Saturday, December 3, 2022 Dec 3, 2022
62° F Dallas, TX


I don’t like it and neither should you. How managed care is tying my hands and damaging your health.

PLEASE CONTINUE HOLD-ing. Your call is important to us. Do not hang up. Your call will be answered in the order in which it is received…”

I think I’d rather hear this disembodied, computer-generated voice over and over than return to the inevitable piano solo of “Feelings.” But since the average time on hold can range from as little as two minutes to as long as 40 minutes, there is usually ample opportunity to listen to both.

There was a time, they tell me, when a physician never had to speak to an insurance company representative on the phone. In fact, there was a lime when the physician’s business office rarely spoke with an insurance company, It’s not that there is anything particularly distasteful about speaking on the telephone. It is, however, difficult to do so for every single procedure, surgery, hospital admission, hospital stay, etc.

This time, after only 17 minutes, a different voice comes over the speaker phone on the credenza behind my chair. I whirl around, snatching the handset from the cradle in time to hear…

“If you wish to inquire about a specific claim and you are a client, press the pound sign and one now. If you are inquiring about your premium or other account information, press the pound sign and two now. If you know the party’s extension to which you wish to speak, press the pound sign and three now. If you are a physician, physician’s office, hospital, imaging or surgery center, press the pound sign and four now. If you wish to continue holding, please press five (God’s honest truth-press five if I wish to continue holding). Hold the line (again) and an operator will (may or may not) be with you soon…

Like the puppet that I am, I press the pound sign and four.

“You have accessed the health-care provider client representative. If you wish to inquire about precertification fora procedure or admission, please press one now. If you wish to obtain a referral code number, press two now. If you wish to discuss reimbursement on a claim already filed, please press three now. If you need farther assistance, please stay on the line and an operator will be with you soon.”

I press one and pray that I’m almost out of the loop. After all, I do have three patients waiting in the exam rooms. Since I’m scheduled in surgery during the insurer’s lunch hour and their closing time is 5 p.m. EST, I must call between patients.

“Good afternoon, APSCO Insurance. Your health is our concern. Angela speaking. How may 1 help you?” Well, this is a start.

“This is Dr. Thurston in Dallas, and I’m calling…”

“Do you have the party’s name to which you wish to speak?”

“No, I do not. As I was saying, this is Dr. Thurston and…”

“Patient name and group number please.”

“The patient’s name is Jackson, Brooke T, and I don’t have the group number. Look I just need to speak to…”

“Hold, please,” she commands, and I’m back to “Feelings” again.

Now, often this is where I get off. Patients are waiting. Some frontline person has already denied precertification for a medically necessary procedure, and I need to speak to the medical director. But this time I just can’t hang up. The procedure is scheduled in two days. The patient informs me she was precenified with no problem, even had a confirmation number. My office staff was told the opposite on the same day. Damn it, I have to speak to somebody.

” I’m sorry. Doctor, but we have no Brooke D. Jackson. The group number would really help.”

“It’s T., Brooke T. Jackson, and I’m sure the group number would help, but that doesn’t change the fact that I don’t have it. Now all I need is…”

“No need to get testy now. Hold, please,”

It’s a good thing not everyone has video phones yet. When they do, I’m going to stop using the telephone completely. After 15 seconds or so of a refreshing version of “People,” Angela returns.

“I have it on screen now, Doctor. How can I help you?”

After an all-too-audible sigh, I try again.

“I need to speak to the medical director regarding the denied pre-certification on Ms. Jackson’s laparoscopic ligamentopexy. The patient claims she was precertified, our office was informed that she was not.”

“Well, let’s see here. Nope. No record of either your office or the patient contacting us about this matter.”

My intercom rings. It’s my nurse: I’ve been on the line 20 minutes since the last patient checked out. Mrs. Schwartz is a postpartum and has her pediatrician’s appointment in 15 minutes all the way across town. Candy’s crying in the treatment room with that right-side pain again. And Mrs….

“I’ll be there as soon as I can.”

“I’m in Hartford, sir.”

“Oh, sorry, not you, that was the intercom, I’ve ah, ah, got people waiting. Look, I know the patient called. She was given a confirmation number. Here, it’s on her chart. AP93-117493-22-018.”

“Hold, please. ” Damn ! Why does this surprise me every time? Even a fully orchestrated “To Sir, With Love” does little to placate me. After 45 seconds or so, my misnamed Angel returns with good news and bad.

