 |
Keep an Eye on Impact of Managed Care
by Debbie Marshall
Neurologist Steven Ringel is worried about the future of health care for the chronically
sick. But he has a plan.
As president-elect of the American Academy of Neurologists, he is traveling the country to
speak to doctors who "are struggling with managed care and having the insurer between
us and our patients."
"We always did everything for everyone—a lot of it unnecessary. We're going to
have to throw out the 'everything unnecessary'," said Dr. Ringel, who is the
Myasthenia Gravis of Colorado Association's medical adviser. "Some have been greedy.
We've wasted a lot of money. It's the responsibility of physicians to help society
prioritize.
When society is trying to reduce medical costs, "The vulnerable population is the
chronically sick," said Dr. Ringel. That's because 70 percent of health-care dollars
are spent on 10 percent of the patients. Getting rid of the expense of those 10
percent—which includes myasthenics—looks pretty attractive to insurers and
perhaps society at large.
"I worry the (chronically) sick are going to get screwed," Dr. Ringel said
during a February interview in his University of Colorado Health Sciences Center office in
Denver. Although health care is and should be headed in a new direction, "We need to
get across to people, 'Don't be stupid.' We should advocate for changes in society that
don't do in the sick. The mood in the country is not to help."
So what's his plan?
"We're starting to develop national measures," Dr. Ringel said. "I think we
will have consumer guides to who gives the best care for a certain disease. If we want
insurance companies to let us treat myasthenics, we'll have to prove what we do is better
for myasthenics—develop data systems. The hardest part is making it understandable
for the consumer."
Dr. Ringel advocates hard data on treatment and outcomes, not evaluations based on patient
satisfaction. "A good bedside manner doesn't mean sufficient care," he said.
Right now, Dr. Ringel believes, "Insurance companies focus on our cost, not our
quality. When the (potential data) system shows quality is better, consumers will be
outraged if their insurance company won't let them go where there's the best care."
What's the scenario for you, the myasthenic, right now? Perhaps you have some double
vision, trouble talking, you're slurring your words . . . so you see your doctor. Most of
the time, that doctor was chosen because he/she's available on your health
plan—either the one provided by your job or yourself. It may be the doctor you've had
for a long time, or it may not.
If you're lucky, he/she sends you to a neurologist—despite the penalties probably
built into his/her agreement with the company that insures you if you're sent to a
specialist. That neurologist also will be selected based on who is on the plan, probably
whomever your primary care physician routinely uses.
Your neurologist may or may not be knowledgeable in the diagnosis and treatment of
myasthenia gravis. As many myasthenics have learned, it is not the easiest illness to
diagnose, or to treat. It's not common enough for every neurologist to be an expert, or
for it to be widely understood even within the medical community.
Instead of a neurologist who treats one or no myasthenics a year, what you want is a
neurologist who treats at least several, perhaps a hundred a year. But you won't get that
unless you know enough to demand it, and unless you're willing to pay for at least part of
it if your insurance company won't.
"When you (or your company) bought your insurance you didn't know what disease you
were going to have," Dr. Ringel said. If the best doctor for the disease you develop
isn't on your plan, you won't see him/her unless your plan allows you the option of going
out of the plan for care. Choosing a non-plan doctor, even if allowed, probably will cost
you more than seeing one of the plan's doctors.
Most people won't go to that expense, and don't understand that it may be worth it.
"The crux of the problem is the consumer doesn't understand when he's getting
quality," Dr. Ringel said. "I'm shocked at how for $10 patients will walk. They
might have to pay $20 to see Dr. Ringel and nothing for Joe Blow. They're gone in the next
day. But they'll go out to dinner for $20."
It's not that Steve Ringel is trying to drum up business. He's been treating myasthenics
for 25 years and about 100 a year are seen in his department, but, "The average
neurologist can manage most myasthenics and some (myasthenics) need more expertise. I
can't take care of all these people anyway."
The direction health care is taking is not all bad, according to Dr. Ringel. "I think
there's something good about it," he said. "We've actually hurt people with (too
many) tests."
He observed that in Italy there is one month a year when mortality is significantly lower.
That month is August—"when doctors go on vacation."
"We are aggressive," he said. The most treatment is not necessarily the best
treatment, with plasmapheresis (the process of removing antibodies from a myasthenic's
blood) an example. "It's not always the best use of resources," he said.
"Bad doctors and bad health plans may make judgments based on money," Dr. Ringel
said, but make no mistake: "Doctors have ethics. For years they made money for doing
things, not not doing things. But they're still going to do what's right."