Memo From The Editor

Doctors have learned

Marianne Dekker Mattera

Over the past few months, there's been lots of rhetoric about the death of managed care. And we've reported on countless problems in the industry in these pages recently, from the discussions among our roundtable panelists on the future of health care to last issue's cover story on the misuse of hospital-stay guidelines. Next issue we'll go into depth on a court case that strikes at the very heart of managed care.

Many worry that, if managed care does die, we'll find ourselves in the same boat we were in back in the '70s and early '80s when health care costs were skyrocketing, with no checks at all on physicians' practice patterns.

We need to keep a rein on physicians, these worriers argue. Otherwise we'll see an upsurge in patient visits—both to primary care physicians and to specialists—tests, and hospitalizations. Doctors will abandon generic drugs and formulary choices, choosing to write scripts for higher-priced products simply because they're familiar with them or because a detail rep happened to be in that day touting the value of a particular drug.

Well, I don't think that will happen.

True, doctors didn't think much about the economics of health care—the big picture and their individual roles in it—back in the days before managed care. But, painful as the HMO/PPO/MCO experience has been, it has made doctors much more cost-conscious.

You've learned how to manage a patient with fewer office visits and fewer—and shorter—hospitalizations. And, more important, you've learned how to maximize the care you can deliver in those fewer, shorter encounters. In many cases, you've re-engineered your practices, looking at systems and personnel, making sure that time isn't wasted and what needs to be done gets done.

A parallel move at hospitals, coupled with new tests and procedures, has allowed more and more patients to be treated on an outpatient or short-stay basis.

Some of you have also learned that patients can do just as well on a lower-priced medication as they do on the higher-cost one you've been prescribing as a matter of habit. And that, as long as the clinical outcome isn't affected, choosing the lower-priced one makes good economic sense.

I don't think visits to specialists will increase significantly if we lose the gatekeeper concept, either. Frankly, I don't know any primary care physician who won't give a referral, without hesitation, when there's a true need. The malpractice risk of refusing the referral is just too great. It could even be argued that the overall number of visits might decrease if patients can go directly to a specialist without having to go through the PCP.

We shouldn't have to worry much about an increase in visits to primary care providers, either. Although the disincentive to see patients inherent in some managed care arrangements might disappear, you still have to factor the patient's desires into the equation. And no matter how good a doctor's rapport with his patients, only the smallest percentage of people schedule a visit just to drop in and chat. Face it, most people don't want to go to a doctor, never mind be hospitalized.

And no matter how enticing the ads on TV or in the movies, if you tell a patient that an equally effective medication is available at half the price, she'll go for the lower-cost option every time.

So, can we afford to let managed care die without fear of breaking the country's health care budget? You bet.

Why? Because we don't have the same kind of doctor we had when managed care was introduced. Today's doctors are more aware of the entire scope of health care—they know the economics, not just the medicine—because they've had to learn the hard way.

Doctors have also learned the devastating effects that focusing too hard on the economics can have on the medicine. That's something the managed care folks have never learned.

 

Marianne Mattera. Memo from the Editor: Doctors have learned. Medical Economics 2001;16:6.