“Dr. Thornton?”

“It’s Thurston, Dr, Thurston.”

“Well, Dr. Thurston, we do show a Mrs. Jackson receiving that number to precertify a laparoscopic tubal ligation, but after further review, and recognizing that her PPO policy does not cover birth control, we informed your office of the reversal and subsequent denial of her precertification.”

“That would be just fine, except the procedure requested is a laparoscopic ligamentopexy for chronic dyspareunia.”

“This procedure is for ICD9 623.8?”

“Could be, if that’s the number for dyspareunia!”

“Well, painful sex is hardly a medical necessity, now is it?”

“I guess that would depend on your point of view. I would like to speak to the medical director, please.”

“Have you tried lubricants? The computer under ICD9 623.9 lists dryness as the most common cause, you know.”

“Ma’am, to be honest with you, I don’t have the time or the inclination to discuss this with you. Now what is the medical director’s name?”

“We don’t give out our medical directors’ names.”

“Well, could you connect me with him now?”

“I’m sorry, that’s quite impossible. We will give him the case number and ask him to call you back ASAP “

“Well, might that be this afternoon?” I queried hopefully.

“Most likely tomorrow. Our doctors are very busy, you know.”

I wanted to say, “Is that so? Well, I have nothing to do but sit around and play this asinine game all day long!” But I just gave her the number for the OB office where I could be reached the following day.

Now, remembering how difficult it was to make it this far, when a nurse retrieved me from an examining room the following afternoon for the medical director at APSCO’s call, I rushed from the patient s room as though it were Ed McMahon on the line.

“Yeah, this is Dr. Thurston.”

“Hello, I understand there is some confusion over Brooke Jackson’s precertification?”

“Excuse me, but are you the medical director?” He sounded more like my great-grandfather.

“Yes, that’s right, son.” Son? Can you believe it? He actually called me son. I wanted to address him as Dad, but thought better of it at the last second.

“Your name, please?”

“I am the medical director for this claim. My name is of no consequence. Now how can I help you, Doctor? ” The emphasis on the last word established firmly what I had initially suspected, This guy was condescending to me, not vice versa! But if I was ever going to help my patient, I had to continue playing the game.

“My patient has suffered from deep dyspareunia for all of her adult sexual life. She has a severely retroverted, retroflexed uterus, and I believe deep penetration leads to contact with an entrapped ovary.”

“Is that ICD9 623.8 or .9?”

Exasperated, I replied through clenched teeth. “I’ve been told it’s 623.9. Does that help?”

“Hold on for a moment, please.” Then came “Feelings” again. I was getting nauseous. I think this jerk was actually looking it up on the computer.

“Sorry about that. Listen, have you tried lubricants?”

“You cannot be serious. We have tried everything over the three years that she has been my patient. Her husband is cooperative but as frustrated as she is. It is beginning to seriously tax what is otherwise an apparently loving relationship.”

“Well, what is it exactly that you propose to do?”

“As I said, a laparoscopic ligamentopexy.”

“What is that?”

“What is what?”

“A laparoscopic liga…whatever you said.”

“You’re going to decide what procedure is medically necessary, and you don’t know what the procedure is?”

“Now you listen to me, son. I was a general practitioner for 55 years in Flatbush, Nev? and believe you me, I’ve done plenty of procedures, and many I’m sure before you were born, so don’t talk down to me, Doctor!”

Stupefied, I actually apologized.

“I’m sorry, Doctor…er…sir, I only find it difficult to understand how you can make a decision in this case.”

“Are you going to describe the procedure or not?”

“Yes, sure. It’s a laparoscopic procedure in which the round ligaments are redoubled and thus shortened, pulling the fundus to the anterior abdominal wall with only two small incisions. The ovaries are thus suspended away from the pouch of Douglas. “

“Did you say suspended?”

“Yes. So?”

“That’s procedure code G421.2. It’s not covered. Any uterine suspension is considered elective major surgery, and it’s not covered. Sorry.”

“But that’s the point, this procedure doesn’t fall under the old code. It’s outpatient. It takes maybe 30 minutes and the patient is home in two hours, back to work in three days! “

“Well, there’s no code for it specifically. Furthermore, sexual enjoyment hardly seems a life or death matter, does it?”

