John La Puma, M.D.
MANAGED CARE January 1997. ©1997 Stezzi Communications

John La Puma, M.D.

Here in Chicago, of the rugged elbows and tattooed muscular shoulders that carry the Bulls, only basketball lets people believe we all live in the city that works.

Basketball makes Neiman-Marcus shoppers and K mart shoppers believe that they share the same values. Amazingly, basketball creates a community.

Driving across Chicago this week, I noticed a billboard claiming "We Hear You," next to a giant ear. Another billboard, with a happy family as backdrop, announced "More Choices, Better Value." A third had no graphics, just text: "We're Your Health Plan, Not Your Doctor."

What sort of community makes it seem extraordinary that doctors listen to patients? Why does one community health plan promote choice for consumers, instead of unity and shared fortune for citizens, as its value? Why does another plan separate "health" and doctors? Are doctors, patients and health plans one community or three?

Physician community

Doctors behave as a group, and in many ways, we are not different from other groups. As workers, we do more of what we are paid well to do. As fraternity and sorority brothers and sisters, we try to take care of our own. As colleagues, we try to uphold professionalism. As leaders, we set the tone for our practices, and to some extent, our communities.

As a group, doctors are disappointed and bitter these days, though not so much about the way managed care has changed practice, reducing marginally effective care and futile care. The disappointment is not about shortened hospital stays or lengthened home health visits without commensurate charges.

Physicians' disappointment is really about money. Most doctors don't have the training to talk about money in a way that benefits our patients. The language of money in the clinic is unfamiliar to most doctors — sterile and corporate and without feeling, like the language of administration. Cost-effective treatment with a good loss ratio is one thing; defervescence after a four-day course of intravenous antibiotics, when your 65-year-old chronic lunger seemed destined for the intensive care unit, is quite another.

Some physicians are pessimistic about community and see our group split into winners and losers, or generalists and specialists. Other physicians want to remain optimistic and, though tired of paper work, approval processes and the pressure to see more patients, have begun to innovate.

Some physicians have begun to unionize. Others have joined the ranks of physician executives and are trying to keep one foot in both camps. Still others have become entrepreneurs, and developed ways to increase and promote satisfaction in their practices, transforming their own offices and clinics into communities unto themselves. Ever individuals, most physicians still have trouble thinking of themselves as just one community.

Patient community

Patients can also behave cohesively but, like doctors, don't think of themselves as members of a single group. As workers themselves, they try to make a living and hope their employers pay for insurance. As parents and children and spouses, they value their families and their families' health, sometimes before their own. As community members, they care about public health, especially as it affects them individually.

Individual patients are not disappointed with their individual physicians, but with physicians as a group. Physicians are thought to make too much money, spend too little time, run chronically late and have God complexes. Patients know we have financial conflicts of interest in managed care, and are worried about them. Thankfully, patients have not yet held physicians responsible for "drive-by deliveries" or, more recently, fewer than four days in house post mastectomy.

What do patients want? Well, from their own physicians, they want attention, trust, personal care and time. Evidence of compassion and excellent communication skills are also desirable. A neat appearance, promptness and ordinary courtesy also help.

Patients also want doctors to practice with cost in mind, but not first in mind. But why do patients as a whole want prudence? To know that resources are stewarded wisely, and being saved for those who really need them? Or to avoid being subjected to unnecessary procedures, and their potential financial, medical and personal cost?

If the former is true, then patients who signed up at work for Too Good HMO understand population-based health and principles on which good managed care is founded. Their assumption is that all Too Good HMO members are in it together. They are believers in public health, community and justice.

If the latter is true, then patients are watching out for themselves as individuals, and for their families. Their assumption often is that their monthly premium goes for their own health care — not someone else's. These are people just trying to make a living every day, and trying hard to make good choices.

Managed care community

Community in managed care? There is a community of covered lives, but HMO communities lack the shared assumptions and values characteristic of communities we can recognize, like school, work and home. Traditional communities have face-to-face contact. Members share at least one belief. They care for and even recognize each other. Many try to be fair and responsible.

Health plans recruit new members aggressively. Here in Chicago, there has not been the same effort to retain old ones, but in other parts of the country with greater managed care penetration, competition for retention is fierce. In Albuquerque, for example, plans advertise their mammography rates in hope of retaining their customers.

But for all the scoffing at managed care organizations, especially those whose sense of community seems tied to their stock price, these organizations can take moral positions currently out of reach of ordinary, individual doctors and patients. How? By deciding whom to contract with for services and whom to avoid serving.

Physicians, patients and executives could act as a population with shared values — as one community, instead of three. But to pull doctors, patients and health plans together, the shared values will have to be explicit, even if they turn out to be money, prudence and fairness to others.

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