Helping Your Patient Overcome Barriers to Obtaining Good Diabetes Care

Let's look again at the standards of care to prevent long-term complications ... but this time from a managed care plan's point of view. Under managed care, there is little incentive for the primary care physician (PCP), or for the plan for which he/she works, to encourage questions or conversation about diet, exercise, pregnancy, or medication interactions. If the PCP is being paid under a capitated contract, he/she receives a certain amount of compensation per patient per month (PPPM) regardless of how much time he/she spends with any given individual. If the cost of caring for the patient outstrips this fixed monetary rate, the additional costs must come out of the PCP's own pocket. Diabetics can voice concerns and ask for help in protecting against future complications, but any additional conversation threatens the caregiver's pocketbook under the capitated payment system.

Managed care plans promote themselves as being at the vanguard of preventive medicine but are well aware that diabetics are among the most expensive patients. They also know that the fierce competition between managed care companies soon causes a competitor to undercut their adversary's premium rate. When that happens, the employer, to lower his/her own costs, will jump to the competitor's plan. Therefore, a given managed care company knows in advance that a diabetic will, in all likelihood, not be with them five years from now. The result is a financial disincentive to invest in the diabetic's future by offering preventive care.

For example, the standard of care for diabetes mandates that a patient be seen every three to six months. At those visits, certain lab tests, from an HbA1C to a 24-hour microalbumin level might be needed. Again, if the PCP is capitated, there is far less likelihood he/she will receive adequate compensation to cover those lab costs. The more he/she has to order, the more he/she stands to lose. Conversely, the less he/she orders, the more money he/she gets to keep.

In addition, computers track what most PCs order so that the managed care plan can easily detect a doctor's "overutilization of services." A diabetic threatens to get a doctor in trouble with his/her boss. Overutilization can carry with it monetary penalties, advancement sanctions, or even physician termination (especially if the doctor is employed under a termination without cause contract). Some plans divert patients to other doctors to punish the physician who orders too many tests. Those physicians then see their total income fall because they get less when forced to apply their capitation rate to fewer patients.

Because the PCP's activities are so carefully monitored, the physician has a disincentive to help the diabetic stay in tight control. When the family practice doctor of a managed care plan prescribes expensive home glucose monitoring supplies or an insulin pump, the computer can compare that choice to the other physicians' orders. The more aggressive a doctor becomes in controlling his/her patient's diabetes, the more he/she will tend to appear on a graph as an "outlier." While your colleagues save money, you start to look more and more like a "medical rebel" when you follow the standard of care and refer your patient for her yearly ophthalmology exam. Now that many regulatory agencies are monitoring how HMOs take care of diabetics by looking for a documented yearly dilated eye exam, patients are suddenly receiving letters from their HMO administrators to "go and ask your doctor for an eye exam." These heretofore unknown physician-patient conflicts of interest threaten the fiduciary relationship on which preventive care is premised. The patient feels the doctor's conflict as a lack of caring and predictably responds by being more willing to sue. Thus, while family practitioners are doing legal risk sharing, they soon find they are also doing legal risk shouldering. Managed care plans let doctors take the brunt of the litigious ire by claiming that they are an insurance company and not practitioners skilled in the art and science of medicine and, therefore, could not possibly be responsible for medical malpractice.

When a family practitioner has a diabetic for a patient, he/she now faces an unfamiliar dilemma. He/she can either care for his/her patient with aggressive, tight control and suffer the vocational ramifications of so doing, or practice lax medicine and face a heightened sense of legal liability. In this setting, only one entity stands to get well -- and that entity is usually neither doctor nor patient.

For these reasons, it has never been more important for a diabetic to be educated about the ramifications of his/her disease and knowledgeable about all the preventive and reliable treatment options. The more patients can help themselves, the more time they can have with their PCP to discuss unanticipated problems. The more a patient understands the importance of home testing, the more active he/she can become in demanding that his/her insurance plan pay for the products necessary to achieve tight control. Finally, the more vocal the patients become, the easier it becomes for the PCP to practice effective as well as efficient medicine while simultaneously avoiding legal pitfalls.

Primary care doctors can get the ball rolling by distributing pertinent literature in their waiting rooms and by volunteering information as they examine their patients. They can help their own cause by encouraging their patients to write the insurance plan and explain to the administrators their needs to achieve tight control, higher levels of fitness, better eye and foot care, etc… They can encourage the managed care plans for which they work to set up educational programs and dedicate funding for such programs -- in effect, to offer the kind of preventive care programs for diabetics their ads imply they have already established.

On a more personal level, every primary care physician needs to become conscious of the new financial pull away from providing the diabetic with the best possible care. Every doctor must order the necessary tests, spend the necessary time, make the necessary referrals, and contribute to the patient's long-term outcome even though they may know the patient may soon be with another plan. They must help the diabetic patient prevent his/her own individual complications even though the effort to do so may run afoul with the company for which the doctor works. Obviously, PCPs must be practical, choosing to take a stand only when necessary. But when a plan is systematically denying a patient the standard of care in diabetes, we believe that doctor has an ethical and legal duty to speak up for his/her patient.

The best example of this sentiment is seen in the California Appellate Court's opinion in Wickline v. State of California, (12986) 192 Cal. App. 3d 1630. In that case, a patient's doctor felt she needed an eight-day period of post-thrombectomy observation in the hospital but Medi-Cal, the insurer, said it would pay for only four days. The doctor complied and sent the patient home on the fourth post-operative day. The patient clotted at home and required an amputation. The court said, "...the physician who complies without protest with the limitations imposed by a third-party payer, when the physician's medical judgment dictates otherwise, cannot avoid his ultimate responsibility for his patient's care," and is liable. After unsuccessfully trying to sue the HMO, the physician who initially asked for the hospital stay extension was sued.

It is therefore in the primary care doctor's best interests to write supportive letters on behalf of his diabetic patients when care that might otherwise prevent long-term complications is denied by the managed care plan. The PCP can support the patient in his/her appeal through the health plan's internal administrative processes and even later should the matter come before arbitration. It will never be in the doctor's own best long-term interests to work against his/her fiduciary responsibilities to his/her patients. There are already many bills in state legislatures attempting to reverse the managed care trend toward avoiding care of the patient with diabetes. In Minnesota, one such bill has become law. It reads: "Minn. Stat. @ 62A.45 (1996) 62A.45 Coverage for equipment and supplies for diabetes: A health plan...must provide coverage for all physician prescribed medically appropriate and necessary equipment and supplies used in the management and treatment of diabetes. Coverage required under this section is subject to the same deductible or coinsurance provisions applicable to the plan's hospital, medical expense, medical equipment, or prescription drug benefits. A health carrier may not reduce or eliminate coverage due to this requirement."

The need for such a law comes to a state legislature only when patients make noise or doctors educate their representatives on these issues. No one has more influence or is in a better position to advise government leaders than is the primary care physician caring for his/her diabetic patients on a daily basis. If moral imperative does not cause a physician to provide the standard of care for his/her patients, eventually the legal imperative will. Whenever we speak to primary care physicians we always give the same advice: when in doubt about clinical expense, always ally yourself with the patients' best interests. Your moral and legal duty always rests with them, regardless of the financial incentives or controls under which you provide that care.