In an episode of the TV show "ER," tough emergency room doctor Kerry Weaver gives a $500 medication to a patient whose blood does not clot properly. A few days later, the man returns to the emergency room to complain that his HMO will not pay for the drug, insisting that he take a less expensive but less effective generic instead.
Incensed, Weaver telephones the health plan and screams that its decision is foolish, that her patient will have to be admitted to the hospital at far greater cost if he cannot take the best medicine. The HMO refuses to relent.
The recent plot line on one of the nation's most popular television programs plays to -- and reinforces -- widespread frustration with the state of health care in this country. It also helps to explain why the House voted resoundingly Thursday to grant patients a new set of rights to increase their clout against health maintenance organizations, including broad freedom to sue HMOs that deny them the care they want. Justified or not, anger with managed care has penetrated American culture so deeply that it drowned out long and well-funded protests by insurance and business lobbyists.
Even for a country with ebbing faith in many of its basic institutions, managed care holds an exceptionally low berth in public esteem.
Although medical evidence is mixed on whether people in such arrangements are better or worse off, only 45 percent of Americans believe that managed-care companies treat consumers well, according to one recent survey. In contrast, more than 70 percent give good ratings to car manufacturers, telephone companies and banks. Such mistrust is especially striking because HMOs were born in a burst of idealism by progressives who viewed them as a path to better medicine.
Why their reputation has sunk so low can be explained partly by peculiarly American expectations of the U.S. health care system: a sense of entitlement and an infatuation with newfangled medical technology not common among patients in many other Western countries. "Health policy experts are constantly talking about rationing and setting limits and balancing costs and the benefits of care, but for the average American those are just ridiculous notions," said Larry Levitt, a senior policy analyst at the Kaiser Family Foundation, which sponsors public opinion research on health care. "When they are sick, they want it, and they want it now."
But there are other reasons for the bruised image. They include physicians' influence on the thinking of politicians and the public, employers' decisions to shift millions of Americans into managed care without asking them first and the capture of HMOs by insurance corporations that twisted managed care away from its original ideals.
Taken together, those forces have demonized managed care in popular culture in a way that is virtually unparalleled among any sector of the economy except for the tobacco industry, according to historians and public policy experts.
Resentment against HMOs has supplied plot lines for successful, prime-time television shows in addition to "ER," such as "Law and Order" and "Chicago Hope." It has figured in several recent movies -- most notably, the 1997 film "As Good as It Gets," in which actress Helen Hunt portrays a waitress and single mother who cannot persuade her health plan to pay for her son's asthma treatments. HMO "horror stories" told by disgruntled patients have become a staple of television news.
And as he campaigns for the Democratic presidential nomination, Vice President Gore invariably draws laughter from audiences with an old joke about an HMO executive arriving at the Pearly Gates, who persuades St. Peter to let him into heaven -- but only for three days.
The joke and the spotlight by the mass media reverberate because "a lot of people are unhappy with the system, including those of us who designed it," said Paul Ellwood, president of the Jackson Hole Group, an architect of the fledgling notion of managed care three decades ago.
The basic idea was to improve medicine by changing its organization and economic incentives. Although the first HMOs date to the 1940s, the "competitive health maintenance strategy," as it was originally known by proponents such as Ellwood, really took root in the 1960s as a reaction to a medical system that was becoming increasingly fragmented and was overlooking preventive medicine in a zeal for high-technology care.
Instead of patients flitting among independent physicians who were paid by insurance companies each time they provided treatment, the thinking ran, people would be members of large, nonprofit organizations that employed a stable of high-quality physicians who collaborated to take care of the same patients for years. The incentives to provide excess care -- and to overuse the lustrous medical technology -- would be removed. Doctors would be paid a salary, patients would pay for a year's care up front, and the health organizations would have say over how much and what kind of treatment members needed.
It was this last part -- the ability of HMOs to control the amount of care -- that captured the attention of the nation's employers in the late 1980s and early 1990s, a period of rampant medical inflation. From 1988 to 1991, the percentage of U.S. workers in medium-size and large companies with traditional "fee-for-service" coverage plummeted from 71 percent to 42 percent, then dropped to 14 percent last year, according to figures from KPMG Peat Marwick.
