A Dose of Reality

When Marina del Rey internist Alan J. Steinberg was interviewing doctors for a book he was writing about HMOs, he heard troubling confessions from some of his colleagues about their attitudes toward HMO patients.

“They’d say things like, ‘If I can get rid of the 10% of people who are ill that take up 40% of my time, I’m left with 90% of people that I can really make money on,� Steinberg recalls.

Those same doctors would “tell me how they would have ill patients wait longer in the waiting room, or tell the office not to return their calls. They were happy if those patients left and switched to another doctor.�

Steinberg says most of the 100 doctors he interviewed over two years in researching his book didn’t express such harsh views, which he says he distains. But he says he understands why, in today’s market-driven medical industry, some doctors might feel that way.

Putting his biases out front, he blames these attitudes on the HMO payment system known as “capitation,� calling it a “fundamentally flawed system� that can encourage under-treatment. Under capitation, doctors receive a flat monthly rate for treating patients regardless of how much or how little care they need.

“When forced to choose between the best interests of their patient and their own interests, human nature may prevail more often than even the doctor may realize,� Steinberg writes in his new book, “The Insider’s Guide to HMOs,� due in bookstores next month. “Money clouds judgment.�

Steinberg is a former doctor with Kaiser Permanente, the nation’s largest HMO. A board-certified internist, he now practices full time and is a part-time medical director for a managed-care company.

Proponents of managed care contend that capitation is the best way to align doctors’ incentives with those of their patients. They say it encourages doctors to emphasize preventive services, such as mammograms or child immunizations, and early treatment of life-threatening disease.

Most experts agree that traditional “fee for service� insurance, in which doctors or hospitals bill for each office visit, test or service performed, created a perverse incentive for providers to over-treat because they made more money by doing so.

Steinberg says that while the promise of managed care is laudable, in reality it often doesn’t play out well because of the payment system used by most--but not all--managed-care firms in California.

“If your doctor’s getting paid $10 a month to treat you, he really doesn’t want to provide $100 in services,� he says. “People have this romantic notion that their doctor is above that, and many of them are. But doctors care as much about what they are getting paid as your lawyer, accountant or the person who cuts your hair.�

Steinberg says the main purpose of his book is to help HMO members better understand an often-confusing system. He stresses the need for patients to educate themselves about how the system works and, above all, be assertive about seeking care.

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Confidence Thermometer: A federal Medicare-fraud investigation and the swirl of controversy surrounding Columbia/HCA Healthcare Corp., the nation’s largest hospital chain, may be giving Americans second thoughts about the growth of for-profit health-care companies, according to a new study.

Since March, when Columbia/HCA’s problems exploded into the headlines, Americans’ perceptions of for-profit hospitals and health plans have dimmed. Fewer American now believe that for-profit health plans offer better quality care, are more responsive to patients or more efficient than nonprofits, say researchers at Harvard University and the Kaiser Family Foundation, a Menlo Park-based health-care charity and research group.

“The public’s perceptions about for-profit health care are part of a growing angst about the changing health system that is fueling renewed interest in consumer protection and government regulation,� says Drew Altman, foundation president.

Even so, 42% of Americans still believe that for-profit hospitals offer better quality care, compared with 37% who think nonprofit hospitals are better, according to results of an August survey. Back in March, 55% of Americans liked the quality of for-profits better, while 32% preferred nonprofits.

Of course, the survey begs the question of whether most people know whether their hospital and health plan is organized as a for-profit or nonprofit entity. The researchers say the study didn’t take that into account.

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Times staff writer David Olmos can be reached by e-mail at [email protected] or by fax at (213) 473-2481.