A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
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Chapter 7: Are HMOs the problem?

HMOs (Health Maintenance Organizations) have become the bad guys of Health care. They were the alleged culprits who prevented us from doing what our patients needed, or who made us comply with silly documentation requirements. Indeed, I have filled out many a form to get a test or medication approved for a patient. However, I can not recall a necessary test ever being denied by an HMO. Of course they have denied tests such as neuropsychological testing (a detailed battery of cognitive tests used to assess brain function), requiring me to send the patient to a psychiatrist for an evaluation first, but this was a matter of style, and not substance. Neuropsychological testing was expensive, and if they could eliminate one test without a clear purpose, they could pay for 5 evaluations by psychiatrists. So, clearly the psychiatric evaluation was less expensive, and not necessarily, an irrelevant barrier.

I believe HMOs are the focus of our malcontent, but not the cause. HMOs extended Health care coverage much further than it ever went before. When I was in med school in the early 1980s, a person’s health insurance only covered sick care. Insurance companies didn’t develop coding procedures for preventive Health care visits until the early 1990s. If a doctor billed an insurance company service code for a sick visit and matched it with a patient diagnosis code saying the patient was healthy, the insurance company would reject the claim and not pay for the service provided. This left a doctor with the option of writing off the bill, or charging the patient, and have them complain that it should be covered by their insurance. Often a patient would ask me to modify the diagnosis on the claim so the insurance company would cover it (e.g. instead of saying a patient was completely health, I would use a diagnosis for a sore elbow, hay fever or some other benign condition). Of course, this led doctors to automatically bill for visits as though they were sick visits, to avoid such financial conflicts with their patients. Once the coding for preventive visits became standardized in 1992, annual physicals become routinely covered by HMOs, and we could finally use healthy as a “diagnosis” for our patients.

HMOs also lowered the cost of co-pays, making the concept of a deductible and 80/20 (where an insurance company paid 80% of a service, and the patient paid 20%) largely a thing of the past. This made visits affordable, and with the extension of this concept to medications, they also became more affordable. In some cases, HMOs had placed restrictions on access to care. However, in my experience, they had been reasonable, though at times, burdensome. I believed it was appropriate to ask physicians to justify their reasoning, at times, especially when the care ordered was expensive, or outside the normal pattern of care.

My sense is that HMOs, in large part, have broadened access to care by making routine care more affordable to patients. At times, HMOs have created obstacles for physicians when they have provided care for their patients. Yet, these obstacles aren't limited to just HMOs, but are part and parcel of all health insurers. The problem is not so much the limitations. Even Medicare, the non-HMO, governmental, health insurance program for senior citizens, has as many rules and restrictions as any HMO (e.g. essentially all insurers have lists of medications that require prior authorization on their part before a prescription written by a doctor is paid for by the insurance company). From my perspective, the major issue is the need for a standardization of rules, so providers can learn them once, and learn them well. During my latter years of practice, I had a dozen "playbooks" to follow as I cared for my patients. Each playbook was a manual distributed by each insurance company I contracted with, detailing their rules and regulations. This was a major obstacle when it came to providing efficient care. It also required doctor's offices, clinics, etc. to have additional personnel to help navigate and adhere to the myriad rules and regulations, so the doctors could do what they did best, see patients (which was code language for generate revenue).

A single set of rules would have been helpful, and need not have been linked to a single payer system. In fact, one of the more important reforms proposed by President Clinton in 1992 would have achieved this by standardizing a basic benefits package. However, he didn't have the political savvy to negotiate Washington Politics at the time, and thus, he was chewed up and spit out by the lobbyists. The day Hillary Clinton testified to the U.S. Senate with her initial presentation of the Clinton Health care reform legislation, she was extolled as a great communicator and a formidable negotiator. In reality, the U.S. Congress was just setting her up for the inevitable fall they knew she would ultimately take. She came to epitomize the failure of the Clinton Administration to develop support for his Health care legislation, which wasn't in the interest of the Congress or its contributing supporters (i.e. the Health care and drug industries).