“I don’t think the patient would agree with you. Who else…”

“You can’t talk to anyone else, Doctor. If Ms. Jackson wants this unnecessary procedure, she can pay for it herself! Good day! “

He hung up! He hung up on me! That was a twist. I usually hang up on “Feelings” or “People” or whatever,

That evening I called Mrs. Jackson and relayed her insurer’s opinion. She had exactly no recourse, other than paying legal fees to sue an omnipotent insurance company that could well afford better representation than she. We agreed to talk again soon and try to come up with some other options. But I hung up knowing that the only real option was for her to live with her pain until after she had completed her childbearing and then pray for some pathology that her insurer would feel qualified her for hysterectomy.

VISUALIZE THIS TYPE OF EXCHANGE HAPPENING THOUSANDS of times every day all over the country. Similar exchanges occur between office personnel and insurance company RNs perhaps a hundred times more frequently. Frustration and wasted time are magnified by the fact that insurers use independent agencies on a contract basis to handle precertifica-tion. As a consequence, the potential for error in communication is increased, and the insurer has the opportunity (and frequently uses it) to deny payment retroactively, citing the nonbinding nature of approval before the fact by an outside agency.

In our OB office, we have about 800 ongoing pregnancies. Currently, our receptionist has to call for precertification for (1) OB care, (2) ultrasound, (3) oral glucose screening for gestational diabetes, (4) vaginal delivery or c-section, and (5) hospital admission. That is about 4,000 more phone calls than prior to managed care. Each of those phone calls can involve the “please hold” phenomenon for many minutes, Each of those phone calls is an opportunity for human error. Mind you, these 4,000 additional calls are for each of the patients with no problems. Additional calls are generated for anything not completely routine.

I am confident that any surgeon today could give you examples of the precertification nightmare. One of my colleagues recently carried on a conversation similar to the one I had above. It took longer than a week before he could actually talk to the “medical reviewer” for this particular company. After a long discussion about laser endometrial ablation it became clear to my associate that the reviewer had no idea what he was talking about.

When he repeatedly pressed the reviewer as to her qualifications, she couldn’t give an answer to any questions about her internship, residency, practice experience, etc. After several more infuriating phone conversations, my associate discovered that the so-called “medical reviewer” was in fact a southern California medical student working on an hourly basis to help defray some of her living expenses. So a student made the decision that denied a patient a procedure that my colleague, with 20 years of experience and multiple board certifications, thought was appropriate.

I recently had precertification denied on a repeat cesarean section. I happen to be a big proponent of VBAC, or vaginal birth after cesarean. Educating the patient as to the safety of trying to deliver vaginally after a previous c-section has helped lower the repeat section and thus the total c-section rate. This in turn lowers length of stay, which lowers total cost.

That’s all well and good. But VBAC is not appropriate for every clinical situation. The young lady whose precer-tification was denied had a 16 cm posterior lower uterine segment fibroid (benign uterine tumor) blocking her birth canal. She also had a previous uterine rupture with an attempted VBAC elsewhere! Her insurer still denied payment l’or a scheduled cesarean section!

The patient had one anyway and paid the difference in hospital costs herself. But she was understandably indignant at what she viewed to be potentially dangerous strong-arm tactics to lower her hospitalization costs.

The frustrations are by no means confined to precertification. For the patient with painful intercourse, it is true, the insurance company’s decision to deny the procedure may not be life-threatening, even if it leads to the dissolution of her marriage. It is also true that the decision with respect to the VBAC patient only cost her money and not her health. But other issues affect the welfare of the patient more immediately. In fact, other managed-care rulings-on length of stay, choice of pharmaceuticals, choice of laboratory tests, and restriction of appropriate consultation-are leading to dangerous situations.

“Outta Here”

IT HAS NOW BECOME COMMONPLACE FOR PATIENTS TO BE Discharged at the dictates of the payor-without regard to their condition-by people who lack an adequate understanding of the patients’ needs,

Classic examples in the obstetric area would include patients seeking admission to the hospital for antepartum care due to high-risk conditions. These commonly include bleeding placenta previa, preterm labor, premature rupture of membranes, and preeclampsia or toxemia.

While it is true that in certain instances all of these situations might be managed with bed rest at home, each individual case is unique.

For instance, a 31 -week preterm-labor patient on a subcutaneous pump for administration of medicine might be managed at home with home monitoring if certain conditions were met. Those conditions might include proximity to the hospital, a cervical exam that was not worrisome with respect to dilatation, softness, position, effacement, and condition of the lower uterine segment, a vertex presentation, intact membranes, and others.

