Managed care has its virtues, to some extent conserving resources and  making health care more affordable. However, it does so by placing limits on physicians, hospitals and patients, while restricting services wherever it can. The dynamics of managed medical care are playing out against a background of a previously freewheeling increasingly expensive health system.

As managed care programs chart new territory, some of the measures taken by them have the potential to produce adverse consequences. The stories here illustrate some of the pitfalls of managed care and demonstrate how an individual, with the help of an independent physician advocate, can navigate the modern health care system.

Patient 1:    Dr. Robinson had been following a female patient with HIV for nearly three years. This is a lovely married woman in her 20's, well-educated, a national class athlete, who was exposed to the virus during her single years. Her only risk factor for acquiring AIDS was maturing into a robust sexually mature attractive woman. She has been entirely healthy and vigorous with no anti-retroviral therapy.

However,  medical research has been confirming that even during an apparently quiescent or latent period, the human immunodeficiency virus was multiplying vigorously and aggressively destroying the immune system. In early 1996, an increasing cascade of studies demonstrated that a triple cocktail of newer medications, including protease inhibitors, could take the viral load of a person without symptoms and drive it down to undetectable levels. This had the potential to reverse the otherwise inevitable decline of a patient with HIV. It also became evident that sooner was most likely better than later, with regard to starting treatment.

In the summer of 1996, Dr. Robinson told his patient that the time had come to start these medications. She readily agreed. However, she had been coming to Dr. Robinson out of her health plan, so he suggested that she go to her plan doctor and arrange for payment for the medications, estimated to cost $15,000 per year. He gave her a detailed written summary of her medical course, his recommendations for drug therapy, and copies of all the relevant laboratory studies. In her own words, here is a recollection of the interactions which ensued with her health plan doctors, and how the gate was opened for her.

Go to the patient's story in her own words.

Patient 2:   This is a patient of Dr. Robinson who moved from Washington, DC to the Boston area. He has a number of health problems and went into a managed care program under his wife's insurance. However, he could not seem to get anyone to take charge of his health care and continued for months to consult by phone with Dr. Robinson. He describes the problems he had when his divertiuclitis flared up. This appears to be an example of rationing health care by inconvenience.

The story of patient two is in preparation.

A closed gate.

Patient 3: This is a healthy single woman who works in New York City and was visiting her mother in a medium size town near Baltimore, Maryland at the end of 1996. While she was at home, she developed a fever, cough and shortness of breath which did not respond to an initial course of antibiotics. When her chest X-ray showed bilateral pneumonia, her gatekeeper physician in New York refused by phone to authorize consultation with a pulmonary specialist. After intervention from a physician with AHAC, she was authorized to see a pulmonologist who put her on more aggressive treatment, successfully resolving her pneumonia and preventing lung damage.

The story of patient three is in preparation.

An open gate. It doesn't have to be very big; it just needs to be open.

Contact DrRobinson@MD-1.com for further information.
Copyright, 1997, American Health Advisory Center

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