By PHYSICIANS FOR A NATIONAL HEALTH PROGRAM

Managed care is bad for your health, according to the first comprehensive survey of physicians involved in research and teaching published in a recent New England Journal of Medicine. But the nation's best and brightest physicians don't want to return to the old fee-for-service system, either.

So what does this prestigious group think would make a good health system? According to the study, "all groups [Deans, department chairs, residency training directors, physician faculty at medical schools, resident physicians, and medical students] expressed a preference for a single-payer health care system over both managed-care and fee-for-service systems. Overall, 57.1 percent thought that a single-payer system with universal coverage was the best health care system... A total of 21.7 percent favored managed care, and 18.7 percent preferred a fee-for-service system."

"I'm not surprised at all by these findings," said Dr. Douglas Robins, Chair of the D.C. chapter of Physicians for a National Health Program. "A survey of all physician members of the D.C. medical society found that 69 percent support single payer. The academic medicine physicians are just the tip of the iceberg."

In an accompanying editorial in the Journal, Dr. Robert Michels strongly disagreed with the view that the purpose of medical education should be to "prepare students to fit into the new world of health care, to work in it effectively and presumably happily." Dr. Michels noted that "the unhappiness of academic physicians ... reflects the recognition that managed care threatens medicine's core values," and that "medical education is working well ... by underlining the urgent need to change managed care." He also noted that physicians support single payer national health insurance even though physicians know that "a single-payer system would be unlikely to increase the financial rewards of medical practice."

"We know physicians support single payer national health insurance because of the increasing numbers of medical associations and prominent physicians that are endorsing it," said Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard.

They include: The D.C. branch of the American Medical Association (AMA), the American Medical Women's Association (AMWA), the National Medical Association (NMA), the Gay and Lesbian Medical Association (GLMA), the American Medical Student Association (AMSA), the American Public Health Association (APHA), the Islamic Medical Association (IMA), the American Association of Community Psychiatrists (AACP), the American Family Therapy Association, and others. The leadership of the newly formed National Hispanic Medical Association (NHMA) is supportive. The Maryland and Massachusetts' branches of the AMA are studying single-payer, and the American College of Surgeons' Dr. David Murray testified before Congress in 1994 that single payer would "probably provide the best assurance that patients would be able to seek care from any doctor of their choice."

Dr. Christine Cassel, the first woman president of the American College of Physicians, the nation's second largest medical association, is a strong advocate of single payer and a founding member of Physicians for a National Health Program.

Physicians for a National Health Program is an organization of over 8,000 physicians who support universal access to health care.

ACTION: Express your thoughts to PNHP at www.pnhp.org or California Physicians Alliance at www.capa.org.

From Physicians for a National Health Program

A recent study published in the Journal of the American Medical Association (JAMA) finds that investor-owned HMOs scored worse than non-profit HMOs on all 14 quality indicators reported to the National Committee for Quality Assurance in 1997. The quality measures ranged from routine preventive care (e.g. childhood immunizations, pap smears, prenatal care, and mammography) to care for patients with serious illness (e.g. eye examinations to prevent blindness in diabetics, follow-up visits for patients released from psychiatric hospitals, and prescriptions of life-saving beta blocker drugs for patients surviving heart attacks).

Between 1985 and 1998 the proportion of HMO members enrolled in investor-owned plans increased from 26 percent to 62 percent. Until now little has been known about the quality of care in investor-owned plans. Previous research comparing HMOs with fee-for-service care has generally found similar outcomes for healthy enrollees, but sick patients have fared poorly in managed care. Most of this older research examined non-profit HMOs, whose quality is far higher than the newly dominant for-profit plans. Hence, the new research indicates that average HMO quality is lower than previously believed, and significantly worse than fee-for-service care.

Some of the biggest quality differences between investor-owned and non-profit plans were in the care of seriously ill patients. As compared to non-profit plans, investor-owned HMOs had a 27 percent lower rate of eye examinations for diabetics; a 16 percent lower rate of appropriate drug treatment for heart attack survivors; and a 9 percent lower rate of follow-up for patients released from mental hospitals. Childhood immunization rates were 12 percent lower, pap smear rates 9 percent lower and mammography rates 8 percent lower in investor-owned plans.

"Investor-owned HMOs pay more attention to their profits than to their patients," said Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard and one of the authors of the study. "Mammography rates in investor-owned plans are 8 percent lower. If all American women were enrolled in for-profit HMOs instead of non-profits, 5,925 more would die from breast cancer."

While the study found that costs in investor-owned and non-profit plans were similar ($128 per member, per month, vs. $127.50), investor-owned plans spent 48 percent more of their revenues on administrative costs and profits (19.4 percent of revenues vs. 13.1 percent). Hence, investor-owned HMOs spent significantly less for patient care.

"It’s a simple equation," said study co-author Dr. Sidney Wolfe, Director of the Public Citizen Health Research Group. "The quest for profit endangers medical care. The more money that goes for profit, the less goes on health care."

The study analyzed 1996 quality-of-care data from 248 investor-owned and 81 not-for-profit HMOs that provided coverage to 56 percent of all Americans enrolled in HMOs that year. The data were submitted in 1997 to the National Committee for Quality Assurance (NCQA) from the Health Plan Employer Data and Information Set (HEDIS) Version 3.0. Fewer data are likely to be available in the future. The number of plans refusing to allow release of their data grew from 41 in 1997 (the data analyzed for the JAMA study) to 155 in 1998. The NCQA reports that lower quality plans are most likely to refuse public release of their data.

"Our decade-old experiment with market medicine is a failure," said study co-author Dr. Ida Hellander, Executive Director of Physicians for a National Health Program. "Investor-owned plans have worse quality than non-profits, and non-profits are increasingly forced to mimic the for-profits. It’s time to end our race to the bottom in health care and implement nationwide quality improvement and universal coverage through single-payer national health insurance."

ACTION: For copies of "Quality of Care in Investor-Owned vs. Not-for-Profit HMOs" (JAMA, July 14, 1999-Vol. 282, No. 2), call the PNHP headquarters in Chicago at (312) 554-0382. See also: www.pnhp.org and www.capa.org