Manage Care So Patients Come First

Next time you need to make a doctor’s appointment, be sure you’ve got a lawyer’s phone number handy as well.

It’s not that bad - yet. But increasing pressure from insurance companies on doctors raises questions of whether people are getting proper care as quickly as they need it.

A Wall Street Journal article earlier this month spelled out the problems on a national basis, but it’s evident locally that insurance companies lately seem to be dictating health care more than doctors do. New mothers sometimes spend less than 24 hours in the hospital after delivering their children, because insurance companies don’t want to put up the extra money for a day or two of badly needed recuperation.

But a growing concern - and one that has the lawyers involved - is delayed referral, doctors declining to refer a person to a specialist because of the increased cost.

Sometimes the referral comes, but too late. In one California case outlined by the Journal article, a woman went to a doctor for abdominal pains. Three months after she asked for a referral to a specialist, her family says, the doctor finally relented. She learned too late that she had terminal cancer.

Indeed, insurance companies used to deny care in experimental or specialized cases, but lately - with every penny spent scrutinized - even routine care is under the magnifying glass. In one recent case, a child was denied coverage for a tonsillectomy - hardly an experimental procedure.

Granted, there are times when a headache is just a headache. But doctors’ role as gatekeeper is getting in the way of their primary roles of care-giver and patient advocate.

Certainly there are good things to be said about managed care - primarily its emphasis on preventive medicine. By stressing regular physicals, stop-smoking workshops and substance-abuse programs, HMOs are effectively saving money down the line.

And, yes, there’s been an understandable backlash against lawsuit-happy Americans who turn to the courts for trivial things. But this is a case where the law can help balance a system that is listing too much to one side. These suits are a healthy warning to the HMO industry that the patient comes first - not cheap care.

And eventually, after so many lost lawsuits and out-of-court settlements, it will simply be too expensive to deny care to people who need it.

, DataTimes The following fields overflowed: CREDIT = Anne Windishar/For the editorial board