A Physicians Perspective on Managed Care

1
A Physicians Perspective on Managed Care

• A presentation of the Texas Medical Association
  and
• Your County Medical Society

2
A Physicians Perspective on Managed Care

• Ideas do count!

3
Defining the Physician-Patient Relationship

• The physician-patient relationship is the very
  essence of medicine.
• We will always, always, always make the medical
  decision that best benefits our patient.

4
Defining the Physician-Patient Relationship

• The Hippocratic Oath
• American College of Surgeons Fellowship Pledge
• Basic Rights of Patients
• The Patient-Physician Covenant An Affirmation of
  Aesculapius

5
The Hippocratic Oath

• I swear by Apollo the physician, by Aesculapius,
  and Health, and All-heal, and all the gods and
  goddesses, that according to my ability and my
  judgment, I will keep this Oath and this
  stipulation--to reckon him who taught me this Art
  equally dear to me as my parents, to share my
  substance with him, and relieve his necessities
  if required to look upon his offspring in the
  same footing as my own brothers, and to teach
  them this Art, if they wish to learn it, without
  fee or stipulation and that by precept, lecture,
  and every mode of instruction, I will impart a
  knowledge of the Art to my own sons, and of my
  teachers, and to disciples bound by a stipulation
  and oath according to the law of medicine, but to
  none others. I will follow that system or regimen
  which, according to my ability and judgment, I
  consider for the benefit of my patients, and
  abstain from whatever is deleterious and
  mischievous.
•  
• I will give no deadly medicine to any one if
  asked, nor suggest any such counsel and in like
  manner I will not give to a woman a pessary to
  produce abortion.
•  
• With purity and with holiness I will pass my life
  and practice my Art.
•  
• I will not cut persons labouring under the stone,
  but will leave this to be done by men who are
  practitioners of this work.
•  
• Into whatever houses I enter, I will go into them
  for the benefit of the sick, and will abstain
  from every voluntary act of mischief and
  corruption and, further, from the seduction of
  females or males, of freemen and slaves.
•  
• Whatever, in connection with my professional
  service, or not in connection with it, I see or
  hear, in the life of men, which ought not to be
  spoken of abroad, I will not divulge, as
  reckoning that all such should be kept secret.
•  
• While I continue to keep this Oath unviolated,
  may it be granted to me to enjoy life and the
  practice of the Art, respected by all men, in all
  times. But should I trespass and violate this
  Oath, may the reverse be my lot.

Into whatever houses I enter, I will go into
them for the benefit of the sick
6
Patient-Physician Relationship

• Immediate past
• Psychiatrists Soviet Union
• Physicians Nazi Germany
• Current
• Bosnia
• Rwanda
• Upper Africa

7
Development of the Health Insurance Industry

• Spread risk
• Blue Cross/Blue Shield
• Employee Entitlements
• Medicare/Medicaid
• Kaiser Model
• Managed care

8
Defining Managed Care

• A general term for organizing doctors, hospitals,
  and the providers into groups in order to enhance
  the quality and cost-effectiveness of health
  care. Managed care has, unfortunately, also had a
  negative connotation when used as an adjective to
  describe some health plans and payer
  organizations whose payment, coverage and benefit
  decisions undermine the patient-physician
  relationship.

9
Managed Care

• Corporate ideals
• Physician ideals

10
The Nations Health Dollar 2000Where it Came
From
11
The Nations Health Dollar 2000Where it Went
12
The 25 Highest Paid Executives

• 2000 Annual Compensation Exclusive of
  Unexercised Stock Options
•  
• Name Title Company
  Compensation
• William McGuire CEO UnitedHealth Group
  Corporation 54,129,501
• Wilson Taylor Chair (ret) CIGNA Corporation
  24,741,578
• Ronald Williams Executive VP WellPoint Health
  Networks Inc. 13,205,631
• Total Compensation for these 25 Executives
  201,140,449
• Average Compensation for 25 Executives
  8,045,618
• Source Families USA

13
Cost Controls

• Health provider contract discounts
•  Preventative medicine
•  Quality medical care-utilization review
•  "Cherry picking"
•  Economic profiling

14
Cost Controls

•  Economic incentives and disincentives
•  Restrictions-therapy and testing gag clauses
•  Physician panels
•  Medical necessity
•  Capitation

15
A Free Market System?

• Never was and never will be
•  Government intervention
• ERISA Act
• FTC rules

16
A Free Market System?

• Never was and never will be
•  Government intervention

17
A Free Market System?

• Texas HMO Market Share 1994
• In 1994, 20 licensed HMOs served about 3 million
  Texans. Numerous plans had significant market
  share.

• Market Share 2001
• By 2001, merger mania had changed the face of the
  market in Texas few plans hold significant
  market share.

18
The Truth About Care for the Poor

• The average Texas physician provides about
  22,200 every year in charity care
• That amounts to nearly 1 Billion a year
• Pediatricians provide the most charity care in
  Texas -- 29,400 per year
• Source 1998 TMA Survey of Texas Physicians

19
The Truth About Care for the Poor

• Managed care is forcing doctors out of charity
  work.
• US doctors provide 11 billion in free or
  discounted care each year
• Physicians with heavy managed care practices
  devote only half as much time to charity care as
  doctors outside of managed care
• As managed care grows, the number of uninsured
  Americans increases by about 1 million per year
• Source Houston Chronicle, April 6, 1999

20
Managed Care Impact on Quality
21
Managed Care Impact on Quality
22
A Physicians Perspective on Managed Care

• A presentation of the Texas Medical Association
  and
• XXXXXX County Medical Society