Monday, June 12, 2006

Who Should Manage Care?

A front-page story in its June 11, 2006 issue, the Boston Sunday Globe, under the byline of reporter Christopher Rowland, was about one Dr. Stephen A. Hoffman of Framingham, MA who admitted to cheating the Tufts Health Plan. It seems that the Plan will only pay for 10 pills a month of the sleep aid drug Lunesta. Dr. Hoffman thought his patient needed more than that, so he wrote a second prescription for the patient’s husband. He conceded that this was not the first time he had done such a thing to get around insurance restrictions.

The general theme of the story was the frustration of primary-care physicians with “increasingly restrictive rules imposed by health insurance companies in an effort to reduce healthcare costs.”

The story went on to talk about how these rules and other bureaucratic hurdles are discouraging doctors from specializing in primary care and to confirm that what Dr. Hoffman had done was not condoned by governmental agencies or professional bodies.

All of which raises a straightforward question. Should healthcare be managed or should every physician be at liberty to treat patients in whatever way he or she sees fit?

If healthcare is not to be managed, then the prospects of doing anything about cost and quality are dim indeed.

If healthcare is to be managed, a second question arises: who should do it?

It seems clear to me that it ought to be done by the providers themselves (e.g., doctors and hospitals). But with the exception of the few remaining integrated HMO’s, like Kaiser of California, who operate their own insurance plans, employ their own doctors and run their own hospitals, they have so far been unwilling to do so.

Until that changes, the insurance companies have little choice but to do it in ways that are necessarily clumsy and insensitive to individual cases.

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