Outlawing Practice of Capitation Is the Heart of Reform

It has been refreshing to see all the articles lately about health maintenance organization reform. Unfortunately, most of the suggested reforms are just politically correct window dressing.

The only real solution is to give specific rights back to the patient and the doctor-patient relationship.

What the politicians are missing is that patients need a bill of rights because regulators have allowed capitation, the practice of HMOs paying a medical group a small, fixed amount per month to take care of each patient. The medical group then has to pay the doctors and their hospital bills out of this small amount.

It doesn’t take a genius to realize that medical groups can only make money if they sign up thousands of patients that they rarely see. Consequently, because every encounter with a capitated HMO patient is lost money, it is unfortunately cost-effective for doctors to give patients the runaround with long delays for appointments, difficult access by phone and difficulty seeing specialists.

By annoying the patient sufficiently, they make chronically ill and high-maintenance patients more likely to switch medical groups.

People need to remember that HMOs do not practice medicine. Doctors practice medicine and still have the power to do what is right.

Unfortunately, this often isn’t happening, and it is very sad to see doctors who were once great fall into the abyss of managed-care influence. These doctors often argue that they’ll go broke or be fired if they speak up. But we must speak up anyway because the Hippocratic Oath should never be for sale and the doctor-patient relationship should always remain sacred.

Furthermore, if the doctors retain their integrity, the patients will stand up and overthrow any corporate middlemen who are undermining their right to the best health care available.

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I propose a patients’ bill of rights that would require:

* Same-day appointments. Anyone who is sick and needs to be seen should be allowed to be seen the day he or she calls. I hear countless stories of HMO patients being told there are no appointments available for days, weeks or even months. That’s unacceptable; stall tactics should not be tolerated. If your doctor can’t get you in when you are sick then he or she either needs to stay after hours to see you or hire another doctor.

* Access to specialists. Patients should have a right to consult a specialist if they want and in a timely manner. If they make you wait more than a week, then you should have the right to go out of network at no extra charge.

* Prohibition of bait and switch. Each doctors’ office should clearly inform the patient what to expect from the practice. This includes office hours, availability of the doctor in person or by phone, whether the doctor will meet the patient in the emergency room after hours, if and when the office uses a nurse practitioner or physician assistant and if the doctor will see the patient in the hospital. That way, consumers can reasonably choose a primary care doctor and can reasonably complain if they did not get what was advertised. Patients should have a right to look at the schedule books and be told scheduling methods if they are consistently told that their doctor is unavailable.

* No double standards. Many practices have different scheduling and medical treatment policies for HMO and non-HMO patients. This must be outlawed. A patient is a patient.

* A chief executive officer salary cap. HMOs are whining that they are losing money and say they need to raise premiums, especially if patients get more rights. Premium increases should be prohibited because HMO CEO compensation of more than $100 million has been commonplace in the past five years. No CEO businessman who has nothing to do with the care of a patient should be allowed to make more than $250,000. In addition, all the HMO CEOs who made the hundreds of millions should be asked nicely to donate most of it back to a health care fund that would be used to help treat the uninsured or to help compensate any patients found to be harmed by HMO policies of the past.

* Prohibition of wrongful termination. There must be substantial penalties if a doctor is fired for standing up for patient rights. This law exists now but it must be enforced.

* Free choice of second opinion. A second opinion on denied care has been proposed by others but it needs to be a second opinion of the patient’s choosing.

* Prohibition of doctor conflict of interest. Treating physicians should not be allowed to profit financially from denial of care and neither should they be penalized if they feel a patient needs a specialist. Doctors should not be allowed to have any financial interest in any corporate entity that would benefit from their medical decision.

* A complaint process. The department of corporations should have an efficient complaint procedure if patients are mistreated. Doctors should have a forum for complaint if they are being pressured to give less-than-optimal care or if the HMO is acting unreasonably.

* HMO accountability. Not only should patients be allowed to sue HMOs but HMOs need to be accountable when medical management groups they hire declare themselves bankrupt.

* Telephone medicine limitations. Stories abound about HMO capitated patients being given prescription medicines by phone when they should be seen by a doctor. Strict guidelines are needed to protect patients from diagnosis guesswork by phone.

* Mandatory 48-hour maternity stay with newborn follow-up. The 48-hour stay is law now, but it is actually much more important to see the newborn two or three days after discharge (especially breast-fed babies) to make sure the infant hasn’t lost too much weight and is not too jaundiced. Many HMO patients are given a two-week follow-up appointment, far too long to wait to pick up potential serious problems before it is too late.

* The outlawing of capitation. Capitation always has been and always will be a conflict of interest that erodes trust in the doctor-patient relationship. If capitation were outlawed, we might not need a patients’ bill of rights.

This should at least be a start. I hope Sen. Barbara Boxer (D-Calif.) and her cronies will take some of these ideas and return health care back to the patient and the doctor. If they really want meaningful reform, I would love to help.