Now let’s assume that, in this very common, uncomplicated circumstance, you have no idea what I am talking about. Now recognize that we may be seeking approval from an orthopedics nurse on the phone from Hartford, Conn., who has no more idea about the subtle difference in situations than you do, She makes the decision about whether the patient can stay in the hospital on the basis of criteria on a computer screen in front of her. Reasoning with her not only can require huge amounts of time, but is usually futile. If the patient is not independently wealthy and the screening nurse denies her stay, she’s outta here.

So, let’s say the patient lives 120 miles away, has a worrisome cervix, but is doing fine at this moment. Should she go home? Of course not, medically. But if her insurance denies her, the hospital wants payment. Even if she chooses to stay and can negotiate with the hospital, the uncovered portion of her bill can be astronomical.

Recendy I had a patient two days post c-section with a 102.6 fever; a reddening, oozing wound; breast engorgement; and anemia with a blood count of 24 (32 is normal post-op). Her insurance refused to pay tor continued hospitalization despite IV, antibiotics, lack of bowel function, likely wound infection, and severe anemia with increased pulse and light-headedness.

She left the hospital after two hours of telephone work setting up and approving home care-IVs, nurses, etc. Admittedly, with cost-shifting on the hospital’s part, each 24 hours would run an astonishing $ 1 ,800 including nursery care. At home the insurer paid only $900 per day. But this patient’s care was altered solely on the basis of financial pressure. She was readmitted three days later with a severe post-op ileus (lack of bowel function), inability to urinate, continued fever, and a swollen arm from an infiltrated IV. She was in the hospital an additional five days. Was her early discharge either safe or cost-effective? Probably not.

Not on Our List

TWO WEEKS AGO A PATIENT OF MINE WAS DIAGNOSED WITH a brain tumor of unclear etiology. While imaging studies showed characteristics compatible with a benign meningioma, the neurologist still recommended consultation with a neurosurgeon, The neurosurgeon with whom this neurologist works was not on the patient’s PPO list, so he helped her choose one that was.

The approved neurosurgeon agreed that she needed surgery, but when they attempted to schedule it, they learned the hospital at which he operated was not on her PPO list. Appeals to her insurance bureaucracy have been fruitless to date. Surely this situation will be resolved, but if you were the patient, would you be happy spending three weeks working with administrative cretins?

This week a 36-year-old woman, a longtime patient of mine, came in with gradually worsening left-sided pain. On ultrasound in the office she had a cystic and solid 11 cm ovarian mass, I had delivered all three of her children. I had helped her through the tough times five years before when her mother had died of ovarian cancer. Now she needed me.She needed surgery, but I think she also needed me.

When we started to schedule her surgery, we discovered that she had been seeing me “out of network” for the last two years and paying out of her pocket for office visits. I told her I would do the surgery, and she could pay whatever she thought was fair over whatever time she needed.

That didn’t solve the problem. My hospital was no longer on her network. Payment to out-of-net-work facilities in this case was zero. Hospital costs would probably top $6,000. She and her firefighter husband just couldn’t do it. So, with a newly diagnosed tumor and a history of her mother dying of ovarian cancer, she was forced to see a physician she had never seen before at another hospital.

Not Necessary

SUSAN HAD JUST EXPERIENCED HER fourth consecutive miscarriage. Blood-testing of anti-cardiolipin, lupus anticoagulant, antinuclear antibody were all negative, as were X-rays of her uterine lining (HSG.) Every test in the world agreed that it was time for chromosomal testing of her and her husband. The karyotype on their blood samples would be $310 apiece. Her carrier, after multiple discussions with all my office personnel and my discussion with the medical director, felt that this testing was unjustified. No appeal.

Corazon is a 42-year-old Latin patient with a history of previous tubal ligation. She has periods that last 15 to 40 days at a time that are unresponsive to hormonal treatment due to large uterine fibroids. Her blood count hovers around 25 (normal 40). She has bladder pressure and cramping almost daily. She was scheduled for a total abdominal hysterectomy. Her managed-care company said she would need a second opinion. I always welcome second opinions, but felt it absurd in this case and expressed this to the nurse reviewer. She said she would present it to the review board and let me know in two days.

