Primum non noccre. First do no harm.
Attributed to Hippocrates, the above aphorism is often cited in discussions of medical ethics. The fact is that it is impossible to practice medicine without causing some harm. Nothing from taking a medical history to administering chemotherapy and everything in between is free of potential harm. As in life, few things are simple and a ballance of risk and benefit is always made. The aphorism should be rewritten as:
Primum minimus noccre. First do the least harm.
I no longer see patients and have no first-hand experience with the new state-wide Medicaid Managed Care systems. I can however still read, and it is clear that things are not going very well, at least if the testimony at Frankfort hearings is generalizable. Some of the reports sound just plain awful. I cannot conceive that a stable epileptic would have medicines dolled out two weeks at a time. Is there a copay involved that would also double?
Managed care companies are charged with weeding out the unnecessary or poor quality medical care that physicians and other providers are unable or unwilling to tackle themselves. I acknowledge and even applaud those efforts. Active managed care however is very difficult to do and requires cooperation from both patients and providers– cooperation that has never been in abundance. As a result, managed care companies have evolved to depend more on things like preauthorizations, copays, formularies, and restricted payments. Cynics will call this rationing by inconvenience. Modern insurers are certainly practicing medicine in the sense that they are determining treatments or withholding them. (Sometime they practice better than free-range doctors.) All this micromanagement might trim medical expenditures, but it also increases overhead costs to both the insurer and the providers. Where is the balance point? If needed services are delayed, then the cost will be more than just in dollars. I honestly do not know how much is really saved by managed care as it currently is practiced. Perhaps not much at all. It has never been shown to me that Passport (which provided good care) ever saved the state money.
What to do now?
I do not believe things will be sorted out quickly. Not only are the systems all new to the state and providers, but also to patients who do not know what to expect. An attempt to apply the full bore of managed care protocols that might have worked elsewhere to a new population was probably doomed to failure here, at least I think so. What the state needs to do now is to signal the three new Medicaid companies to back off a little and apply their controls in a more gradual manner. This will require that some money be allowed to flow into the system. Don’t waste time trying to adjudicate bills from last November or you will never catch up. The overbearing principal here is that sick people should be protected. This will hurt the bottom lines of doctors, hospitals, pharmacies, insurance companies, and the state treasury. This was never going to be easy or cheap. Real reforms are not going to me made by requiring long phone calls between doctor’s offices and drugstores to authorize prescriptions. Effective reforms must be made in the entire medical marketplace, and not just in the market of the most vulnerable. Bite the bullet and make a nationwide medical system that is a coherent whole, not one in which some benefit at the expense of others. Any Medicaid problem will then melt away. This will take more political courage and true professionalism than we have been able to manage up to now. I am not optimistic. In the meantime, do less harm.
Medicus quidem faciendum malum.
Feb 24, 2012