By Joseph A. Giordano, M.D.

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The prime sponsors of both previous managed care bills are health care professionals. Neither, however, are physicians. Representative Patricia Vance, R-Cumberland, is a registered nurse, and Senator Timothy Murphy, R-Upper St. Clair, is a licensed psychologist. The distinction from a physician is important. For years the patient’s number one health care advocate has been the physician, but with this new statute, medical care delivery and patient advocacy will decline.

Managed health care with its associated physician capitated rates, e.g. $6-$10/month, and annual-biannual physician evaluation scores have downgraded medical responsibility. The above factors are economic and emotional disincentives.

With Pennsylvania’s new statute, one will fathom that after January 1, 1999, medical care for urgently ill patients will degenerate. How is this possible? The answer is not singular, as the law provides loopholes for insurance companies.

When the insurance (managed care) plan supposedly reviews and then denies a physician’s method of treatment, the physician or the patient can appeal this initial denial. However, one must request an internal review (internal grievance process). If the first evaluation (i.e. reevaluation) confirms the insurer’s denial, the patient or physician can then submit to a second "independent" internal review. As the case is reexamined by a different group and is again negatively decided, an external review (external grievance process) can be filed. Weeks will have passed before this third stage is approached.

The external grievance process as stated in the statute "... shall be conducted by an independent utilization review entity not directly affiliated with the managed care plan." The Pennsylvania Department of Health

shall randomly assign a utilization review entity on a rotational basis from the list maintained...and notify the managed care plan within two business days of receiving the request. If the department fails to select a utilization review entity..., the managed care plan shall designate and notify a certified utilization review entity to conduct the external grievance.

Over the last several years, the Pennsylvania Department of Health has been overwhelmed and/or understaffed due to the changes in health care delivery, in which managed care has expanded in the state. The Department of Health will, therefore, delegate its oversight to the managed care organization.

During this external grievance process the patient pays nothing, if he or she seeks a personal review. (The managed care plan may, however, charge upwards of a $25 filing fee.) Physicians, as stated previously, are the patients’ advocates, so doctors will assume the responsibility of initiating this final review. This procedure becomes another insurer loophole, since the physician has to place in escrow one-half of the estimated costs. If the physician loses this final "investigation," he or she pays the full amount.

The expense for the external review can range from $400 to $1000. The higher figure would be seen in a metropolitan area like Philadelphia. The Philadelphia region, by coincidence, also has the highest penetration of managed care in Pennsylvania. One only needs to divide the monthly capitated reimbursement into the external review spendings to realize how many times these proceedings will be pursued by physician!

If the external grievances’ monetary outlays were not enough to dissuade a physician, what would be the effect on the patient and physician, when the utilization time is considered? This Pennsylvania "patients’ bill of rights" grievance course to closure takes 210 days. Only after this period can one seek redress in the state’s judicial system.

When judicial adjudication is contemplated, the patient can only recover what the initial treatment would have comprised. Unless the physician, therefore, is independently wealthy or Albert Schweitzer, M.D., this new Pennsylvania managed care act cannot be taken seriously. The Quality Health Care Accountability and Protection Act comes with the loss of physician advocacy for patients.

When the insurer denies, especially in urgent cases, a physician’s treatment protocol, the patient is the one who ultimately loses.