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Those who, like Ponce, lament the anonymous quality of their treatment reflect a second revolution in patient care: the rise of the medical- industrial complex. Every bit as important as the advances in technology are the means of delivering them and deciding who should pay. Instead of an individual doctor seeing his regular patients in the privacy of his office, the typical encounter now occurs in the thick of a vast corporate hierarchy that monitors every decision and may weigh in against it. Marketing medicine has become very big business.
As costs have risen, the past decade has seen an explosion in prepaid, "managed" care. More than half of all physicians work in some kind of group practice, most commonly a health-maintenance organization. Patients pay a flat annual fee in exchange for care that is provided by HMO member doctors. As private corporations, many HMOs can be quite profitable -- so long as their patients do not get too sick. The number of patients enrolled in HMOs has doubled in the past five years, to 32 million, often at the urging of cost- conscious employers. The goals: efficiency through greater competition, lower costs, accountability and better preventive care.
But the results may be mixed. Patients relinquish much of their freedom to choose who will treat them, and can be lost in a shuffle between rotating doctors. The physicians, meanwhile, are transformed from professionals into employees, with a duty to serve not only the interests of their patients but the demands of the corporation as well. "They're asking physicians to pay for their decisions," says internist Madeleine Neems in Lake Bluff, Ill. "That's a terrible concept. When you analyze whether or not a patient needs an expensive test, a lot of times it's not a clear-cut yes or no. I don't want my finances tied into those decisions."
Doctors resent spending extra time with patients who demand exhaustive explanations or who merely exercise their hypochondria. "If you have to spend twice as much time because a patient's assertive and he wants to ask questions, it's certainly difficult to bill for that period of time," says cardiologist Alexander. "Lawyers and accountants don't have third parties or government agencies looking over their shoulders to determine whether their billings are fair." Patients understandably take a spare-no-expense attitude toward their health, but that is not a philosophy likely to keep a medical company in the black.
Physicians and patients who are not part of an HMO have found their lives affected too. The government (as the largest health insurer) and the private insurance companies have tried to cap medical costs by deciding in advance how much a particular treatment should cost and balking at anything above that amount. Many doctors can no longer decide how often they see a patient, when one can be hospitalized, or even what drugs may be prescribed. Those decisions are now in the hands of third parties, hands that have never touched the patient directly.