COHEN AND SOLOMON: HMO Scandals
The future of American health care may depend on the news media this year. A recent flare of brilliant journalism could turn out to be a flash in the pan -- or a guiding light for reporters and editors across the country. What's badly needed is illumination of the huge medical institutions known as HMOs. The number of Americans enrolled in "health maintenance organizations" has more than doubled since 1986. Upward of 50 million people now rely on HMOs; most are run for profit. From here to the horizon, the trend is clear: More of us will be getting our medical care from HMOs as they continue to expand and merge. We'll be able to choose from just a few HMO giants. The outlines of the HMO future are already visible in a "managed care" landscape where the bottom line is superseding the Hippocratic oath. "In managed care, profit comes from enrolling patients, not from spending money on them," says Dr. Steffie Woolhandler of Harvard Medical School. She warns of "a deep ethical swamp." Last fall, the tabloid New York Post -- ordinarily a stranger to quality journalism -- ran a well-documented series under top-of-the-eye-chart headlines like "Outrage At HMOs." While HMOs have some advantages -- such as relatively low premiums for individuals and employers -- the downsides are apt to be steep. One result: a ground swell of anger among patients and health practitioners. Now, Time magazine has produced a breakthrough with an eight-page investigative piece in its Jan. 22 issue. Titled "The Soul of an HMO," the article shows in painful detail how cost-cutting edicts from HMO managements put doctors in a box -- and, all too often, shove patients up against an unyielding bureaucratic wall. According to Time, managed care is "raising the question of whether patients, especially those with severe illnesses, can still trust their doctors." Faced with directives to help maximize profits, many physicians are under constant pressure to shift their allegiance from patients to company stockholders. Patients seeking care are liable to encounter delays and obstructions. As Time reports, the HMO process requires that "considerations other than mere health are brought to bear by corporate managers who must approve even such minor procedures as blood tests and mammograms." When we spoke with Time senior writer Erik Larson, who authored the article, he emphasized that the proliferation of for-profit HMOs is central to the worsening plights of health-care consumers. It is symbolic, he said, that HMO managements routinely refer to the cost of actually providing health care as the "medical loss ratio." In the upper reaches of HMOs, the lingo certainly tilts toward the fiscal. When we contacted Health Net, a large managed-care firm skewered in the Time story, we were referred to spokesperson David Olson. His official title? "Vice president of investor relations." Olson denounced the Time article as "agenda journalism" -- and added that he was in touch with other managed-care executives to discuss how to counteract the bad press: "As an industry, we have to start fighting back." But managed-care corporations have never been idle on the public-relations front. Eager to boost enrollments and vanquish the competition, HMOs have been blitzing many communities with warm and cuddly outreach, ranging from slick brochures to billboards and television commercials. Naturally, the advertised HMOs sound great. Few of us have the patience to scrutinize -- much less comprehend -- their fine print. What the billboards and TV ads don't divulge is that many doctors and other health-care providers are afraid to speak out publicly. Larson -- a former Wall Street Journal reporter who has written one book about handguns and another about corporate surveillance of American consumers -- told us that he had never encountered as much fear among sources as he did while interviewing doctors for his Time article about HMOs. "Doctors are petrified of saying anything about HMOs," Larson commented. Many have signed contracts requiring them not to disclose information that might shake public confidence. But some physicians have spoken out. Appearing on Donahue several weeks ago, Dr. David Himmelstein explained that "one of the HMOs that I practice in tells me I can't tell my patients if there's something wrong [with what] the HMO insists I do." Three days after the TV show, the HMO -- U.S. Healthcare -- abruptly canceled its contract with him. The retribution did not silence Himmelstein. He told one reporter that numerous HMOs "offer doctors steep financial incentives -- what I consider bribes -- to minimize care." Himmelstein teamed up with Woolhandler to write a scathing editorial about HMOs in the Dec. 21 edition of the New England Journal of Medicine. They noted that "many patients...object to the transparent incentives for providing too little care." Indeed. Many patients are seething as they discover what managed care portends for themselves and their loved ones. So far, in the opening weeks of 1996, the path-breaking coverage of these concerns has been provided by Time's Erik Larson. Most of the rest of the news media have some urgent catching up to do. The HMO onslaught "kind of snuck up on everybody" during the last few years, Larson said. "I don't think the press was aware of the turmoil that managed care was bringing." Today -- like health care providers, consumers and public officials -- journalists face the imperative of playing catch-up as the HMO juggernaut rolls on. It's time to get moving.