As their popularity soared, HMOs largely became the province not of nonprofit groups that employed salaried doctors but of commercial insurance companies that created networks of resentful community physicians and reported to investors. Contrary to what he had expected, Ellwood laments, employers selected their workers' health plans based on their price -- not their caliber.
Charles N. Kahn III, president of the Health Insurance Association of America, contends that health plans often unfairly were "caught in the middle between employees who were nervous about change and employers who wanted to make change and didn't want to take the blame."
Kenneth S. Abramowitz, a health care analyst with the investment firm Sanford C. Bernstein & Co., says employers erred in not explaining the changes well enough to their workers and in not sharing some of the savings with workers -- and thus giving them a reason to like the confining new arrangements. Meanwhile, Abramowitz said, health plans made the problem worse by turning down too many requests for care and by not dwelling enough until very recently on making their patients healthier.
He predicts the current public anger will diminish after a shake-out period in which both HMOs and patients adjust. But others are less optimistic.
With their 800-numbers and restrictions on care, HMOs push people in a direction opposite the trend toward dramatically expanded consumer choice in other key parts of the economy, such as telecommunications, said Robert J. Blendon, a professor of health policy who specializes in public opinion at the Harvard School of Public Health.
In recent surveys by Blendon and others, half of Americans say they have been personally frustrated by HMOs or know someone who has -- often delays in getting services -- although only a few say they have suffered outright physical harm.
The public discontent also has been fomented by physicians, who have long resisted any efforts to insert a third party between them and their patients. In the 1930s, the American Medical Association (AMA) fought what it called federal "socialized medicine." In the early 1960s, it unsuccessfully fought the creation of Medicare, and earlier this decade, it helped to defeat President Clinton's attempt at health reform, which would have relied on managed care in creating a system of coverage for all Americans.
So by the early 1990s, when it became clear that the threat to their autonomy was coming this time from the private sector, not the government, physicians began to fight HMOs too. Late last week, top officials of the AMA stood beaming before news cameras with Democrats and a faction of rebellious Republicans who had pushed HMO regulations through the House over the objections of GOP leaders.
The resistance of doctors and anger of patients has welled up despite conflicting evidence of whether people in HMOs end up healthier. Harold S. Luft, professor of health economics and health policy at the University of California at San Francisco, has reviewed dozens of articles comparing the outcomes of patients in different kinds of insurance arrangements. One large study in California, he said, found that babies born at dangerously low weights died more often if they were in HMOs. On the other hand, another large study in the same state found that people admitted to hospitals with appendicitis fared better if they were in HMOs.
"If you have an ax to grind in either direction," Luft said, "you can find evidence to support it."
But as House negotiators prepare to seek common ground with the Senate, which passed a far more limited patients' rights bill in July, it is the public anger -- not the medical literature -- that the insurance industry and its allies will have to overcome. "It is incumbent upon the industry to find better ways to communicate with the public," said Kahn, the president of the trade association. "It is our problem, and we need to deal with it directly."
How Health Insurance Has Changed
The kinds of insurance Americans in medium and large companies have:
A way to pay for health care in which providers receive a fee for each medical service they render, as opposed to receiving a salary or a flat payment for every patient they have under their care.
X Health Maintenance
A managed care plan in which enrollees usually pay a set fee, for say a year, and sometimes a small co-payment for each visit and are put under the care of a primary physician who coordinates all their treatment. Patients are usually restricted to network specialists unless they are referred to non-network providers by their primary care physician.
Y Point of Service (POS)
Combines the HMO prepaid concept and fee-for-service. Enrollees decide whether to use network or non-network providers but usually face reduced coverage and bigger co-payments if they go to a non-network provider.
Z Preferred Provider
An organization of providers that contracts to serve patients on a fee-for-service basis at discounted fees. Patients can use any provider but have a financial incentive such as lower co-payments to use doctors on the preferred list.
NOTE: Totals may not add to 100% due to rounding.
SOURCE: KPMG Peat Marwick