By KIP SULLIVAN, JD
A mere two decades ago, the headlines were filled with stories about the “HMO backlash.” HMOs (which in the popular media meant most insurance companies) were the subject of cartoons, the butt of jokes by comedians, and the target of numerous critical stories in the media. They were even the bad guys in some movies and novels. Some defenders of the insurance industry claimed the cause of the backlash was the negative publicity and doctors whispering falsehoods about managed care into the ears of their patients. That was nonsense. The industry had itself to blame.
The primary cause of the backlash was the heavy-handed use of utilization review in all its forms –prior, concurrent, and retrospective. There were other irritants, including limitations on choice of doctor and hospital, the occasional killing or injuring of patients by forcing them to seek treatment from in-network hospitals, and attempts by insurance companies to get doctors not to tell patients about all available treatments. But utilization review was far and away the most visible irritant.
The insurance industry understood this and, in the early 2000s, with the encouragement of the health policy establishment, rolled out an ostensibly kinder and gentler version of managed care, a version I and a few others call Managed Care 2.0. What distinguished Managed Care 2.0 from Managed Care 1.0 was less reliance on utilization review and greater reliance on methods of controlling doctors and hospitals that patients and reporters couldn’t see. “Pay for performance” was the first of these methods out of the chute. By 2004 the phrase had become so ubiquitous in the health policy literature it had its own acronym – P4P. By the late 2000s, the invisible “accountable care organization” and “medical home” had replaced the HMO as the entities that were expected to achieve what HMOs had failed to achieve, and “value-based payment” had supplanted “managed care” as the managed care movement’s favorite label for MC 2.0.
Today, few managed care advocates, and certainly no politician, would hold up HMOs as the goal of health care reform. Today, the managed care movement and politicians across the political spectrum, from Trump’s HHS Secretary Alex Azar to Bernie Sanders, promote ACOs and other “value-based payment” vehicles that Americans don’t understand and can’t see. 
So far, the strategy is working. With the possible exception of the increased use of narrow networks, the media is paying little attention to MC 2.0. The media is not reporting on the spread of “value-based payment” nostrums, and it is not warning the public that these nostrums are affecting the doctor-patient relationship even while they fail to contain inflation.  Not surprisingly, there are at this date no signs of an impending “value-based payment” backlash.
Unlike the media, the health policy literature does pay attention – lavish attention – to the “value-based payment” bandwagon. But like the media, the health policy literature pays virtually no attention to the impact “value-based payment” is having on the doctor-patient relationship. Health services researchers have yet to produce even a small body of research on doctors’ and patients’ views of how a half-century of managed care experiments – HMOs, PPOs, utilization review, limited choice, “coordination,” drug formularies, report cards, P4P, ACOs, medical homes, EHRs, bundled payments – has affected the doctor-patient relationship.
Voices from the trenches
Timothy Hoff’s latest book, Next in Line, seeks to fill that hole. It is a rare attempt by a bona fide member of the health services research community to understand the impact of managed care on the quality of the physician-patient dialogue. This requires actually talking to doctors and patients as opposed to collecting crude data on the “value” (the cost and quality) of doctors, hospitals, insurance companies, or ACOs. We have reams of studies that tell us, for example, what percent of the diabetics assigned to Tendercare ACO received an annual eye exam or were advised not to smoke. We have virtually no research on how the spread of ACOs is affecting the quality of doctors’ interactions with their patients. “[F]ew seem to care … about promoting strong doctor-patient relationships…,” Hoff declares early in his book. (p 11)
Next in Line is based on interviews with 44 primary care doctors and 36 patients. The interviews were designed to find out what primary care doctors and patients think the doctor-patient relationship should look like and what it actually looks like under the onslaught of what the author variously calls “corporatized care,” “retail thinking,” and “value-based health care.” Hoff reports that doctors and patients share a nearly identical definition of the ideal relationship, and they share similar views on the damage “value-based payment” and the corporate takeover of medicine have inflicted on that relationship. Both doctors and patients define a relationship built on trust as the ideal relationship, and both parties perceive multiple forces around them destroying trust or preventing it from forming in the first place.
