LAWYER: MANAGED CARE SLOW COMING

Attorney Patricia Ray is surprised that Cape Girardeau has been able to hold off managed health care.

In larger communities, patients and physicians have suffered from over regulation and lots of changes brought about in an effort to control health-care costs, she said.

Ray, a Cape Girardeau lawyer and a registered nurse, practiced health-care law 15 years in Southern California. During that time, she saw the sweeping changes that hit health care, changes that can also be seen, to a lesser degree in Cape Girardeau.

She spoke Wednesday at the Cape Girardeau Lions Club.

Ray called a decision to dissolve a partnership between local physicians and a large insurer a power move for retaining local control.

"In Cape Girardeau the doctors are running the show," she said. "Managed care has not gotten a foothold."

However, she warned that managed care in other areas may cause encroachment into Southeast Missouri.

"Facilities will be looking for a way to grab the patient base," she said.

In larger cities, managed care made inroads primarily because of an oversupply of providers, she explained.

Doctors signed contracts that directed patient care. For example, some contracts contain gag orders. Doctors are prohibited from mentioning treatment options if insurance won't cover it. Patients would never know about a different choice, she said.

Managed care in Southern California led to delays in care for three, four and five months. "It meant patients not getting in to see a specialist until it was too late," Ray said.

At the worst, she said, health-care decisions were being made by high-school-age clerks employed by managed-care companies.

Health care is a highly regulated industry with thousands of pages of rules governing what can be done. As a result, health-care law has expanded. Years ago the only legal issue faced by most physicians was malpractice; today the legal issues range from underpayment to fraud.

At the same time, the federal government has instituted new rules and dusted off old laws in hopes of gaining some control over health care.

The result, Ray said, has been added watchdogs for health-care providers.

"If doctors choose to participate in federal programs, there are a lot of strings tied to the money," she said.

The federal government began using a false-claims law first enacted in the 1800s against health care. "Deliberate ignorance" is punishable. In other words, doctors whose office staff make billing mistakes can be fined.

So far the law has been used to collect $1.8 billion, Ray said.

Managed care evolved because health-care dollars were spent but expenditures were virtually unchecked.

The result was a tremendous amount of change in the health-care field, change that has been hard to manage, she said.