in their services.

In the decades since, especially after World War II, general, psychiatric, children’s and rehabilitation hospitals, clinics, nursing homes, clinical laboratories, home care agencies and ambulatory surgery centers have sought review and accreditation by private entities whose sole purpose has been to assure compliance with the optimum standards of medical care and sound financial management.

Government oversight of providers has grown more stringent, especially with the advent of Medicare and Medicaid in the mid-1960s, but the private accrediting agencies have provided the professional and technical expertise to make the evaluations.

Federal agencies have formed public-private partnerships with those entities, saving taxpayer money by avoiding expanded regulatory bureaucracies and taking advantage of the expertise to encourage compliance with standards that are in the public interest and providers’ own self-interest.

Accreditation is the seal of approval that the facilities meet strict standards of medical care and financial soundness, and makes them openly accountable to the government, patients, insurers, payers of insurance premiums and related health professionals.

Guess which sector of the health care system resists being required to submit to such accreditation. You got it: managed care networks, on the specious notion that they aren’t really health care deliverers but mere brokers of a professional service.

Horse hockey and bull roar.

Until the entire U.S. health care system is held accountable, under law, for the quality of patient care - including measurable performance for good medical outcomes - public confidence in managed health care will continue to deteriorate because one segment will continue to evade complying with standards of excellence that all Americans should expect of the system.

A bill to create a comprehensive national health care framework to ensure such accountability, including managed-care networks, got lost in the undertow of the recent balanced budget agreement in Congress. That’s a shame.

Until the networks are brought into the tent with the other elements of the health care system, state and national legislators will be confronting a new “disease of the week” that forces its way into the headlines because HMOs are dodging the duties of care in pursuit of the maintenance of profits.

Last week it was inferior care for stroke victims. Wonder what it will be next week?

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