The Evolution of the Managed Care "Medical Director”

The Evolution of the Managed Care "Medical Director”
By Charles Phillips, M.D.

Webmaster's note: This piece was inspired by a quote of a medical director of a very large national HMO as it was posted on the listserv (Dialog) of the Health Administration Responsibility Project (HARP).

Webmaster's additional note: February 5, 2000 - Charles Phillips, M.D. is a former Kaiser physician. He left the system when he found his "shifts" suddenly cancelled causing him profound economic stresses. He believes that this is as a direct result of his very outspoken criticism of Kaiser and its policies.
[Dr. Phillips worked an average of 2/3s time in a Kaiser hospital emergency room over an 18-month period. While he is still on the Kaiser medical staff as confirmed this week in writing, his outspokenness on Kaiser and managed care in general has lead to the absence of any scheduled hours. In fact, Kaiser has suggested that if Dr. Phillips resubmitted hours, he would be put back on the schedule immediately.]
Dr. Phillips has written a number of pieces that appear on this web site. We are publishing them as a service to Dr. Phillips and to the general public. We at RHCD believe that the only way the public will be able to ever make informed choices about health care is with unfettered access to multiple sources of information about Managed Care as it exists today. We at RHCD and its sponsoring organizations and the individuals and organizations that are in support of and will participate in RHCD present this information as a service and in no way are responsible for the validity of the content of any of these pieces. This responsibility remains with the author.
[Dr. Phillips personally accepts full responsibility for every published comment he makes. He is a direct observer of medical care and represents no outside group. One of his nicknames is Hospital Cop. His opinions are those formulated over a 32 year career included such roles as publishing five medical textbooks, being president of a medical staff, serving perhaps 18 years as a medical director, being a state of California quality inspector, providing consultations to five paramedic systems, teaching trauma at the university, offering direct care as a Board Certified Emergency Physician, and being the proud the father of six children - five of whom have had to get their care through Kaiser.]

Quote in HARP Dialog : "When a doctor calls and says, 'You're coming on too strong,' we listen and take advantage of his expertise and modify,” says Joseph Carver, M.D., senior medical director at Aetna U.S. Healthcare, who adds that his HMO has not had conflicts with physicians over Disease Management programs. "We don't ask him to do anything that isn't evidence based and best practice. We don't have any nuances for what we do for patients, because they're Aetna U.S. Healthcare members that a doctor wouldn't want to do for everybody else he takes care of."

A Short Comment - 2/1/00:
The Evolution of the Managed Care "Medical Director”
By Charles Phillips, M.D.

As I learn more about the typical "Medical Director" in mangled care, I have come to reflect on the great fall and decline of this very physician title over the last thirty years. What was once a position of great trust with teacher-like authority has rolled downhill into the rat infested caverns of greed.   In my wanderings through the world of these latter gate owners, I find empty shells - yes, smiling as they greet you at the door - but the hello is accompanied by a cold handshake, one that suggests I should either search for a pulse or turn on a heater.

Medical Directors are critically needed by all of the health armies of the good and the bad. Some of these armies actually want to improve patients - like community hospital boards, others simply want to advertise and then withhold health care, and a few more are -- by rule of law - drawn, albeit kicking and screaming, into a mandatory responsibility for the health care of the poor.

Every state law prohibits any entity except a licensed professional from practicing medicine. But to practice medicine through a Medical Director and his supplicants and slaves, well, that is a different matter. And if it is no longer medicine but the illusion of care (yet still is fronted by a "Medical Director "), well then that's money in the bank. The problem, as one HMO consultant wondered in his book, is how to reward the Medical Director as a management executive with perks but yet convince other physicians being managed that they are still talking to a colleague, one still holding out trust to the public.

I was unfortunately spoiled in my residency training to serve under a great medical director. I suppose I only knew how great he was the day the government tried to fire him - after thirty years: "Clean your desk; you have one hour to get out."   Well, it didn't work. The poor camped out in the chambers of government; a county came to a stop. A county chief administrator had to have his attempt at dismissal reversed publicly; his own career was shortened.

My chief was a great Medical Director, because he was a great teacher first.   Not just how in a small town to put in a burr hole through the skull of a motorcycle accident victim or, instead, how to catch a pancreas cancer at the first symptom. No, it was also about how to give dignity to the drunk.   Yes, even how to insult a county bureaucrat for getting a new carpet before authorizing a few eyeglasses for some children at the retarded care center nearby.

But this was a great liability for me to carry - the image of what a Medical Director could be, as a magnification of a plain license. To make it worse, I later learned that this same teacher was a millionaire through family inheritance and only came to work because of the love of teaching.   Now that was really unfair

Imagine now my great sadness to see those who masquerade as mangled care "Medical Directors." They have their quips of care, blackboards for coaching how to retain premiums - "Patient care is a loss ratio," with more shoe shine than the drug reps, pretending "open door" policies as the drawbridge lifts, and passing off managed care errors as a few growing pains of "a new industry." And, when that fails, the modern "Medical Director" falls back on managed care as the great and only hope for the uninsured - when, in fact, that status of uninsured may be the safest label in critical care. "Real Best Practice" and "Managed Care" are as opposite as the light and dark sides of the moon.

Hippocrates put a curse within his oath. He invited the dishonor of the present and the wrath of the future meted out to those who would fool the public so profoundly in the name of medical trust - the gift he had so well defined. He would have loved using April fool's Day 2000 to rescue health care once again from the very snakes he competed with over two millennium ago.

Also by Dr. Phillips:

"Evidence Based Medicine" and "Best Practice" of Medicine -- The Dynamic Duo

Talk About Kaiser Chutzpah

Health Care Diary - 2/10/00

The Killing Fields

Inside Kaiser's ER

The Evolution of the Managed Care "Medical Director”

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