In the "who's hot, who's not" game that has become healthcare reform American-style, there is new evidence that doctors are making a comeback. They stand poised to reassume their pre-eminent position as care managers in lieu of health plans that have taken authority from them over the past several years.
Early in the debate over the Clinton healthcare reform plan, when little else could generate consensus, politicians and policy experts across the political spectrum could agree on one thing: The fee-for-service medicine that enabled physicians to order tests at their pleasure was driving costs upward, and some form of managed care-with costs paid upfront instead of after the fact-would be necessary to drive costs down.
This approach has helped reduce the rate of increase in healthcare costs, so much so that current discussions are starting to move away from controlling costs to guaranteeing quality of care. Indeed, the president's recent step in creating a commission on quality of care was intended to reassure the American public that we, as a nation, can have managed care that earns our collective confidence.
With health plans threatened in ways very few of us imagined a few years ago, a big battle is brewing for control of healthcare. Health plans obviously want to retain their control of the healthcare dollar, but they find themselves in a Catch-22. Capitulation to consumers may affect their position in the marketplace, but ignoring consumers will leave them with the same result.
Today's horoscope has the American Medical Association and the American Hospital Association sitting pretty, where they used to be as recently as the early 1990s. Health plans, meanwhile, are on the run, trying to hold onto the leverage they've acquired.
The lynching in the press that has soured many on managed care has been just one reason physicians are likely to regain the upper hand and actually push managed-care organizations to change their behavior.
We know this is happening based on interviews conducted by the Center for Studying Health System Change, a Washington-based research group that has spent a year interviewing insurers, physicians, health plan managers, actuaries, employers and consumers in 12 communities across the country. The results of these interviews will be distilled further, but certain trends are already clear.
First, consumers are demanding much broader choice of physicians in their health plans, and employers continue to shop for the best value they can get for their dollar. Consumers are resisting the following notions: that their preferred doctor is not in the network, that they can't always get care from this particular doctor even if he or she is in the network, and that they should always be required to get approval from a primary-care doctor before they see a specialist.
They are, in turn, voicing these concerns to their employers, and the employers are voting with their feet-giving their business to those health plans that have competitive prices but also respond to their employees' needs. After all, the people who run the companies are generally covered under the same plans as their employees, and there's no evidence to suggest they are any more pleased than their employees with a different doctor every day or a gatekeeper who may deny treatment.
Second, though many health plans have met consumer demands by increasing their physician networks, they find themselves in the difficult position of managing the care provided by many more physicians than they bargained for. It's one thing to oversee a select number of physicians and physician groups; it's quite another to manage the infrastructure involved in dramatically increasing the number of physicians and groups under a plan's purview.
With an increasing number of physicians providing services under multiple plans, individual health plans have less leverage to dictate physician behavior than they did when physicians were dependent on one or two plans for their livelihood.
Third, as the networks are broadened and physicians participate in several networks simultaneously, consumers aren't limited to one plan because that particular plan is the only one in which their physician participates. Indeed, if a consumer chooses to get care at a particular facility, there are increasingly any number of plans that list the facility as preferred. Consequently, the health plans find themselves less differentiated from their competition, leading to more intense premium competition and more difficulty in demanding deep discounts from physicians and hospitals.
A fair question at this point is why physicians and hospitals would want to take over the risk and some of the administrative headaches that now rest with the health plans. The answer is simple: a drive to regain economic power in the healthcare system and in communities, and an abhorrence of health plans that they accuse of "practicing medicine" by hassling them about what they can and can't do for their patients.
What does this mean for consumers?
If physicians are happier, maybe consumers will feel better about the care they're getting. But the shift in power to physicians and hospitals also may lead to a major threat to the trust dynamic in the physician-patient relationship.
With managed care perceived by some as the devil that denies care, physicians have been shining as the guarantors of good medicine. But if the risk for managing healthcare systems is shifted to physicians, and it's the physicians who are making decisions on whether a patient should get a test or stay in the hospital the extra day, patients may become suspicious of the physician's financial motivations for making these decisions.
Stay tuned. Of one thing we can be sure: Change is coming soon-if it hasn't already-to a community near you.
Ginsburg is president of the Center for Studying Health System Change in Washington.