Michael S. Victoroff, M.D.

Michael S. Victoroff, M.D.

One of the ethical successes of managed care has been the improvement it has made in people's access to physicians. A $5 copayment saves lives and enhances the well-being of millions who would never have gone to a doctor in an indemnity or high-deductible environment.

However, opening medicine's doors to a broader population has invoked the law of unintended consequences. Primary care physicians feel an increased demand for visits, referrals, and advice. Some of this is inappropriate. We gripe about patients with trivial complaints clogging the waiting room. Mosquito bites, for heaven's sake! In the days of $50 office visits, we'd never have seen this.

Fortunately, amid the throng of self-care candidates and worried well, low copayments have lured into treatment some patients with early-stage disease and presymptomatic conditions who would have delayed their visits under conditions that put more financial responsibility on them. These patients no longer postpone visits with the thought, "I think I'll give this melanoma a little more time before I bother my doctor with it." These precious opportunities justify the triage burden that wider access imposes on primary care practice.

There is a level of out-of-pocket payment at which a patient may elect not to go to the doctor. This varies with the perceived seriousness of the need, the relative value of money to the patient, geography, age, sex, race, education — all kinds of factors. Overall, by opening its arms to a large, new population of patients, managed care has altered the pathodemography of primary care. From a public health viewpoint, this has been a positive change. However, primary care as a whole has not fully adapted to its new demands.

Another double effect of wider access has not yet generated much public attention. This affects the commercially insured, working poor.

Ironic discontinuity

In the economic no man's land between Medicaid and commercial insurance coverage lies a zone of ironic discontinuity. Here, rising income means losing the comparatively rich benefits of public health care coverage. A family that crosses the asset threshold — different from state to state — becomes ineligible for public assistance, and, paradoxically, may suffer a decrease in standard of living.

The true medically indigent — those with no public, private, or charity benefits — pose a perennial moral problem for American health policy. However, adjacent to this population is another group with a unique difficulty: Members who have commercial insurance but no discretionary cash to obtain benefits that are usually not covered by commercial plans. This situation could be described as a benefit gap.

All commercial insurance plans have some coverage limits. The clinical formula, "medically necessary," is not the most problematic exclusion. All plans pay for coverage from premiums, and no premium pool is infinite. The cost of a policy that offers "anything you want, whenever you want" simply equals the cost of the care. It may be financing, but it's not insurance.

So, for a commercially insured, low-income family with no discretionary cash, standard coverage restrictions can be insurmountable barriers. To the middle class, denial of coverage means making a value judgment. To the marginal class, it may require substantial sacrifice.

For cash-poor employees, $10 can be the difference between filling a prescription and not. Have you ever heard a mother say, "Can you see both my children for one copayment? Because I don't have another $10 for my second child." Or, "I'll have to buy just one prescription for the two of them, and let them share it."

In contrast, I've heard highly compensated people (some earning more than their doctors) complain vehemently about the difference between a $10 and a $15 copayment. I don't have the same sympathy for this group; they are good targets for satire. I don't lose much sleep at the thought of denying coverage for a $2,000 hearing aid for someone who spends more than that on golf clubs. But there are cases where denying coverage burdens people with out-of-pocket costs enough that they forgo treatment because the expense is simply out of reach.

Remedies vary. A legislature might expand coverage by a mandate; an executive might add a rider to the company policy; both contrivances allow the well-off to keep their golf clubs and have hearing aids, too. Either approach may create a tragedy next year, when some employees cannot afford the increased premium required, and thus lose their insurance entirely. Such solutions are counterproductive.

The problem is, commercial benefits are not adjusted to the means of beneficiaries. Their benefits and exclusions apply equally to the rich and the poor. Might some refinement of this system be possible? Could commercial insurers install mechanisms for income and asset testing into their precertification processes? Besides weighing "medical necessity" and "coverage," why not also test "ability to bear the out-of-pocket cost of a coverage exclusion?"

Surveying commercial plans on this issue has been informative and disheartening, but not because the concept is difficult or the principle somehow disagreeable. Rather, the impediments are practical. Collecting financial eligibility data and acting upon them in a timely and consistent way would be a gargantuan undertaking requiring a colossal work force and informational infrastructure. Auditing for accuracy, safeguarding confidentiality, and setting standards for eligibility are all problematic and expensive. Ultimately, the yield in equity for the relatively small group affected can't justify adding such overhead to the whole system, plan by plan.

Still, every state has agencies that surmount these difficulties on a daily basis. Means testing is integral to every public assistance program. What if partnerships could be formed between commercial carriers and the public agencies with the experience and bureaucracy required to operate such programs? This problem of marginal benefit coverage is one seam along which public and private interests might join.

Is this possible? Do examples of public/private collaboration of this sort exist? (Oregon — where are you?) Let's hear your suggestions, anecdotes, and advice.

Michael S. Victoroff, M.D., is medical director for Aetna U.S. Healthcare of Colorado. He had practiced family medicine for 19 years and has served on numerous hospital and organizational ethics committees. He also chairs the committee on medical informatics of the Colorado Medical Society. The author's opinions do not necessarily represent opinions or policies of Aetna U.S. Healthcare, its management or its employees.

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