Stop blaming HMOs

July 21, 2000|By Jonathan P. Weiner

THE Supreme Court recently upheld that patients cannot sue their health maintenance organizations (HMOs), representing a victory for the health plans in what has escalated into an all-out health care war.

It is no longer just a "backlash" against HMOs when legions of lawyers, fresh from the tobacco wars, are now aiming their class action laser sights at HMOs and when Congress and the state houses, with great fanfare, are calling for a wide-ranging Patients' Bill of Rights.

For their part, Americans are cheering on such attacks and declaring themselves to be more concerned with issues surrounding health care insurance coverage than with the economy, crime or Social Security.

And yet, in our attempt to regulate and litigate HMOs and other health insurance plans into submission, we have once again side-stepped the two real U.S. health-care issues: the more than 40 million Americans who have little or no access to services and -- election promises and contingency fees aside -- that health-care resources are finite. Neither of these two issues are the HMOs' fault. In fact, quite the opposite is true.

Managed care has forced Americans to look limited health-care resources squarely in the face and to start realizing it is no easy task, within a fixed health-care budget, to determine if a regimen of care is necessary, only marginally beneficial, or downright useless. And perhaps more difficult still: How can a given health-care dollar be used to benefit the lives of the maximum number of people enrolled in the plan?

These are not academic issues.

For example, should a managed care plan, nonprofit or otherwise, be obliged to cover a $200,000 repeat liver transplant for a baby whose first transplant failed? What about a $15,000 battery of MRIs and arthroscopies to ensure that a weekend athlete's aging joints can continue to take a pounding? How about $80,000 for a year's worth of in-vitro fertilization attempts so a couple can reproduce? Or would you want to be the one to decide whether an end-stage cancer patient should get a $100,000, last-ditch procedure with a less than 10 percent success rate?

In the United States today, we blame managed care executives for denying such treatments. Yet we overlook our bosses, governors and legislators, all of whom have deputized the plan administrators to take on the thankless task of deciding how best to spend the limited health insurance premium.

Could these types of decisions be avoided if we had a universal government health care program? The answer: no.

Every other industrialized nation has decided that to implement effective socialized health care it cannot continue to pay for "marginally beneficial" services like those described. Making this tough decision has allowed these other nations to cover every citizen, spend far less on medical care per capita and at the same time achieve better health outcomes than does the American system.

Underscoring how far behind we are in this regard, a just-released World Health Organization study ranks our health care system 37th in the world in terms of value for money.

If the United States ever hopes to see progressive health care reform, we are likely to see more, not less, of the types of tradeoffs that today's legislators and HMO patrons now scorn. It is a pipe dream to believe we can avoid this truth.

The bottom line is that, one way or another, before a fiscally and morally sound system of care for all Americans can be achieved, some mechanism must be implemented to deliver medical care within a finite budget.

In the meantime, it is fruitless and unfair to blame all the ills of our health care system on the HMOs, which are based on an attempt to maximize the population's health within a pre-set budget. HMOs are part of the cure for what ails us, not part of the disease.

Jonathan P. Weiner is a professor of health policy and management at the Johns Hopkins School of Public Health.

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