- Email: [email protected]
Patient decisions
Chronicles of Small Beer
PATIENT DECISIONS As this was written, I am in the company of every other Medicare beneficiary in trying to decide what to do about two basic changes in the program. One is a new pharmaceutical coverage program, and the other is a further push to get me and everyone else into managed care. Both changes were pushed through a reluctant Congress in the name of improving coverage and enhancing competition in provision of health services. Both should be commendable changes. As legislated, I have my doubts. I have been reading laws, regulations, and even insurance policies for most of my career and I am confused by the information offered by the government and the private organizations that have most of the action on the new coverages. There was a time when physicians and their patients agreed that the physician knew what was best for the patient and the patient did not. If the physician said surgery, who asked for other choices? If the physician said use hospital A, who asked if the infection rate was the highest in the county and what about hospital B? If he or she said the needed medicine cost $5 a pill, who would ask for an alternative or a generic product? Radiologists avoided telling patients what they saw. That was the prerogative of the primary caregiver. What patient was bold enough to ask the cost of medical services, ask for a second opinion, or shop for less expensive providers? So now, I have some 40 choices of a Medicare-approved private plan to provide pharmaceutical coverage. What are their differences and advantages? The government does not tell me. Each day I get several cards or letters urging me to visit a Web site where all will be revealed, but it never is. Or else I am invited to a seminar for a hard-sell pitch for a Medicare advance managed care scheme. Thus far, only one potential pharmaceutical provider has sent me enough information for me to understand what it is offering. It makes no comparison with any other vendor. Federal employees are offered a range of health care insurance options, together with detailed analyses and comparisons of what each one covers. The rest of us need, but do not get, that kind of help. As most of you are painfully aware, Medicare and its intermediaries now do a substantial amount of review and auditing of health services to both monitor price and profile state-of-the-art practice. One of my main chores at the American College of Radiology was to assist Medicare and other health insurers in making good coverage and reimbursement decisions—which is to say, covering new developments in radiology at a price we thought reasonable. That
battle continues. My competition was other providers and never anyone representing patients. It did not occur to any of us that patients should make the decision to cover positron emission tomographic scans with appropriate indications and charges. Since my departure from those chores, we have seen intensive and effective lobbying by manufacturers for Medicare coverage of added costs of digital mammography and computer-aided breast diagnosis before you had scientific documentation of the value of either one. Clear winners in the Medicare changes of 2003 were the pharmaceutical manufacturers and the health insurance industry. Under the law, the federal government is prohibited from any effort to restrict what any of us or Medicare will pay for their products. Those companies sell to the Veterans Administration or military for a bulk price, but not to the rest of us. They sell to Canadians at a reduced price, but they persuaded the Congress to decree that a bottle of pills manufactured in New Jersey is somehow tainted if it is shipped to Toronto and back. The new federal subsidies for managed care plans are paid to the plans and not to any of us as subscribers. Earlier federal efforts to stimulate managed care for Medicare patients were not successful without bribing the carriers. Both of these new “benefits” are in fact marginal to the original concept of Medicare as a uniform nationwide coverage program. Both rely on subsidized private efforts. Where the term “government efficiency” is regarded as an oxymoron, it seems odd to observe that for Medicare patients, the public payment mechanism is now a better package than we can find anywhere else. And it is downright scary to think that it is a better payment mechanism for physicians and hospitals than most of the private competition. By the time you read this, I will have chosen a pharmaceutical plan. I would be punished by the program for not doing so. I can ignore the blandishments of the managed care gang, at least for a while longer. After that, who knows? Otha Linton, MSJ Potomac, MD
LEARN BY DOING For my entire career, I have been involved in devising and implementing methods of teaching doctors about radiology. It was not my end of things to decide on content. That was left to you real teachers and to the high court of pedagogy, the American Board of Radiology. In my checkered academic career, I avoided all courses in educational psychol-
531
PATIENT DECISIONS As this was written, I am in the company of every other Medicare beneficiary in trying to decide what to do about two basic changes in the program. One is a new pharmaceutical coverage program, and the other is a further push to get me and everyone else into managed care. Both changes were pushed through a reluctant Congress in the name of improving coverage and enhancing competition in provision of health services. Both should be commendable changes. As legislated, I have my doubts. I have been reading laws, regulations, and even insurance policies for most of my career and I am confused by the information offered by the government and the private organizations that have most of the action on the new coverages. There was a time when physicians and their patients agreed that the physician knew what was best for the patient and the patient did not. If the physician said surgery, who asked for other choices? If the physician said use hospital A, who asked if the infection rate was the highest in the county and what about hospital B? If he or she said the needed medicine cost $5 a pill, who would ask for an alternative or a generic product? Radiologists avoided telling patients what they saw. That was the prerogative of the primary caregiver. What patient was bold enough to ask the cost of medical services, ask for a second opinion, or shop for less expensive providers? So now, I have some 40 choices of a Medicare-approved private plan to provide pharmaceutical coverage. What are their differences and advantages? The government does not tell me. Each day I get several cards or letters urging me to visit a Web site where all will be revealed, but it never is. Or else I am invited to a seminar for a hard-sell pitch for a Medicare advance managed care scheme. Thus far, only one potential pharmaceutical provider has sent me enough information for me to understand what it is offering. It makes no comparison with any other vendor. Federal employees are offered a range of health care insurance options, together with detailed analyses and comparisons of what each one covers. The rest of us need, but do not get, that kind of help. As most of you are painfully aware, Medicare and its intermediaries now do a substantial amount of review and auditing of health services to both monitor price and profile state-of-the-art practice. One of my main chores at the American College of Radiology was to assist Medicare and other health insurers in making good coverage and reimbursement decisions—which is to say, covering new developments in radiology at a price we thought reasonable. That
battle continues. My competition was other providers and never anyone representing patients. It did not occur to any of us that patients should make the decision to cover positron emission tomographic scans with appropriate indications and charges. Since my departure from those chores, we have seen intensive and effective lobbying by manufacturers for Medicare coverage of added costs of digital mammography and computer-aided breast diagnosis before you had scientific documentation of the value of either one. Clear winners in the Medicare changes of 2003 were the pharmaceutical manufacturers and the health insurance industry. Under the law, the federal government is prohibited from any effort to restrict what any of us or Medicare will pay for their products. Those companies sell to the Veterans Administration or military for a bulk price, but not to the rest of us. They sell to Canadians at a reduced price, but they persuaded the Congress to decree that a bottle of pills manufactured in New Jersey is somehow tainted if it is shipped to Toronto and back. The new federal subsidies for managed care plans are paid to the plans and not to any of us as subscribers. Earlier federal efforts to stimulate managed care for Medicare patients were not successful without bribing the carriers. Both of these new “benefits” are in fact marginal to the original concept of Medicare as a uniform nationwide coverage program. Both rely on subsidized private efforts. Where the term “government efficiency” is regarded as an oxymoron, it seems odd to observe that for Medicare patients, the public payment mechanism is now a better package than we can find anywhere else. And it is downright scary to think that it is a better payment mechanism for physicians and hospitals than most of the private competition. By the time you read this, I will have chosen a pharmaceutical plan. I would be punished by the program for not doing so. I can ignore the blandishments of the managed care gang, at least for a while longer. After that, who knows? Otha Linton, MSJ Potomac, MD
LEARN BY DOING For my entire career, I have been involved in devising and implementing methods of teaching doctors about radiology. It was not my end of things to decide on content. That was left to you real teachers and to the high court of pedagogy, the American Board of Radiology. In my checkered academic career, I avoided all courses in educational psychol-
531