True to her word, she called back in two days and told my nurse that a second opinion would not be necessary. Unfortunately, the reason was that they were denying the surgery outright. Had I tried hormonal therapy? We reviewed that with them again. Had I considered endometrial ablation? We explained why that was inappropriate. Had the patient ever needed blood transfusion? Well, not yet. We were instructed that when that was the case, her circumstances would be reviewed again. Bye. End of story.

Denied.. .Pre-existing

INSURERS FREQUENTLY DENY APPLICANTS COVERAGE ON THE basis of pre-existing conditions, This obviously applies to patients with chronic conditions, whether that be arthritis, lupus, psoriasis, etc With respect to life insurance coverage, it is logical that a company would not want to pick someone up who already had leukemia, AIDS, lung cancer, or some other terminal disease.

But these conditions are not the ones that most frequendy lead to a denial of insurance coverage. In fact, many of the conditions that lead to insurance denial the patient may not even have! Let me clarify this.

Recently a patient of mine was denied life insurance because in her chart, three years and two children before, there was a note about the patient inquiring about the safety of a certain antidepressant while having unprotected sex. She was told there would not be a problem. Now, she and her husband have applied for life insurance and been denied on the basis of that note. Well, not only was the patient not depressed, she never took the medicine. She had asked the question for her next-door neighbor! I never prescribed the drug, there is no evidence that I did so, and yet after multiple communiqués and documentation, the insurer will not reconsider.

Another common one for health insurance is HSV, or genital herpes. It is estimated that 10 to 20 million American women have this viral infection. We now know it is not the precursor to cervical cancer. It has no long-term health effects. It may not even be necessary to do c-sections for active lesions in the near future, as we have come to realize that only first-time lesions hold high risk of infection for the newborn. Despite these facts, I constantly receive notification that a woman’s health insurance with a new carrier has either excluded any problems with her reproductive tract or denied her coverage completely, solely on the basis of a history of genital herpes.

Pre-existing conditions have become a convenient, often undocumented mechanism for insurers to deny coverage of entire portions of a person’s health care, like their reproductive tract. Whether it’s HSV and denial of” maternity benefits, or fibrocystic breast changes and subsequent denial of coverage for a totally unrelated breast cancer, these add significantly to the frustrations of health care for both physician and patient.

The stories of wasted time and thwarted effort from any practitioner in this country are endless. “Frustration ” no longer adequately describes the feelings of many. Some physicians would prefer a completely socialized system to this, where at least there would be only one payor-the government-to deal with, and that payor would at least be somewhat responsible to the voters. Insurance companies, by contrast, are responsible only to stockholders-and stockholders want profits.

THE DANGER INHERENT IN THESE SCENARIOS IS NOTHING COMPARED to that looming on the horizon in many parts of the country and in fact already the case in other parts. By that I mean the danger of the institutionally employed physician, in which the institution is the contracting entity with employers and insurers.

Traditionally, or at least since World War II, insurers have contracted with individuals to cover some percentage of their health-care costs after a deductible is met. As costs have risen, this paradigm has shifted such that employers contract with insurers, and the employee-patient is then directed to a PPO plan (preferred provider) with little or no deductible and a tiny co-pay such as five to ten dollars.

The preferred providers aren’t “preferred” in the traditional sense, of course; that is to say, they’re not chosen because they are known to practice good medicine, but only because they’ve signed a contract to accept reduced fees in exchange for listing. Both hospitals and doctors play this game. All of the dangers enumerated above can rear their heads in this situation, but at least the physician is still autonomous, even if the patients’ choices of doctors, drugs, and hospitals are channeled.

But things can get worse. Then comes “capitation. ” An ugly word for an ugly idea. Capitation is simply a per capita system. An insurer will pay a contracting entity, let’s say for sake of argument a hospital, a set amount per patient per month to cover all eventualities. Any money left over at the end of the fiscal year is profit for the hospital. If the hospital either employs or, by nature of the capitation contracts, substantially controls the physicians on its staff, their compensation too is tied to funds left over at the end of the year. The physician’s individual productivity in dollars is tracked by computer and broken down into “fixed overhead” such as rent, utilities, insurance, etc., and “variable overhead” such as supplies, laboratory tests, imaging tests, consults with specialists, and hospitalizations.

It’s easy to see what happens here. A system comes into being in which both doctors and hospitals are rewarded for delivering less health care. Not better, not necessarily more efficient, but less health care. A financial incentive-in fact, for the patient, a life and death financial incentive-is created to lower costs at all costs.