Thus, many of the ideas they proposed then never got off the ground. The well-defined benefits package they sought to develop would have prevented Health care insurers from offering a package with little cost, but also, few, if any, benefits. All basic elements of care would have been required by all health insurance plans. A basic level of benefits would also have made it easier for people to compare insurance plans when deciding on a health insurer. People would no longer have to try to understand the fine print, or use a complicated spread sheet to project their costs when comparing plan A to plan B.

In addition to defining the basics of coverage (and thus, rules for obtaining that coverage), the Clinton plan also would have created health insurance buying cooperatives in each state. As a result, if a person’s employer didn't offer a particular insurance plan, one could have opted out and purchased the insurance plan at a group rate from the state’s buying cooperative. This type of system would have truly leveled the playing field. However, like most free market solutions to Health care, those which permitted real, competitive forces were ignored, while those which touted a market solution, in reality, were not governed by free market forces.

Finally, the Clinton Health care plan called for the establishment of a set of practice guidelines. Such guidelines would have created a set of rules governing how particular medical conditions were treated, which in the end, would likely have been a mixed blessing. If a practitioner followed these guidelines, and a patient had a bad outcome (e.g. they died unexpectedly), the practitioner would have been protected against a malpractice suit. Such guidelines gave the appearance of a suggested mode of treatment, yet ultimately, they could have become a constricting cookbook that limited assimilation of new and/or alternative information. Since such guidelines would have been defined by national consensus, they would inevitably have been a year or two out of date from current research. If one tried to stay at the forefront of managing a problem, one would likely be practicing outside of such guidelines, due to the inherent time lag between new data coming out, and the guidelines being updated. As a result, the guidelines would not only have given a practitioner tort protection, but conversely, if a practitioner didn’t follow the guidelines, they could be vulnerable to malpractice claims. If a patient experienced a bad outcome (e.g. permanent nerve damage), even if the bad outcome was due to a well known, but rare, and thus, infrequently discussed side effect of a particular treatment, a practitioner not following the guidelines might be deemed liable for the bad outcome.

Practice guidelines also would have been inherently biased by the information structure that existed in Medicine. Evidence based medicine is the in vogue parlance for practicing Medicine using the medical literature as one’s guide. In essence we all did this, though some, more closely than others. Unfortunately, much of what a primary care doctor sees on a daily basis hasn't been well studied due to the low mortality associated with these conditions (e.g. muscle spasm may cause disabling pain but you won’t die from it). As a result, a practitioner has to interpolate from the medical literature on a daily basis. Guidelines could have made it hard to bring in alternative therapies, or even nutritional information, because much of what was known in those areas was not at the detailed level as the treatments of asthma and coronary heart disease (these are two diseases with an extensive medical literature defining their cause, and outlining effective therapy for them).

An example of a disorder in which there is disparity between the symptoms a patient might have brought to a visit, and the clinical diagnosis, is celiac disease (also known as gluten sensitivity or gluten enteropathy). It has become apparent that the spectrum of symptoms due to celiac disease may be much broader than just abnormal intestinal function. However, if a patient has a negative biopsy (i.e. no disease evident by microscopic examination of the biopsied tissue) of their small intestine (the gold standard for diagnosis in the eyes of a gastroenterologist), but has lab features suggestive of celiac disease, and symptoms that may be attributed to it, a trial of a gluten free diet is worthwhile. A gluten free diet is totally non-toxic therapy, but potentially requires a major life style change for the patient. Generally such a disorder is considered only when a patient has struggled with symptoms for years, and neither a specific diagnosis, nor effective therapy has been established by the patient or their physician(s). Thus, practice guidelines in an area such as this, where the spectrum of illness is still being defined and debated in the literature, could be problematic, and ultimately, stifling of practical or innovative care.

Indeed, HMOs aren't the cause of all Health care problems, nor the major reason physicians are aborting their Health care careers. Other contributing factors are the corporate approach to Medicine, drug companies and their high profit margins, the disparity in physician salaries, and the inability of physicians to be able to trade off part of their income for a style of practice more conducive to their needs and the needs of their patients. The major problem with health insurers, from my perspective, was the limitless rules and guidelines specified by each of the many insurers a physician had to deal with in order to support a practice. Thus, the most important need in this respect was a single set of rules for the basic issues a primary care practitioner dealt with 95% of the time. We need rules and regulations that won’t change from insurer to insurer, and from day to day.

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