Consider the physician in Tulsa, Okla., who prescribed a sophisticated magnetic-resonance exam to determine the cause of a young woman’s acute headaches. When her HMO refused to pay, opting for a less expensive (but riskier) test, the doctor urged her to protest the decision. Shortly thereafter he received a letter from the health plan’s medical director. ““Pitting the HMO against its member,’’ it warned, ““may place your relationship with [this plan] in jeopardy.''
If you’re among the 150 million Americans covered by managed care, you might be disturbed to think that your doctors ever face such dilemmas. But not infrequently, HMOs do censor what physicians tell their patients. Some bar them from discussing experimental or especially expensive treatments. Others prohibit them from ““disparaging’’ their plans–which doctors often take to mean they can’t be fully honest with patients about their care. The industry claims these ““gag rules’’ are uncommon; under public pressure, some big HMOs have recently dropped them altogether.
Yet consumer groups insist that the rules are still a problem, and they have powerful allies in government. More than a dozen state legislatures have banned such clauses over the past year; similar bills have recently been introduced in Congress. President Clinton’s soon-to-be-announced special health commission will launch a sweeping offensive of its own. That’s good, because almost all experts agree that gag rules interfere with a doctor’s ethical and legal responsibilities to care for patients to the best of his ability. Less good is governments’ unquestioning willingness to jump in. If Congress and the states seek to redress every problem with managed care, as begins to look likely, they could undermine the whole purpose of health reform: quality care at lower cost.
Let’s look ahead. Last year Congress declared that it was wrong for mothers of newborn children to be sent home from the hospital after 24 hours. This year will bring a raft of new issues, ranging from the crackdown on gag rules to a proposed ban on ““drive-by’’ mastectomies (which women increasingly undergo as outpatients) to a requirement that managed-care organizations cover the cost of emergency-room treatment at any hospital, whether or not it is a member of the group’s plan. Earlier this month Sen. Edward Kennedy (Democrat of Massachusetts) introduced a sweeping Health Insurance Bill of Rights Act covering a gamut of simmering health-care issues; Sen. Paul Wellstone (Democrat of Minnesota) wrote a similar Patient Protection Act.
And that’s nothing compared with what the states are doing. Last year, in what The New England Journal of Medicine calls an ““angry backlash’’ against HMOs, roughly 1,400 pieces of legislation attempting to regulate managed-care providers were introduced; 56 new laws were passed in 35 states, and many more are to come. For instance: next week New Jersey laws take effect guaranteeing consumers the right to be referred to specialists and setting up the nation’s first independent panel to review appeals from members dissatisfied with their care. Ohio has banned HMOs from paying bonuses to doctors who delay or withhold treatment from patients in the interest of maximizing profits. Massachusetts’s attorney general last month called for the establishment of a state authority to police what has been an entirely unregulated industry. Maryland proposes to revoke the license of any HMO medical director who sets up a ““substandard health-care delivery system.''
But both HMOs and their discontents are skeptical of this piecemeal approach to reform. One worry is that the tinkering will trigger another sharp rise in costs. Health-care expenses have been rising by a relatively modest annual rate of 3 to 5 percent in recent years, but the backlash against managed care and the new enthusiasm for requiring HMOs to offer new and more expensive treatments, many experts warn, could send health-care inflation back into double digits. There’s also concern that government intervention, especially if left to individual states, will produce a babel of conflicting rules that nobody can sort out, least of all the consumers they are designed to protect. Worse, the current reform efforts raise the specter of members of Congress and regulators making detailed decisions about medical care. ““Legislating the practice of medicine can be very dangerous,’’ says Dr. Ted Lewers of the American Medical Association. Rather than creating a patchwork of quick fixes, he adds, legislators should force all parties–HMOs, doctors, hospitals and consumer groups–to agree on national standards and procedures for cost-effective medical treatment. ““Laws can’t cover every medical scenario,’’ says Lewers. ““If you try, you will only raise costs–and diminish the quality of care.''
