Managed care really has two components. One is carefully managing the actual care - acute and preventive - an individual receives. The primary goal is to optimize health. The second component is to manage the costs of care. In this arena, some argue that health is the lowest priority. Costs, and in many cases profits, are the driving force.

And what does all this have to do with endometriosis treatment? In the view of Dr. David Redwine, the impact may be more far reaching than most would imagine. The following are some of Dr. Redwine's observations about the impact managed care may have on the practice of medicine.

Gynecology Eyes Gatekeeper Role - How Will It Affect You?

Opinion by David B. Redwine, MD

With the collapse of the Clinton Health Plan, pressures for change in health care shifted from the Congress to insurance companies and other payers including the federal and state governments. In this shift, managed care was selected as the answer to most problems, although in my opinion, without convincing supporting evidence.

In a managed care plan, a primary care provider (a nurse or doctor) can decide what care should be dispensed to a particular customer registered with that plan. When a situation arises where they can't dispense care directly, referral to a specialist remains an option. This option, however, is colored by the opinion among some groups that high-priced specialists are the real culprits in the historical rise of health care costs. This presumption is based not only on individual physician income, but also on the costs of tests and hospitalizations they order. The premise is that if primary care providers can just work with patients and improve their health in a preventive fashion, customers can be kept away from specialists and out of the hospital, leaving more money at the end of the year for the provider.

Under this system, being a primary care provider or "gatekeeper" is a desirable thing, since the gatekeeper can keep medical care at a minimum, thus protecting dollars for the system. Specialists have become concerned that they will be shut out of the payment loop of managed care if they cannot be gatekeepers or get easy referrals from gatekeepers.

Strictly as a result of this stark economic imperative, the specialty of obstetrics and gynecology has sought to virtually redefine itself out of existence. The American College of Obstetrics and Gynecology (ACOG) declared overnight that its members and also its trainees should be considered primary care providers and gatekeepers for women of all ages. This represented a radical departure from the historical beginnings of the specialty as a surgical subspecialty to enhance gynecological health care.

To be considered a primary care provider in this new era of managed care, ACOG decreed that obstetrician-gynecologists should be as able to diagnose and treat hypertension, diabetes, angina, intestinal disorders, headaches, substance abuse, and domestic violence as they could diagnose and treat obstruction of labor or stage IV endometriosis with intestinal involvement. This Renaissance gynecologist would have consummate skills in all specialties which would be updated at regular intervals, while also keeping current in all aspects of Ob/Gyn as well. Such care could extend from the cradle to the grave, and would certainly justify defining obstetrician-gynecologists as primary care providers and, more importanly, GATEKEEPERS who are managing health care for women.

Despite any evidence that this could be done successfully, training programs for Ob/Gyn have changed drastically to expand the education of future gynecologists well beyond the traditional realm of Ob/Gyn. Since there are only 24 hours in a day, and since some states have laws limiting how many hours a week a trainee in medicine can work, expansion of Ob/Gyn training into other areas must necessarily result in a reduction of the amount of time spent learning traditional Ob/Gyn skills, such as delivering babies or treating endometriosis.

Since continuing medical education must also cover all medical specialties, continuing education for Ob/Gyn problems must also decrease. If you are concerned about the level of care of endometriosis in America now, just wait.

And there's more to the story. At the same time Ob/Gyn training and practice are being watered down to accommodate pressures from managed care, spending on health services is increasing. The problem is that, in many cases, the additional spending doesn't go toward additional or better care, it is often directed to the bottom line of for-profit insurance companies and health plans. Some health insurance companies are making so much money by limiting or denying indicated specialty care, or by simply not paying for services rendered, that they are planning to sell stock to the public, so shareholders can reap the profit to be made from customer's insurance premiums.

Further, these changes are eroding the decision-making position of physicians who have spent years of higher education acquiring their skills. Under numerous managed care systems, many decisions are shifted to other, usually less expensive, providers who care for patients based on instructions issued by an insurance company or managed health care plan. Since only a tiny fraction of Americans are in the health care system in a serious fashion at any time, the majority of Americans often applaud such changes which may lower their annual insurance premiums by $50 to $200. But what happens to the quality of care if money is the only driving force behind these changes? Is a $50 annual savings worth a potentially significant reduction in quality?

Epilogue

As a physician, I do not participate with any insurance company, HMO, managed health care plan, Medicare, Medicaid, or any other payer because I do not want outsiders trying to control the treatment of my patients. Their care has already been controlled enough. This doesn't mean that I do not accept insurance payments. It simply means that I do not accept artificially imposed discounts for services provided or clinical dictates regarding the care I provide.

I feel that I provide genuine value to my patients for the fees charged (especially since they are often significantly lower than other nationally recognized specialists in this field). While I realize this poses problems for some of my patients who are covered by such plans, I feel it is vital to retain my clinical autonomy. If you have questions about financial arrangements for my services, please contact my office at 541-382-8622. (St. Charles Medical Center does participate with most major insurance carriers, so hospital bills are likely to be processed more routinely for most patients).

In the meantime, the Institute of Medicine recently proclaimed that Ob/Gyn is not a primary care specialty, seemingly dooming the chances for obstetrician-gynecologists to be paid as gatekeepers. Nonetheless, the profession schizophrenically charges ahead under the guidance of ACOG identifying itself as a primary care specialty standing outside the walls of managed care, hopeful that someone may listen and pay. Gynecological surgical skills will be necessarily de-emphasized and will therefore suffer, with the profession being reduced to general office practice, midwifery and performance of hysterectomies. DBR.