Summer 2000

A Story

By Susan Tolbert, M.D.

Two things happened in the year 1995 that would change my life. The first occurred in Austin, Texas, where Governor George W. Bush vetoed the first Patient Protection Act. The act had passed the state legislature with almost overwhelming support and was popular with the public. However, the governor chose to wait until the legislature was out of session, then he vetoed the act, effectively eliminating the possibility of significant managed care reform in Texas for another two years.     

The second event took place in my town, Fort Worth, where a local HMO decided to make some changes.  I will call the HMO in question Heavenly HMO.  In 1995, Heavenly HMO was THE HMO in Fort Worth, controlling a large share of the managed care business in the community and a large part of my practice.  Part of its success was due to its name and affiliation with a local hospital. Since it was organized and managed by physicians, doctors and patients who might not have considered joining another HMO signed up for Heavenly HMO, helping to break down community resistance to managed care.

In 1995, Heavenly HMO decided to change from a nonprofit to a for-profit insurance company.  Due to poor decisions and questionable policies, the new, for-profit HMO ended up falling flat on its face, but not before it destroyed my medical practice.

In the spring of that year, I received a letter informing me that I was over budget. If I did not trim the excess spending, I faced losing half my practice.   In later meetings with HMO representatives, I learned that my problem stemmed from the fact that I had an unusually sick patient panel. My 1000 Heavenly HMO members had an illness burden of 1.8 (average being one), meaning that my expected expenditures should be 80% over the average age/sex adjusted budget for a family physician. My budget was actually only 50% high, which I was told indicated that I was managing my chronically ill patients in a cost effective manner. I was told not to change the way that I practiced medicine, but IF I DID NOT REDUCE MY SPENDING I WOULD BE PLACED ON PROBATION AND POSSIBLY SUSPENDED FROM THE PLAN.  A Catch 22 if there ever was one.

What followed was a three-year nightmare in which I went to bed each night worrying that I was going to receive a letter of termination from Heavenly HMO the next day. Along the way, the HMO cut its fees and slapped me with large financial penalties, but it was the uncertainty, the loss of control of my own practice that finally lead  to a bout of acute depression. In early 1998, I closed my practice, just before Texas state insurance officials ruled that Heavenly HMO's policies were improper.

Sometimes, I wonder what my life would be like now if that first Patient Protection Act had been allowed to become law. Heavenly HMO lobbied hard against it, so presumably HMO officials knew that their new, cost saving policies would be outlawed by the legislation.  If I had not been forced to spend several years of my life with a sword hanging over my head, would I still have my private practice? I will never know.

My problems with managed care are over, since I have vowed never to work with an HMO again. However, there are many doctors and patients who are still subject to the whims of insurance company executives. Despite the Patient Protection Act that finally was allowed to  become law (minus the governors signature), HMOs continue to experiment with policies that place cost containment first and patient care second. The current craze is global capitation. Heavenly HMO has announced that it is selling its plan to another HMO, one that specializes in global capitation of primary care physicians. For the uninitiated, this means that family doctors receive a lump sum per month per member. From this money, the doctor must pay all medical costs including specialists' fees and medication.

You do not need an accounting degree to know that global capitation will have the same effect as Heavenly HMO's outlawed policies.  Doctors who take care of chronically ill patients will be driven bankrupt--assuming that they are foolish enough to sign onto the plan.  Patients with serious chronically medical illness will find themselves shuffled from doctor to doctor, vainly looking for some physician or group willing to take a big financial risk.   And, HMOs will be able to brag, "We do not require precertification. We allow physicians to make all treatment decisions."

Suzanne Tolbert   MD, 17 January 2000

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