5 September 1998

Health Maintenance Organisations
causing more harm than containing medical cost

(Keywords:- HMO, managed care, professional autonomy, health care policy)

          In the run up to the Policy Address of the Chief Executive, speculations abound. With the Armageddon sensation embracing Hong Kong from the financial disaster, it will come as no surprise that economic boosting issues will take the centre page.

          For those who fervently believe that health is still the best ¡§wealth¡¨, and yearn for new and bold health policies to lift the ¡§sword of Damocles¡¨ so precariously hanging on their heads in the form of health care blunders, they will most likely be disappointed. With the consultancy report on health financing commissioned by Government not quite ready and the economic crisis dampening the political clout of the already inert relevant bureau, very little breakthrough, if at all, on health care reform will feature in this Policy Address.

          Yet, with the likely cut of social sector spending, of which health care is a major part, due to economic nose-dive, Government has suddenly awaken to the need for containing health care cost. The Policy Address may, thus, be forced to include comments or immature proposals in this direction. Rumours are that top health and finance officials have recently been on an overseas study tour to assess the feasibility of ¡§managed care¡¨ for Hong Kong.

          The concept of ¡§managed care¡¨ originated in the United States. Yet, to date, the American health care system has become the most wasteful. Americans spent many times more than European countries, let alone Asia. Regrettably, some 40 million Americans have no medical coverage. All these are the aftermath of some 20 years of managed care. Yet, chief executives of managed care organisations are amongst the highest paid in the United States, many travel on private jets and luxury yachts, at the expense of money designated for treatment ¡§squeezed¡¨ from clients. So much harm has managed care produced in the country that there are websites such as ¡§Managed Care Atrocity of the Month¡¨ and others where revelation of dissatisfaction and horrifying experiences are surging.

          Superficially, the principle and concept of ¡§managed care¡¨ is not only acceptable but honourable -- to cut the cost of health care, yet maintaining its highest quality. It is whether such could be achieved that is in doubt. It is how such could be achieved that has thrown the whole issue into disarray, especially in Health Maintenance Organisation (HMO) -- a form of prepaid managed care that ¡§cap¡¨ the health care payment of clients yet for unlimited number of treatment. Ironically, the money so installed into HMOs has also to pay the insatiable demand of the administrators and the shareholders.

          Health care providers are micro-managed within the HMO system to ensure that they contain cost. Under the all empowering and indisputable slogan of ¡§eliminating inappropriate treatment and ensuring most cost effective practice¡¨, HMOs select specific doctors for patients. Health care providers are not preferred if they use ¡§inappropriate¡¨ treatment or investigation, where ¡§inappropriateness¡¨ implies expensive one, often times necessary for definitive diagnosis.

          Overnight, patients have no more interaction with doctors. They have somewhat surrendered their freedom of choice of doctors. The time-honoured doctor-patient relationship so vital to patients¡¦ well being vanishes.

          Overnight doctor¡¦s autonomy in performing their professional duties are eroded, if not removed -- expensive treatment or investigation decisions must be supervised and approved in accordance with guidelines administered by managers or coordinators. In extreme case, a doctor may even have to work with a ¡§case manager¡¨ -- a non professional -- to develop treatment plan that is less expensive. Regrettably, when patients complain of not getting the best of care, it is the service provider that suffers, facing professional discipline; whilst the case manager gets away Scot free with his share of profit.

          Is this what Hong Kong want? Is this what Hong Kong people desire? Or is this just a knee jerk response for our policy makers to dilute their guilt of years of procrastination of not upgrading our health care policy? It would be foolhardy to rush in. Even in the United States where health care is a commodity to be bought and sold, patients and service providers alike are suffering from the devastation produced by managed care. Shouldn¡¦t we learn from, instead of following, other¡¦s mistakes?

          Yes, health care cost must not be allowed to exponentially escalated. There are many solutions. Government must deliberate with the health care providers!

(Hongkong Standard)