Putting patients before profits

Union would stem greed of HMOs, doctor argues

July 04, 1999|By Glenn Flores

LIKE MANY in my profession, I chose to be a doctor so that I could help people. I love the richness of life as a physician: preventing disease, curing illnesses, alleviating suffering and, most of all, helping fellow human beings in their times of greatest need.

My vision of the ideal practice of medicine never included membership in a union -- until recently. A doctors union might be the only way to protect a patient's rights and ensure quality health care for all.

The juggernaut of managed care necessitates such a drastic step. Its very existence requires the maximization of profits for executives and shareholders at the expense of patients and their physicians.

The goals of managed care are ostensibly to reduce costs and eliminate wasteful spending. The sad reality is that managed care's blatant profiteering endangers the health of many Americans, particularly the most disenfranchised: the poor, the uninsured, the chronically ill and minorities.

In a recent national survey, most Americans said that managed care has reduced the quality of care for the ill and decreased the amount of time that doctors spend with patients. Fifty-five percent said they are at least somewhat worried that if they become ill, their managed-care plan would be more focused on saving money than on finding the best medical treatment for them.

The list of managed-care abuses is long. Denial of needed medical visits and procedures is the cornerstone of the cost-containment strategy that managed care euphemistically calls "utilization review." Serious injuries, permanent disabilities and even deaths have been caused by such denial-of-care decisions.

These decisions reveal the unfortunate "profits over patients" agenda that all too often characterizes managed care. Linda Peeno, a former claims reviewer for several HMOs, recently testified before the House Commerce Committee that she had denied a necessary operation to save a man's heart. That denial caused his death. She was not punished, she said. Instead, she was rewarded by the HMO. As she put it, "Not only did I demonstrate I could do what was expected of me, I exemplified the 'good' company doctor: I saved a half-million dollars!"

Dollar is the priority

Managed care's treatment of physicians also demonstrates that the dollar is usually the priority. HMOs often have productivity requirements, such as seeing a minimum of eight patients per hour (an average of seven minutes per patient). Bonuses greet the doctor who meets or exceeds these requirements, and salary deductions or dismissal might await those falling short.

To join an HMO, physicians might have to sign "gag rules" prohibiting them from informing patients of treatments that might be most beneficial but are considered too costly by the company.

"Medical red-lining" is a process by which a managed-care plan can rid itself of "unprofitable" doctors and their patients. For example, a physician caring for many minority or poor people is more likely to encounter a greater severity and prevalence of disease. Dealing with more illness means more treatment and more hospitalizations. An easy way for an HMO to reduce costs is to drop both the physician and his or her patients from its health plan.

Frustration with managed care has led to efforts by physicians to unionize. The American Medical Association recently voted to form a union for doctors who are salaried employees. About 40,000 physicians, or 6 percent of American doctors, belong to unions. In response, health-insurance representatives are asserting that unions are only about boosting doctors' incomes, which will raise health-insurance premiums.

Well-paid executives

The irony is that managed-care executives are some of the most well-paid in the world. HMO executives average $2 million per year in compensation, according to Families USA, a health-advocacy group. In 1997, the 25 highest paid executives in 15 of the largest for-profit HMOs made more than $128 million in annual compensation, an average of $5.1 million per executive.

The 25 executives with the largest unexercised stock-option packages in 1997 had stock options valued at $290.4 million, an average per executive of $12.6 million. These exorbitant annual executive compensations cost health-plan enrollees anywhere from $1.51 to $40.30. In contrast, providing consumers with the right to independent appeal of health-service denials would cost between 4 cents and 84 cents per HMO enrollee per year.

Every day in my inner-city pediatric practice, I see children and parents who have no choice but to confront homelessness, violence, hunger and poverty. William McGuire, the CEO of United HealthCare Corp., had a stock-option package valued at $61 million in 1997. I would love to see McGuire sit down with one of my families and explain why it is reasonable for him to earn tens of millions of dollars in one year, while they can be denied basic medical care and health insurance.

Until that meeting happens, our only hope for protecting people from the greed and abuses of managed care might be the unionization of doctors on behalf of their patients.

Glenn Flores, M.D., is a pediatrician at Boston Medical Center and an assistant professor of pediatrics and public health at the Boston University School of Medicine. This article was distributed by Knight Ridder/Tribune Information Services.

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