HMOs drop the ball after heart attacks
By DrRich
(Revised with permission from YourDoctorintheFamily.com)
If you're planning to have a heart attack any time soon, pay heed:
A study published in the November 16, 2000 issue of the New England Journal of Medicine showed that Medicare patients enrolled in HMOs and other managed care plans often fail to receive appropriate therapy after a heart attack. This failure occurs more often than for similar patients enrolled in traditional, fee-for-service plans.
The authors of the study examined the care received by 50,000 Medicare patients in seven states, after those patients had suffered myocardial infarctions (heart attacks). Of the patient who met generally-accepted guidelines for needing heart catheterization, only 37% of these enrolled in HMOs or managed care plans actually received the catheterization tests. In contrast, 46% of those in traditional fee-for-service plans received the needed tests.
The results were even worse when patients were admitted to hospitals that do not perform cardiac catheterizations on-site (that is, to hospitals in which transfer to another facility would have been necessary for appropriate therapy). For these patients, only 15% in managed care plans and 31% in fee-for-service plans received catheterizations.
The lead investigator suggested that these results ought to make one wonder whether financial incentives might be limiting access to needed medical care for Medicare patients enrolled in HMOs.
DrRich comments:
These results are even more disturbing in light of data presented at the Annual Scientific Sessions of the American Heart Association in New Orleans this week, showing that patients who are tested early-on with cardiac catheterization following even a mild a heart attack have a significantly better prognosis than patients not receiving the test. ( Click here for the press release. )
Notably, while the thrust of the New England Journal article is that HMO/managed care patients are subject to a special level of neglect, the article in addition reveals that Medicare patients in traditional fee-for-service plans also tend to receive substandard care. Even for these patients, less than half received cardiac catheterizations when they were medically indicated.
So, while being enrolled in a managed care plan does indeed compound the problem, the problem is bad enough even without managed care.
What does all this mean? It means that the concerted effort being made by the health care system to separate the interests of the doctors from the interests of their patients are working wonderfully. (See DrRich's The importance of the doctor-patient relationship, and why we can't have it anymore.)
The financial incentives of HMOs/managed care to withhold expensive medical procedures are well known. Just how deeply these incentives have penetrated into the conscious and unconscious actions of physicians, however, is only faintly understood. (For DrRich's unique analysis of this problem, see Portrait of a Modern HMO.) The New England Journal article merely helps to quantify this effect.
But why the surprising failure of even fee-for-service patients to receive the needed catheterizations? There are many possible reasons, including ignorance, sloth, and the habit doctors have of treating all patients alike. (When a minority of patients were enrolled in managed care, doctors treated their managed care patients as if they were fee-for-service. Now that a majority of patients are in managed care plans, doctors treat their fee-for-service patients as if they were in managed care. It's all very democratic.)
Beyond this, however, is a more sinister reason that even fee-for-service patients are not receiving necessary services - doctors are being cowed by aggressive regulators (and the somewhat veiled threat of a federal anti-fraud rap) to become reluctant to push expensive procedures when it's just as easy to avoid them. (See The Anti-fraud Imperative.)
For patients, this latest evidence provided by the New England Journal ought to provide even more incentive to become knowledgeable and vigilant regarding one's own health care. Question your doctors; challenge them. Doctors badly want to do the right thing, but there's so much incentive in the other direction that sometimes they need a little push.
After you've had a heart attack, you should either have a heart catheterization, or a test (such as the stress and/or /thallium test) that clearly indicates you don't need one. Remember: a heart attack is merely one event in a disease process that is progressive and continuous. It is imperative, after being informed by the heart attack as to the existence of coronary artery disease, to do everything possible to arrest that progressive, continuous disease process. And a catheterization often provides information vital to formulating a optimal treatment plan. (For a fuller treatment of what's supposed to happen after a heart attack, see Surviving a Heart Attack - After the first day.)
If your doctor isn't discussing this issue with you, then you discuss it with her. And if your bringing it up doesn't elicit a meaningful response, remember Rule #1: you hired her, you can fire her.
What do you think? Enter the Heart Disease Forum:
