Meningitis and Managed Care

Author: 
Lawrence R. Huntoon, MD, PhD
Article Type: 
Commentary
Issue: 
Summer 1996
Volume Number: 
1
Issue Number: 
2

As state and federal bureaucrats are busily working to force government-owned patient (Medicare and Medicaid) into managed care organizations and passing laws subsidizing and providing unfair advantages to HMO companies, one thing seems to have been totally forgotten — the patient. While some HMO CEOs are taking home salaries in the $15-$20 million per year range, the patient is getting short-changed in the medical care they have been led to believe they would receive when they enrolled. Managed care is based on lies. None of the HMO executives or the government officials who promote managed care ever took an oath to place the welfare of patients first.

Many patients are not aware of the built-in conflict of interest for doctors who participate in managed care. Under managed care and particularly with capitation, the doctor no longer works for the patient. The doctor works for the HMO. The less care the doctor provides to patients, the more profit he or she and the HMO company make. The financial incentive for the doctor to withhold medical care, particularly procedures or treatments that are expensive, is very strong: Under managed care, profits come first, patients come second.

One is always hearing the managed care propaganda that their care is so “cost effective.” But what happens to those under managed care who get really sick? As a patient, do you want someone worrying about the company’s bottom line or do you want someone worrying about your health? Where do the doctors’ loyalties lie?

One day last winter, I was called into the emergency room to see a patient with suspected meningitis. As she laid on the ER gurney suffering in pain, I could hardly believe the story she was telling me. This was a young lady in her twenties who lives only a short distance from our modern 350-bed, regional hospital. Her husband works for a company that forced all employees into managed care. So, the first thing she had to do when she began suffering from potentially life-threatening meningitis was to call her “gatekeeper physician.” Going to the ER without his permission is strictly forbidden. Her gatekeeper physician, apparently not wanting to incur the expense and loss of profit associated with sending her to the nearest emergency room, advised her to come to his office instead. His office is in a small town approximately 20 miles from her home. In the wintertime, travelling that distance through the heavy snows over very hilly terrain can be a harrowing experience, even for the boldest and healthiest person. But, threatened with the prospect of not having her illness “covered” by the HMO, the patient drove herself through the heavy snow to the little town.

Her gatekeeper physician subsequently examined her, and it was his impression she was likely suffering from meningitis. Now, of course, there is no way of knowing exactly what type of meningitis a patient has before doing a lumbar puncture (LP). Bacterial meningitis can be fatal within a matter of hours if not properly diagnosed and treated. The time this patient lost calling her gatekeeper physician and driving through the heavy snow to a little town with no guarantee of getting through placed her life at risk. She understandably, not being a physician, wasn’t aware of this risk and simply followed the instructions given by her gatekeeper.

Fortunately, she did not have the lethal type of meningitis. As it turns out, her gatekeeper physician had apparently tried to save (himself) some money by performing the spinal tap himself and avoiding the referral. He recognized that is he sent the patient to a neurologist, it would come directly out of his pocket. So, the patient was transported by ambulance to a small 30-bed hospital in yet another town where the gatekeeper performed the LP. According to the patient, he was very persistent and attempted the procedure at least eight times before being successful, although the patient was a thin, young lady and should have posed little problem in performing the LP.  At the end of the ordeal, the patient said she was feeling miserable, her back hurt almost as much as her head, and she was vomiting profusely. Since it was getting close to 5 p.m., the time most gatekeepers like to go home, and there are no neurologists on staff at the 30-bed hospital, the gatekeeper reluctantly decided to transfer the patient back to the 350-bed hospital in her hometown. So, later that night, the patient was transported again by ambulance back to her local hospital.

There, I was summoned to see the patient late that night. Unfortunately, the cerebrospinal fluid (CSF) wasn’t transported with the patient. It was back at the little hospital in the small town far away. When I called there, I learned the lab had closed at 6 p.m., and the CSF results were unavailable until the following morning. (Tiny little hospitals, you see, can’t afford to keep their labs open 24 hours per day.) Without the CSF results, an accurate diagnosis would be impossible. All I had to go on were a few barely legible notes the gatekeeper had scribbled before he went home. As it turned out, propitiously, the patient had aseptic meningitis and she improved rapidly with appropriate treatment at our hospital. She was discharged within a few days.

Before leaving the hospital, the patient asked me why I wasn’t called to see her in the first place? I told her she would need to ask her gatekeeper physician. As I thought back over the patient’s convoluted journey from town to town via ambulance in the dead of winter, I couldn’t for the life of me figure out what was so “cost efficient” about the “managed” care she had received. This patient could have walked a matter of blocks to her local hospital where she would have received faster and better care at a much lower cost. “More cost efficient,” “better quality care under managed care,”…I think not.

Dr. Huntoon is a neurologist in Jamestown, New York. His address is 560 West Third Street, Jamestown, NY 14701.

Originally published in the Medical Sentinel 1996;1(2):24. Copyright©1996 Association of American Physicians and Surgeons (AAPS)

 

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