Recently I had lunch with the medical director of a nearby family practice group. They had formed their own HMO without walls and took almost 90 percent of their patients on capitation. During the usual tuna salad and iced tea fare in the hospital’s conference room, I asked this 60-year-old physician how his group handled referrals.

“What do you mean, referrals?”

“I mean, if a patient presents with a difficult arrhythmia and you want them to see a cardiologist, do you subcontract that out or what? “

“We don’t do that.” He said it with finality.

“You don’t do what?” I said, thoroughly confused.

“We don’t refer. To anyone. Ever.”

“You mean you handle renal failure without a nephrologist, and seizure disorders without a neurologist, and ruptured discs without a surgeon?” I was incredulous. “Exactly.”

“Is that a good idea? I mean are your patients really getting the best care?”

“Who said anything about the best care? That’s not the game anymore, Doctor. The bottom line is the game. There are 12 family practitioners in the group. We’d love to have your guys be our obstetrics arm, Currently that’s the only thing we sub out.”

“But what if you just don’t have the expertise to handle someone’s problem? What if it’s life-threatening?”

He looked at me with what I can only describe as contempt, Wiping the mayonnaise off his chin and throwing his napkin on the plate, he abruptly pushed back his chair and stood up.

“I guess the patients should have thought about that when they bought cheap insurance!”

You’ll be happy to know that we didn’t join their merry little band. When I related this story to my brother, the heart surgeon, he laughed bitterly.

“My partner had a bitch of a month in June,” he said. “Three out of six of his coronary bypass patients died either in or right after surgery. He was devastated. But not everybody was unhappy. The first week in July, he got a certificate in the mail for being the “low cost provider” in cardiovascular surgery for the month of June!

“It’s the God’s honest truth ! ” he went on. “Even got a write-up in the HMO paper. Of course no one mentioned that ICU time is very expensive, and if your patients die on the table, it’s extremely cost-effective! “

This is danger with a capital D. At least in a one-party payor socialized system, there’s no disincentive for care. Sure, the government might totally screw things up and end up rationing health care in a big way; but at least under such a system the hospitals and doctors aren’t paid to underdiagnose and undertreat you.

Danger. There is demonstrable danger in removing health-care decisions from the hands of patients and their physicians. Decisions about diagnosis and treatment should be dictated by the patient’s needs and not by fiscal considerations. These decisions should not be dictated by forcing patients to gatekeepers or designated primary care providers; by forced referral patterns or lack thereof with respect to specialists; by misguided, ill-informed purse-string management of pharmaceuticals; or by restricting diagnostic laboratory and imaging tests thought necessary by the attending physician.

WHAT CAN YOU DO TO PRESERVE THE FINEST health care system in the world? What can you do to keep compassion alive in the doctor-patient relationship? Reject any scenario that restricts your choice of physician or facility.

If one of your insurance choices includes such restrictions, I can assure you that the participating physicians have substantially lost their decision-making authority. Your health care will then be controlled by a corporate entity whose sole motivation is to be profitable.

Insist that your employer research and offer plans that do not restrict choice, even if those plans require large deductibles or involve employers contracting directly with health-care systems. At the very least, the doctors from whom you currently receive care should be “grandfathered” for you in such a restrictive system. A choice with a large deductible may not seem financially possible on your income, but we know statistically that paying for your own routine health care out of pocket or out of money pooled and withheld by your employers must be cost-effective because the alternative, which includes filing a claim on relatively small outlays, generates huge profits for the insurers.

Women, don’t allow yourselves to be forced into a situation in which you do not have direct access to your Ob-Gyn. Ninety percent of your health problems under age 50 will fall within the expertise of your Ob-Gyn. There is no reason to accept an insurance plan of any sort that forces you to see a physician other than your Ob-Gyn for your routine care or gynecological problems.

Managed care in some form is probably here to stay. If it is truly your only financially possible option, then look for systems with no “gatekeeper” component. Large multi-specialty, physician-run HMOs not built on a gatekeeper model are more likely to deliver quality care, even if fully capitated, by avoiding the scenario whereby a screening physician decides whether you can see a specialist and which specialist you are permitted to see.

The world community still views health care in the United States as the best available anywhere. I firmly believe the success of our system is rooted in the doctor-patient relationship. It is the joy of the art of healing that drives great minds, great medical education, and great research. If we destroy the joy of medicine for the physician and take away his relationship to the patient, we will lose more than we ever thought possible.