Better deal for the patient Managed care works faster and cheaper

June 23, 1996|By William L. Jews

THOSE OF US who came of age before the Seventies remember pulling our car into a service station and having an attendant fill the tank with gasoline, check the oil and clean the windshield.

Many of us rebelled when self-service pumps were first introduced. Two decades later, however, we fill our tanks, check our oil, clean our windshields and even process our credit card transactions ourselves with nary an attendant in sight.

Remember the first time you used the automatic teller machine at your bank? Perhaps the ATM "ate" your bank card when you punched in the wrong password. If you were like me, you vowed always to bank with a "human" teller, someone who knew your name. Now, I can go months without seeing the inside of my local bank branch. Despite my initial skepticism, banking by ATM has proven to be faster, more convenient, cheaper and more accurate.

For most of us, the changes in our personal transportation and banking habits were jarring and unwelcome. The changes were dictated by the marketplace. With the price of gasoline soaring and faced with paying extra for full service, we opted to fill our own gas tanks. In much the same way, the long lines waiting to see a bank teller persuaded most of us to give the ATM another try. And, after some early awkwardness, these changes have become accepted parts of our lives.

The process is repeating itself in health care. Years of double-digit increases in the cost of health care coverage have led to increased pressure from employers and subscribers to rein in those costs. Fewer employers, who provide health care coverage for four of five Americans with health insurance, were willing to underwrite traditional fee-for-service indemnity coverage for their workers and their families. In response, insurers such as Blue Cross and Blue Shield of Maryland have turned to managed care.

There must be a reason that enrollment in health maintenance organizations (HMOs) has mushroomed so dramatically, both nationally and in Maryland, in recent years. It's that managed care delivers what people want: high-quality, effective care at an affordable price.

All sides of that equation are critical. To be sure, managed care seeks to lower costs by better using services and treatments, such as surgery and hospitalization, and to reduce instances of inappropriate, unnecessary or even harmful care. By one estimate, more than a half million women undergo unnecessary Caesarian sections in the United States each year. One in six G.I.-tract endoscopies and coronary angiographies and a third of all carotid endarterectomies aren't necessary, according to one recent medical journal.

As the University of Maryland's Douglas Peddicord noted in his June 9 Perspective article, "Managed Care and Medicare," health care has been utterly transformed in less than a generation. No longer is the emphasis focused on going to the doctor only when ill. Instead, managed care emphasizes a holistic, preventive care approach to maintaining good health, addressing health issues before they become serious and costly medical problems. That means regular physicals, follow-up care and changing to a healthier lifestyle.

Critics complain that managed care changes the relationship between physician and patient.

In a sense, they're right. Under managed care, health care providers are held more accountable for the long-term well-being of their patients. Managed care also depends on well-informed patients who are actively involved in decisions affecting their health, in full partnership with a primary care physician.

This represents a major change in thinking for many patients who had always viewed their doctor as someone who "fixes" a problem after it occurs. Increasingly, patients themselves are taking personal responsibility for their health. It's working. One recent study found that heart problems were detected and treated earlier among senior citizens who were in HMOs than in traditional fee-for-service programs.

Finally, managed care depends on quality. Employers and consumers alike look for their HMOs to be fully accredited by the National Committee for Quality Assurance, tantamount to a Good Housekeeping Seal of Approval. In its evaluation, NCQA reviews quality standards, physician credentialing, utilization management, medical record keeping, members' rights and the effectiveness of a plan's preventive health services. Common to successful HMOs is the selection of excellent physicians and the avoidance of unnecessary intrusions on the physician's judgment or the doctor-patient relationship.

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