werner@aecom.UUCP (Craig Werner) (03/18/86)
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A Piece of My Mind
JAMA 255:1341, Mar. 14, 1986
The Plan
"Hello, Carl?"
"Yes, Andy, what can I do for you?"
"Carl, do you have a few minutes? I;d like to discuss something with
you."
"Sure, Andy. What's on your mind?"
"Carl, you and I have known each other a long time. We've worked
together on hundreds of patients over the years. You've really been the
ideal consultant. You're there day and night. You're sharp. The families
love you. I'm sure you'll inderstand how difficult this is for me."
"What's the matter?"
"I won't be referring patients to you anymore."
"Andy, what's the problem? Was there a problem with a family?"
"No. Nothing like that."
"Well, what is it? Did I miss something? Was there a complaint about
me?"
"Carl, you've helped me with some tough cases over the last ten years.
You've been available whenever I've needed you. You've seen indigent
patients and unfunded patients just as readily as the well insured. I have
no gripe with you. Hell, you've bailed me out of some tough clinical
situations."
"Then what the hell is the problem?"
"The plan, Carl, the plan. Your name is not on the plan's panel."
"Andy, look. I have the greated respect for you professionally. We;ve
worked together for many years and our association has been pleasant and
gratifying. You're an excellent doctor who always puts the patient's
welfare first, and I understand your concern. But you mean to tell me that
you can't refer patients to me because of a plan? I don't deal with plans,
I deal with people. I have and always will see any patient of your
regardless of paln."
"You don't inderstand, Carl. By signed contract, I can only refer the
patient to a plan doctor. That's the rule. The plan penalizes the patient
and me if the referral is to a doctor not in the plan. Why didn't you sign
up?
"I reviewed the plan's contract. It's a morass of prior approval,
review of my recommendations as a specialist by nonspecialists, poor
payment, and a plan that by capitation pressures all involved to bring the
production in under budget to reap a profit. It's care containment, not
cost containment!"
"But it's the future."
"I know it's the future. I'm sure I'll be on some panel at some time
as the system pressures me into signing because of a dwindling case load.
But not this plan at this time."
"Carl, I hope you understand. If I had my way, all patients that
needed a man in your speciality would go to you. All I know about you is
your medical excellence. No cocktails, no dinners, no schmoozing -- just
medicine. I've found that it's the best way to refer."
"Until now."
"Look, I didn't decide on this. My partners felt it was a move for
economic survival. The accountants and office manager liked it too.
"Andy, don't you find something inherently wrong with the channeling
of referrals along largely economic lines? I mean, the panel of specialists
has been annointed by the ledger, not by demonstrated medical excellence.
"Medically, of course it's wrong. In terms of corporate economics,
it's dead right. The patients see the low premiums and the glossy ads and
sign up in droves. The corporations sign them up, then sign us up and the
contract dictates the terms."
"I understand your situation. I appreciate the honesty of this call."
"I'd rather do it straight up front than let you hear it thirdhand in
the cafeteria."
"Hey -- I'll miss working with you."
"Thanks. This was a hard call for me to make."
"All for the greater good, Andy."
"We'll see."
Leo A. Gordon, MD
Los Angeles
--
Craig Werner
!philabs!aecom!werner
(1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517)
"When I was your age, I always did it for half an hour a day."