[Congressional Record Volume 144, Number 118 (Wednesday, September 9, 1998)]
[House]
[Pages H7472-H7473]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
MEDICAL RED-LINING: ECONOMIC CREDENTIALS FOR PHYSICIANS
The SPEAKER pro tempore (Mr. Everett). The gentleman from California
(Mr. Campbell) is recognized for the remaining time of the gentleman
from Texas (Mr. Paul).
Mr. CAMPBELL. Mr. Speaker, Robert Weinmann is a medical doctor,
president of the Union of American Physicians and Dentists, an
independent labor union based in Oakland, California. He is a resident
of San Jose.
Dr. Weinmann was kind enough to lend his support for a bill that I
drafted that was heard in the Committee on the Judiciary just about a
month and a half ago, and in his testimony he put forward the argument
in favor of my bill which would create an antitrust exemption for
health care professionals to present a united front when they are met
with a united front on the other side by an HMO or some other
intermediary.
Dr. Weinmann requested that I read his op-ed on this subject
personally, and I am pleased to do so, and it is from the San Francisco
Examiner of Friday, January 12, 1996. Its title is: Medical red-lining:
``Economic credentials'' for physicians.
Credentialing for physicians, a dimension that could be disastrous to
patients, it is called ``economic credentialing.'' The term refers to
the use of economic or financial criteria to decide whether or not a
doctor should have the medical staff membership or privileges without
which he cannot practice at his local hospital.
Physicians document their medical education and training when they
apply for hospital medical staff membership for the privilege of
practicing and performing surgery in a hospital. Credentialing
committees in hospitals make sure that physicians do not practice in
specialties in which they have no training. This scrutiny of medical
credentials ensures that patients get properly trained doctors.
Whereas medical credentials determine the expertise of physicians to
evaluate their knowledge and judgment and to grant them the privilege
of practicing in a particular hospital, ``economic credentials'' do not
measure physicians' expertise, knowledge or judgment. Nonetheless,
``economic credentials'' are becoming more important than medical
credentials in determining medical staff membership or privileges.
How do ``economic credentials'' work? Data retrieval is key. Let us
assume one doctor has 100 patients for whom his diagnostic tests and
treatment costs $2,000. Let us assume another doctor has 100 patients
and that this doctor's prescribed diagnostic
[[Page H7473]]
tests and treatment cost $3,000. We can say that the cost ratio of the
first doctor is 20-to-1, whereas the cost ratio of the second doctor is
30-to-1.
In certain managed care plans, such as health maintenance
organizations, HMOs, with prepaid premiums, the doctor with the 20-to-1
cost ratio has preferable ``economic credentials'' in comparison with
the doctor whose ratio is 30-to-1. If the managed care plan is going to
make a profit, it will do better with the first doctor than with the
second. So the plan gives the boot to the second doctor and welcomes
the first one.
Essential to this program is knowing how much doctors actually cost
the program in terms of expenses meted out for patients' medical care.
These expenses used to be called medical care. Now they are
characterized as losses, or expenses that rob corporate owners or
shareholders of profit.
Keeping track of this data and using it to grant doctors membership
in HMOs, independent practice associations, or hospitals is the
backbone of economic credentialing. Unfortunately, this backbone is
spineless and without soul. It doesn't care a whit about patients as
people, but only about patients as progenitors of cost and expenses.
Companies want to minimize these costs to enhance profits.
The danger is that physicians' ``economic credentials'' will become
more vital to managed care companies than their medical credentials.
Court decisions have not shot down economic credentialing.
In Florida, a doctor was denied membership on a hospital staff
because he was already a heart surgery director at another hospital. In
other words, his services were declined not because he could not
measure up medically, but because he was viewed as an economic
competitor.
In Los Angeles, a doctor was terminated from a health care plan based
solely on a business and financial management analysis. The company
told the doctor that, ``This decision in no way is a reflection on your
performance.'' An inquiry has been launched to discover if medical red-
lining occurred.
In San Jose, a group of doctors in a managed care organization were
issued an edict telling them that coronary stents, a type of heart
surgery, no longer would be authorized. To ensure that the doctors took
the edict to heart, so to speak, they were hammered with the following
declaration, ``If any charges are incurred for such (coronary stents),
the cost resulting from such will be deducted from your income.''
Patients need to know that before they join any managed care plan
they must make sure the plan manages to take care of them before it
takes care of its owners.
{time} 1830
This advice will not be easy to follow. In some plans,
doctors operate under ``gag'' or ``no-cause'' clauses,
legally imposed conditions, whereby participating doctors
agree not to discuss with patients the plan's financial
incentives for doctors.
Additionally, a doctor's criticism of a plan's refusal to
provide diagnostic testing or recommended treatment may be
treated as corporate disloyalty and grounds for dismissal.
In the meantime, it behooves patients and doctors alike to
learn how the health insurance industry works. Otherwise, we
risk being red-lined out of whatever health care coverage we
believe we may still have.
This ends the editorial by Dr. Robert Weinmann in the San Francisco
Examiner of Friday, January 12, 1996.
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