Copyright 1999 Times Mirror Company
February 14, 1999, Sunday, Ventura County
SECTION: Metro; Part B; Page 19; Zones Desk
LENGTH: 957 words
VENTURA COUNTY PERSPECTIVE;
THE DOWNSIDE OF ACCOUNTABILITY;
SMALLER NETWORKS, MORE HEALTH PLAN INVOLVEMENT IN MEDICAL DECISIONS, HIGHER
PREMIUMS AND MORE UNINSURED PEOPLE WOULD BE THE RESULT.
BYLINE: ROSS K. GOLDBERG, Ross K. Goldberg of Westlake
Village has worked in health care for, 23 years and is a former senior vice
president of Woodland Hills-based, CareAmerica Health Plans
Many adventurers wandering through the
forest of health care reform find themselves much akin to Goldilocks. They are
looking for solutions that are not too hot and not too cold. Unfortunately, many
of the answers being offered aren't just right.
Such is the case with
those trumpeting unbridled litigation as a way to resolve disputes with managed
health care plans. These zealots steadfastly wager that only through more
stringent judicial accountability can consumers be assured ultimate salvation.
Although such a position easily seduces its sorority of cheerleaders, the
reasoning behind it is alarmingly shortsighted and, if followed, would create an
undertow of unwanted results. Among these could be smaller provider networks,
greater health plan involvement in medical decisions, increased premiums, more
uninsured and continued erosion of trust in our nation's health care system.
For the past decade, consumers have been relentlessly urging health
plans to construct the largest networks possible--more doctors, more hospitals,
more choices for care. Bigger is better and biggest is best. Just as small
market teams in sports find it increasingly arduous to compete, small network
health maintenance organizations are soon buried by plans aglow with thousands,
if not tens of thousands, of doctors from which members may choose.
these contracted networks are assembled, consumers demand that plans "remove
themselves" and delegate all delivery of care decisions to the doctors and their
medical groups. In fact, every step health plans have taken to remain
engaged--from the establishment of drug formularies to utilization review
boards--has been viewed as an unwanted encroachment on the hallowed relationship
between patient and physicians. Mattering little that substantial evidence
supports such interactions as actually increasing care and promoting wellness,
such efforts have fostered a lingering, uneasy resentment among members.
These same people argue that health plans should be held legally
accountable for every action taken in any corner of the plan. If care is denied
and the member suffers as a result, the HMO should be liable. If care is given
but later deemed to have been inappropriate, the HMO should be liable as well.
Beyond the inherent contradiction in demands, what do you think would happen,
given such a state of affairs? Networks would shrink--it is easier to oversee
500 than it is 5,000 physicians--and health plans would become more directly
engaged in all decisions. The exact opposite of what the public wants.
If plans were liable for decisions made by any one of thousands of
contracted physicians, it would create a chilly atmosphere that would encourage
attorneys and their clients to, like Ahab, turn every minnow into a whale: Every
dispute would become an opportunity to petition for large financial damages.
In self-preservation, health plans would do what you or I would do--and
what physicians have been doing through increased malpractice insurance: They
would increase their professional liability coverage.
Such action could translate into higher premiums to employers through
whom 64% of non-elderly Americans receive their health insurance. This increase
might, in turn, cause some employers to drop coverage, and that would lead to
even more uninsured (every 1% raise in premiums results in 40,000 Californians
losing their coverage). Already, 7 million Californians are uninsured, and it is
predicted that 53 million to 60 million non-elderly Americans, or one-fourth of
the population, will be uninsured by 2007. Ultimately we all pay both
financially and morally as this societal tragedy proliferates absent strong
public policy regarding the unalienable right to health care.
understandably, the issue of liability has taken center stage recently in wake
of the $ 100-million-plus judgment against a California health plan. But a
comprehensive study by the renowned Kaiser Family Foundation reports that
members' ability to sue their HMO ranks only fourth in consumer concerns, behind
ability to access a specialist, a fair system of independent review and easier
access to emergency care.
This is strikingly significant because it
points out another drawback of a reliance on litigation: the ticking clock.
Patients must get the care they need today, not after a lengthy legal dispute.
Litigation may serve attorneys and family members tomorrow, but for someone
deprived of care and treatment, a two- or three-year wait for adjudication is
too little, too late. The public understands this, which is why many people
favor other forms of health plan accountability, such as external review, as far
Public trust is sadly missing from
much of our nation's health care system. Encouraging litigation won't build
trust, it will diminish it. Other than trial lawyers, no one likes to go to
court or wants to transform every dispute into a cumbersome, combative and
costly lawsuit. Litigation carries with it an aroma of distrust and is the
quickest way to stamp "canceled" on any effort to build confidence and
Some managed care reform should be embraced, and many
items contained in a proposed patients' bill of rights are to
be applauded. If the proponents of litigation believe they have a strong case to
make, let's have an intelligent debate about that as well. But let's not blindly
march through the woods on a road cobblestoned with rhetoric and unintended
consequences. For when weighing all of the arguments, we just may find that
extended liability for HMOs falls far short of consumer expectations and is not
the best way, after all, to assure that all of us live happily ever after.
LOAD-DATE: February 14, 1999