A BETTER WAY FOR MANAGING HEALTH CARE

There has been a lot of criticism in this community about our hospitals, our physicians and the general provision of health care. As you listen to the people criticizing our hospitals and our doctors, you need to question their motives as well as their sources of income/profit. Personally, I think it is rather nice to have these doctors and these hospitals around. They seem to provide a lot more services to our community than any of the insurance carriers or other critics who like to find fault with every decision our physicians and hospital administrators make and attempt to thwart everything they do.

There is room for improvement in our health-care system. It is dubious that any one person has all the right answers, but people who aren't willing to listen to the experts in any given field show a lack of judgment. The experts who refuse to listen to outsiders are rather elitist and might even be arrogant.

There has been a lot of discussion lately about managed care and its arrival in Cape Girardeau. Managed care always has been here in one form or another. You are being subjected to managed care when your primary-care physician refers you to a specialist or another health-care provider. That is a far different type of managed care than being told by some bureaucrat that you cannot have a particular service which both you and your physician feel you need. Similarly, managed care is being told you have to go somewhere else for services or you won't be reimbursed. That is managed care in the sense that it is a limitation of care. The general feeling among the public is that limited care is far different than what people expect managed care to be.

Humana is one of the managed-care companies that has come to Cape Girardeau. Humana was founded in 1961 by two lawyers. They started selling insurance in order to support their failing hospitals. They offered health insurance at low premiums in order to fill beds as their hospitals continued to lose money. They sold out the hospital chain to Hospital Corporation of America. So they ended up in the health-insurance business. Humana's earnings per share went from 37 cents in 1986 to $1.10 in 1994. The year-end closing stock price in 1986 was $12.75, and in 1994 it was $22.63. At the end of 1994 Humana had $881 million in cash on hand. Cash on hand in an insurance company as well as other assets come from the difference between premiums paid in by policyholders and money paid out for the provision of health-care services to those policy holders.

In 1994, the chief executive officer of Humana got paid $1.8 million. Humana's chief operating officer got paid $1.35 million. Humana's chief financial officer got paid a mere $565,000. The insurance carriers are the ones who joined Mrs. President Clinton in decrying the overpaid doctors of our nation.

The for-profit entity formerly known as Blue Cross-Blue Shield and now knows as Right Choice Managed Care had approximately $580 million in revenue in 1994. Its net income was approximately $27 million. Its stock, offered last year at $11, was trading recently at $14.12. Blue Cross collects 24.5 percent of the health-insurance premiums in Missouri. Its chief executive officers was paid slightly less than $800,000 last year. It is estimated that the Blue Cross organization has approximately $200 million in assets. These assets include the investment in Right Choice, real estate holdings and insurance accounts.

There are managed-care plans in Cape Girardeau that direct patients to other communities for services. This is done under the guise of cost savings, yet little in the way of cost savings comes back to the employers or the patients. Most of those cost savings seem to go to the insurance carriers. In fact, most managed care in Cape Girardeau and elsewhere is merely reduced payment for services.

C. Everett Koop, former U.S. surgeon general, said it quite succinctly when he described health care as having three aspects: quality, cost and access. He said it isn't possible to meet all three of those goals for the health-care system. Any two of the three can be provided, and it is up to the consuming public to determine which two those are. Right now those choices are determined by government and insurance-company bureaucrats. I would suggest that those decisions would best be made by physicians and patients working together.

Until the consuming public takes a more active role in the health-care system and the decisions that are being made, bureaucrats in Washington and insurance company headquarters will be deciding what type of health care you have and truly managing your health care. I doubt you will like the health-care system they will provide for you. Bureaucrats are necessary in order to track costs and effectively control costs, but they should be used as advisers, not as managers. You and your family physician should be managers of this system.

You do not have to accept what your insurance company tells you. Work closely with your physician and demand that you get the medical services you need.

Gerald L. Nicholson of Cape Girardeau is the administrator at Orthopaedic Associates of Southeast Missouri.