Revisiting Rick: more bad news on the HMO front
Online posting: January 29, 1997
Published in print: Mar. 1, 1997 (CMAJ 1997;156:632)
Re: US physician warns Canadians about privatization, by Dr. Michael
Gordon, CMAJ 1996;154:142-3
Last year, during one of my periodic visits to Los Angeles, my
friend Rick (as I have been calling him), a primary care
physician, recounted some of the difficulties he experienced
while working for one of California's largest health maintenance
organizations (HMOs). His warnings about the risks of
corporation-style health care were reported in CMAJ, and a
series of letters followed.
I just returned from Los Angeles and Rick updated me about
further developments in the world of US managed care. He resigned
his HMO staff position after his role as chief of staff at his
health care centre was eliminated and supervisory responsibility
was relegated to department heads who worked from a central
location, and not at the branch level.
The final impetus for his resignation was the untenable
decision that the scheduling of his patients, many of whom were
elderly, would be done centrally. He therefore had no control
over how his clinical practice was scheduled. He discovered that
expectations concerning his "productivities" — the managed-care
term for patient encounters — were ever increasing. However, no
one in administration was sympathetic to his concerns about the
negative impact on patient care of the common practice of double-
booking the allotted 15-minute appointments. He learned after his
resignation was submitted that appointment times were being
reduced to 10 minutes.
Soon after Rick tendered his resignation, Dr. Gigi Hirsch,
director of the Centre for Physician Development at Boston's Beth
Israel Hospital, reported in AMNews, the weekly newspaper
of the American Medical Association, that many managed-care
physicians were experiencing work-related stress syndromes due to
lack of control over scheduling.[1] As Hirsch wrote, "this
inflexible scheduling system made it extremely difficult and
unnecessarily stressful to take good care of patients" and
"adverse working conditions may be undercutting one of the core
strengths of American medicine — the high quality and personal
commitment of its physicians."
Rick's experience is common and reflects the result of the
"corporatization" of US health care, the natural consequence of
privatization in a free-market economy.[2-5] Although many in
Canada believe that we can develop a system that avoids the
pitfalls that exist in the US, they must consider the strong
pressures the US health care industry will bring to bear on
Canada, and the fact that the North American Free Trade Agreement
may make protection from US influence impossible.[6,7]
We should be able to find solutions to our health care
challenges without sacrificing the principles of equity and
justice for patients and autonomy of practice for physicians that
are embodied in our single-payer system. It would be shameful if
Canadians were exposed to the possibility of risk to our medicare
system, however remote, as an illusory solution to the financial
and structural problems that we will face in years to come.
Rick's real name is Vic Wylie. He did not want his name used
in my original letter because of his concern that divulging it
could result in his dismissal, an occurrence that is not uncommon
because of the "gag-clause" mentality so common in the managed
care industry.[3]
Michael Gordon, MD
Vice-President
Medical Services
Head
Geriatrics and Internal Medicine
Baycrest Centre for Geriatric Care
Professor of Medicine
University of Toronto
Toronto, Ont.
m.gordon@utoronto.ca
References
- Hirsch G. A dysfunctional system may be adding to your
stress. AMNews 1996;39:40.
- Kassirer JP. Managed care and the morality of the
marketplace. N Engl J Med 1995;333:50-2.
- Woolhandler S, Himmelstein DU. Extreme risk — the new
corporate proposition for physicians. N Engl J Med
1995;333:1706-7.
- Cimons M. US acts to ease HMOs' cost pressure on doctors.
Los Angeles Times 1996 Dec 26;Sect A:1-2.
- Kuttner R. Putting an end to HMO bribes, gags and denials.
Los Angeles Times 1966 Dec 29;SectM:3.
- Dirnfeld V. The benefits of privatization. Can Med
Assoc J 1996;155:407-10.
- Coutts J. Danger to medicare seen in trade barrier plan.
Globe and Mail [Toronto] 1996 June 11;SectA:8.
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