Doctor No

It now appears that President Bush plans to privatize Medicare, meaning that HMOs could soon assume a prominent place in America's health-care system for the elderly. Past experience has already taught us that such a scheme won't work for seniors, who are likely to have multiple health-care needs that must be addressed in a timely manner. Bureaucratic restrictions, referrals and refusals governed by outside insurance are anathema to very sick people who must get tested and treated quickly before they are overcome by illness.

The way out of our current Medicare conundrum doesn't lie in privatization but in extending coverage and forcing changes in how drug companies behave. But Bush's plan won't help accomplish these goals -- and it will probably make things worse.

Currently, patients who have opted for Medicare+Choice -- a managed-care alternative to traditional Medicare that was created as part of the 1997 Balanced Budget Act -- are miserable: Only 13 percent of seniors are enrolled in the plan, and that number is dropping. (This recent TAP Online article explains why.)

Yes, HMOs offer seniors prescription-drug coverage. But the price of such benefits is to surrender some degree of control over medical decisions. Most of my elderly patients have five to 10 active medical problems at any given time. When an HMO is involved, it evaluates problems and oversees decisions. Months of deliberation by doctors over which tests to order and which medicines to use can be overridden by the insurance company, which may end up dictating an alternative that the patient's doctor hasn't even considered. "This is the preferred treatment," the letter from the HMO to the physician will inevitably read. At this point, the doctor may rightly protest that each drug has its own set of side affects and that there is no such thing as an equivalent treatment. But the HMO is not listening. The patient must switch to an untried treatment or pay out of pocket -- from a fixed income or limited savings -- for the treatment the doctor recommends. The HMO pays for some drugs but refuses many of the most necessary ones. And physicians end up spending a tremendous amount of energy trying to justify essential procedures and treatments, which are regularly denied.

When this happens, a patient's only salvation is his or her relationship with a physician. A doctor can be a patient's guide through the morass of HMO bureaucracy. Unfortunately, by compelling seniors to choose a private option that provides some coverage, the president is also recommending a system that will force many patients to change doctors. If your longtime doctor isn't signed up for your new plan, you will have no choice but to switch.

Yet the president also said during his State of the Union address that he intends to return control of health care to doctors and nurses. This particular rhetoric couldn't apply less to the system of privatization Bush has in mind. Under the current Medicare system, a doctor and patient team up to make decisions on care. But in the private world, that decision-making process is subject to the whims and directives of HMO doctors, nurses and nonmedical evaluators.

President Bush claims that "healthy competition" is good for health care, but the laws of supply and demand don't work when medicines are hyped and promoted at outlandish prices, the public remains ill-informed about cheaper alternatives and the consumer is held captive. You can't choose not to have health care; we all get sick and need to be taken care of. As a result, our elderly -- far from enjoying the benefits of a model marketplace at work -- are hostage to whatever system is out there. There is no altruism in private health care, and why should there be? It's not the nature of the beast.

The best option for Medicare is to remain a single-payer system, as it is now. This would allow the government to use the more than 40 million people Medicare covers as a wedge to dictate drug prices -- and, perhaps more importantly, drug company behavior. Currently, many competing drugs are practical duplicates of one another, varying by no more than a single atom. Lavish advertising campaigns seduce the public into accepting these virtual versions at outlandish prices, which in turn, justifies the costs of the advertising. This insidious process would die down if doctors and a discerning government remain in charge of a prescription-drug benefit. But if private companies wrest control of Medicare, we will see more of what we have now -- where drug sales are like an auction and prices are determined by the highest bidder.

Perhaps the worst part of privatization is that it could sever the important bonds between senior citizens and their doctors. I recently received a letter from a patient in the Midwest that illustrated this point -- and provided a glimpse into what the future would look like should Bush's plan pass. The patient had chosen an HMO to augment his Medicare, but soon discovered that his primary physician shrank to the role of a form-signing referral source, rather than a guide and confidante. When the patient hurt his ankle, he couldn't find anyone to tell him whether it should be X-rayed or not. Finally, his wife, concerned about the swollen, blue limb, insisted on an X-ray, which her husband finally obtained after two referrals from two different offices.

But who would read the film? No radiologist was available, though a computer spat out an official report that even the patient could interpret as showing a fracture. Without professional guidance, he was inclined to just soak the limb and see what happened -- but his wife insisted he see an orthopedist.

A referral from his primary doctor -- who still hadn't examined the limb -- led to a busy private orthopedics clinic where a doctor looked at the X-ray and told him to go home, drink green tea and let the ankle heal by itself.

The patient followed this advice, but over the next week the ankle swelled further, and his wife insisted he return to the clinic. This time, a different doctor insisted that the ankle be put in a cast right away.

A week later, the patient was feeling a lot more pain and numbness than he had expected, so he removed the cast in his own bathtub and found that his leg was blue. He then returned yet again to the orthopedics clinic, where a doctor fixed the cast and put his leg on its path to eventual recovery.

This is a typical example of what happens when a system clogged with red tape comes to bear on the delicate health-care needs of the elderly. Yet the Bush administration intends to formalize this system, making the HMO an inseparable part of Medicare's future. All of which will leave seniors with an ugly choice: Opt for the old Medicare system and continue paying outlandish prices for medicine, or go with the president's privatized system, which would pay for some of their drugs -- but at a cost to their well-being that will be substantial.

Marc Siegel is an associate professor of medicine at New York University.

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