Damaged Care

'if you're having a heart attack, please press 2...'

Back in the days before managed care, the doctor's bag was the preferred symbol of American medicine. (Or, for dress-up purposes, that mysterious reflector strapped to the forehead.) Today we've somehow gotten to the point where the phone mail system would better sum up the American health care experience. It's through the phone that most of the 85 percent of Americans who have some form of employer-sponsored managed care now make our increasingly complicated medical arrangements. And most of the time we're not talking to anyone, just punching in numbers at the behest of automated messages, obediently holding for ''patient-care representatives.''

The indignation that swells in the heart at such moments does much to explain the powerful populist outcry against managed care. Surely by now you've heard the campaign ads in which practically everyone running for office promises to take on HMOs. Democrat Peter Vallone vows to pass a patient-protection act if he's elected governor. Democratic Senate candidate Chuck Schumer says he's ''the cure to the HMO mess.'' And even

Schumer's opponent, Republican incumbent Alfonse D'Amato, has fashioned himself a managed-care reformer, though he's so far avoided saying exactly where he stands on current proposals to reform HMOs.

It may seem surprising that people feel deeply about a wonky policy issue, but not when you consider that health financing is ultimately about our bodies. HMO rage boils down to the sense--some would say knowledge--that the ''patient-care representatives'' who must now approve our every medical move don't really care about our torn ligaments, our allergic reactions, our miscarriages. This cuts deep. It's as if we're holding our boo-boos--both large and small--up for a kiss, but instead of mommy, or even the family doctor, we find only underpaid telephone workers trained to choose the cheapest Band-Aids.

So while we may tolerate a less than heartfelt ''have a nice day'' approach at our computerized banks and the hollow pleasantries printed on our receipts, the creeping conglomeration of the actual practice of medicine is quite another thing. Cheery-sounding names and plastic membership cards haven't fooled most patients, who report in survey after survey feeling less satisfied with managed care than with old-style coverage.

Corporate forces are nothing new in the health insurance world, of course. But while insurance companies might have squabbled over doctors' bills in the past, managed care now positions these corporate elements to have a say in the actual treatment of our very personal aches and pains. And that makes patients, doctors, lawyers--and almost anybody who's not making money off our new system--want to draw the line.

In fairness, managed care itself isn't to blame for our woes as much as the climate in which it's taking shape. Charging patients a flat fee for what is essentially a combination of insurance and medicine actually evolved as a way to remedy some of the injustices of our previous system, under which health expenses went through the roof. While the fee-for-service insurance that used to predominate has built-in incentives for doctors to schedule too many appointments and order too many tests (because the more they do, the more they get paid), the new arrangement is designed to keep costs down. At its best, managed care even pushes doctors to treat problems before they get out of hand--and more expensive to treat.

But the laudable goals of managed care haven't all played out as planned. Operating in a highly competitive market, companies find it hard to resist cutting corners. Some have actually come right out and given bonuses to doctors who keep costs down. It's this bottom-line orientation that's to blame for the most horrifying HMO tales: the upstate woman who died while her managed-care provider hemmed and hawed about the necessity of a liver transplant, the patient whose breast cancer went undetected--and spread--when her HMO botched the follow-up on her mammogram, the teenage boy who died of heart problems after his HMO failed to provide adequate access to heart specialists.

These extreme cases show how far managed care has come from its progressive ideals. While the first HMOs were largely not-for-profit, this is no longer the case. In New York, more than a third of managed-care companies are now for profit. And these days even the not-for-profit HMOs are ruled by the expectations of executives who make oodles off this ''cost-efficient'' health care.

The 15 highest-paid managed-care executives made an average of $5.1 million last year, not including stock options, which themselves can run into the millions. Stephen Wiggins, chairman and CEO of the notoriously problem-ridden Oxford Health Plans, took home more than $30 million--and that's not counting stock options. On top of such astronomic expenses, some managed-care companies have recently announced they're putting additional millions into ad campaigns to spruce up their sickly images.

Few managed-care companies are actually making money for their investors or keeping costs down--and some have even gotten out of the health care business entirely. Yet such expenditures and the backdrop of the high-rolling health care market (which went up before its current down) makes the penny-pinching ways of plans look especially bad. Consider, for instance, the stinginess of most HMOs in even the tiniest details, such as the mailing of basic information required by the law. (According to an investigation by public advocate Mark Green, HMOs in New York failed to provide required materials in response to requests 83 percent of the time.) But, of course, the most troubling failures of managed-care plans are not the small inconveniences, which may be annoying, but the real matters of care, which can add up to a major crisis for anyone who has a real health problem.

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