Patients' rights

From bad to worse: Doctors used to be decisionmakers, now it's insurers

In the Senate the other day, I listened to Byron Dorgan, (D) of North Dakota, telling one of those managed health-care horror stories you hear these days.

A woman fell 40 feet down an embankment, was evacuated unconscious by Medivac helicopter and taken to the nearest hospital emergency room. Her health plan refused to pay because she had not received authorization in advance.

I have a special sense of chagrin about the evolution of the HMO from patient care to investor care because I was present at the creation of a system intended to minimize financial incentives.

In a CBS Reports documentary and a book in 1970, I said, "The newest rage of the government health establishment is something represented by the mysterious initials HMO. They stand for Health Maintenance Organization, a system of paying a fixed annual sum to a group of doctors to keep you well when they can and cure you when they can't."

The idea started in 1938, when industrialist Henry J. Kaiser, seeking to lure workers to remote construction sites, offered to look after their health for a nickel a day. The idea spread fast and would have spread faster were it not for the bitter hostility of organized medicine, wedded to solo practice and fee for service.

But over the years, many HMOs became more interested in profits than patients. To hold costs down, accountants rather than doctors decided what kind of treatment patients could get. Last year, almost 100 HMOs dropped out of Medicare because they found it unprofitable.

Now, in a historic shift, the American Medical Association has voted to form a labor union to bargain collectively for doctors with managed-care units.

But who is there to bargain for the patient?

For several years, Congress has fiddled around with various versions of a bill to protect patients. A major point of contention is whether a patient should be able to sue an HMO for what might be called managerial malpractice.

Until this week, the Senate was bogged down in a procedural debate about whether and when it would be able to vote on a patients' bill of rights.

Finally, the Republicans agreed to a debate and vote when the Senate returns from its Independence Day recess.

I look back to my 1970 book. I said then the trouble was that the doctor, not the consumer, was the ultimate decisionmaker, and that was leading to a crisis.

A generation later, neither the doctor nor the consumer, but the insurer is the ultimate decisionmaker. And based on experience, I would not predict an early solution to this crisis.

* Daniel Schorr is senior news analyst at National Public Radio.

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