ASK DR. BAUGHAN                                                         May 28, 1999

TENDING THE WEB

This is not about monitoring questionable sites on the Internet.  This is about a dilemma in managed care.  The most common assumption about managed care ethical dilemmas is that the primary care physician will be pressured into providing less than optimal care for his or her own financial interests.  Having practiced in managed care settings in Seattle and San Diego for 20 years, that has been an infrequent dilemma.  It is simply too difficult to structure financial rewards to be very meaningful when it comes to individual doctor-patient interactions.  Usually limiting care involves committees or bureaucrats who will say “No” rather than individual providers unless they have a mindset that way already.

But in a rural area like this, the web of referral relationships for specialty care becomes more important.  In a big city, there are usually enough good specialists that if one group does not sign up with a managed care company, another group will, and there will be adequate specialists available for the primary provider to refer to when needed.  When specialists are 1-3 hours away, though, the issue becomes more complex.

Presently, local physicians are having to decide one by one whether to accept a contract with the Blue Cross-Matthew Thornton insurance plan.  The local financial reimbursement for primary care is not a sticking point.  Here is the dilemma.  The insurance company has been negotiating with the cardiac surgery group in Portland for multiple months and has not reached an agreement.  If I have a patient who has a heart attack without complications, I can take care of them locally.  If they have complications and need a cardiac catheterization, Maine Medical Center is the nearest hospital that does that.  I would refer first to a cardiologist in a group which has a long-standing relationship with this community.  They even send a cardiologist to Memorial Hospital twice a month for consultations.  In emergencies, though, patients would go to Portland.  If the catheterization showed the need for by-pass surgery, they would consult the cardiac surgeons.

If the insurance company says I cannot refer to these surgeons, though, there is no sense in referring patients to the cardiologists.  I would need to refer to hospitals in Manchester or Dartmouth, where there are good surgeons, but it is 1-2 hours farther away.  I have referred there before, but less often.  My patients may still receive the necessary care, but at considerably more inconvenience in the emergency setting and in follow-up care.

How can I best tend to the web of care my patients may need?  How big a factor should this be when I decide to sign a contract with the insurance company?  Only a handful of patients may need by-pass surgery each year.  More, but probably less than 50 of my patients with this insurance will need cardiology consultations.  It is a low-volume but high priority issue.  I do not know what the disagreements in the negotiations with the cardiac surgeons and the insurance company are.  Should I try to find out?  Should I pressure the surgeons to accept the contract?  Should I pressure the insurance company to give the surgeons what they want?  What pressure can I exert except by not signing up with the insurors?  Is that fair to my patients who have that insurance?  The ones with heart disease may care a lot.  How about those without heart trouble?  Which health conditions should receive this much consideration - allergy care?  Mental health?  Orthopedics?

I can’t say I have any answers here.  I primarily wanted to share the non-medical dilemmas I face that influence the care I can give.  I need to discuss this with my medical colleagues (which I am doing), and I would appreciate feedback from my patients.