Chilly bedside manner of HMOs

September 30, 1997|By Robert Reno

IN THAT blessed care-giving system that is to come, we will all be herded gently into health maintenance organizations of somebody's choosing, where a board of directors acting in the interest of shareholders will be our angels of death.

These gatekeepers to our afterlife, disinterested practitioners of marketplace, profit-driven medicine, will make highly rational decisions in consultation with state-of-the-art financial calculations.

It is to be an altogether more efficient, if more chilling, system than the one it replaces, where for generations kindly old family doctors might meet in hospital corridors with grieving family members to decide whether some beloved granny should be mercifully shuffled off to the Great Whatever.

At a time when, compared with the populations in most other advanced industrial nations, Americans live shorter lives and have higher infant mortality rates and are less likely to have medical coverage, it is a rather screaming irony that the health care debate is being increasingly driven by the notion that there is too much medicine being practiced in America, more than we need and more than we can afford as a nation with a rapidly aging population and a federal budget we imagine must be balanced.

Of course, everybody knows we have to control medical costs and that caring for the aged population is going to get vastly more expensive in the next century.

The more pertinent question is whether a largely unregulated, profit-driven, HMO-dominated system -- one in which doctors are no longer gods but become junior partners -- is the way most people want to go.

The people who think so will be encouraged by a new study just published in the Journal of the American Medical Association. Because it is the voice of the nation's largest fraternity of doctors, I suppose we ought to listen respectfully, if a little suspiciously. Because for years the doctors told us HMOs were such a pernicious threat to their independence and to the right of patients to choose their caregivers.

Less aggressive care

The study of 81,494 aged California patients hospitalized in intensive-care facilities found that those enrolled in HMOs were 25 percent less likely to receive aggressive, heroic and highly expensive treatment.

This would seem to prove the popular suspicion that the HMO operators are heartless swine.

But, said the study, the HMO patients did not die at a faster rate while they were in the hospital and in the 100 days after they were released they conked at a rate that was only slightly higher than the rate for patients with traditional, fee-for-service Medicare coverage.

Roughly 13 percent of Medicare beneficiaries have elected for HMOs over fee-for-service coverage, not yet a resounding vote of confidence in the supposed superiority of HMO medicine.

We're supposed to be reassured by this study, even if it has little validity for younger HMO patients, who have less reason to view death with equanimity or as a blessed relief from life's cares.

Besides, it's not as if HMOs will deny patient choice in this messy, expensive and for all of us eventual business of dying. Those who can scrape together $1 million or so to pay for aggressive treatment not covered by their HMO, those who can afford gold-plated extra insurance policies, will still be free to tell their HMOs to go to hell.

But I am always reminded of what Prime Minister Winston Churchill said on this subject when Britain was debating the switch to what Americans call socialized medicine: "Disease must be attacked in the same way a fire brigade will give its assistance to the humble cottage as readily as it will the most important mansion."

The old Tory seemed, unrealistically perhaps, to wish for the British proletariat the same services by which the best medical brains in the empire kept him alive to the great age of 90.

But in the fire brigade medicine he envisioned, the financiers are now replacing the physicians as the brigadiers.

How quaint, outdated, utopian, even puerile, Churchill's principle of medical care sounds when confronted with the realities of late 20th century medicine as they prepare to collide with 21st century demographics. Yes, and curiously enough, most of us still believe in that principle.

Robert Reno is a columnist for Newsday.

Pub Date: 9/30/97

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