Hoff’s conclusion that patients want a trusting relationship with their doctor will surprise no one. But his report that doctors share that view, enthusiastically and universally, may surprise those who bought into the campaign, initiated nearly a half-century ago by Paul Ellwood (“the father of the health maintenance organization”) and other founders of the managed care movement, that doctors are driven by money and are not “patient-centered.” Ellwood and his intellectual heirs developed this stereotype of doctors to reinforce their evidence-free diagnosis that excessive volume of medical services sold (as opposed to the price at which those services were sold) was the primary cause of health care inflation. The fact that doctors value the trust of their patients is inconsistent with this stereotype. “[F]ew physicians flinched when asked to describe what a good doctor-patient relationship looked like,” Hoff writes. “Striking to me was the consistent manner in which doctors specifically used the words trust, respect, friendship, partnership and communication to help describe an effective, satisfying doctor-patient relationship. They used these words unprompted….” (p. 69)
Hoff describes in abstract terms the destructive forces set loose by the stereotype of the money-driven-doctor – “metric fever,” “corporate medicine,” and “retail thinking.” And he accurately describes problems caused by these forces, including “checklist medicine,” the “dumbing down” of medicine, and making doctor-patient communication “as ritualized as possible.” But, oddly, he never identifies the origin of those forces, namely, the managed-care movement’s grossly oversimplified diagnosis (overuse due to FFS payment and money-hungry doctors) and the movement’s evidence-free solutions (shifting risk to doctors and micromanaging them). His failure to do so is the main reason why the last chapter in the book, a chapter in which he recommends solutions, is so disappointing.
Spitballs versus rhinos
In the final chapter, Hoff offers a half-dozen ideas for “saving the doctor-patient relationship.” With the exception of his suggestion that doctors form unions, these suggestions are grossly inadequate and, in one case, ludicrous.
Hoff’s first suggestion is that doctors “start caring about building strong relationships with [their] patients.” (p. 173) This makes no sense. In previous chapters, Hoff has carefully documented how much doctors care about good relationships with their patients and what little control they have over the forces corrupting those relationships, and now he calls on them to “start caring” about their relationships with patients. I quote at length from the same paragraph to give you some idea of how muddled Hoff’s thinking is here: “Advance preparation for strong relationship-building matters more now than ever…. Knowing ahead of time how and why such relationships matter …, and being able to engage in requisite features such as empathy, compassion and listening – in ways that are efficient and do not require highly favorable conditions – raises the chance that tomorrow’s doctors can achieve some success in maintaining bonds with their patients.” (pp. 173-174) I have no idea what all those words mean.
He goes on to recommend these actions:
* teaching hospitals should expose young doctors to the opportunity to “work with the same patients over time” so they can learn the benefits of long-term relations with patients (as if that will somehow arm tomorrow’s doctors to go to war with the forces that are interfering with long-term relationships);
* doctors should join unions;
* insurance companies and other entities that bedevil doctors with their P4P schemes should include measures of “trust” in their ever-growing lists of “quality” measures (p. 181) and, to develop such measures, “entire exam room conversations can be recorded and then analyzed … for the presence of various relational features in the doctor-patient interaction” such as trust and empathy (p. 187);
* doctors could hire “concierge staff” to serve as “liaisons between specific doctors and patients” that would serve as “listening relay stations” between patients and doctors;
* smartphone apps could be used to create “real-time outlets for patients to ask question and be heard”; and, perhaps worst of all,
* “some consumers [could be] asked to pay extra … for the right to see their doctors more in person….”(p. 184).
With the exception of unionization, these suggestions are at worst technologically or financially infeasible, and at best the equivalent of shooting spitballs at a charging rhino. Hoff expressed his own disbelief in one of these suggestions – the notion of adding measures of “trust” to P4P schemes – in earlier chapters where he blasted “metric fever” and the emergence of “an entire hidden industry … devoted to making primary care physicians … look good to insurers and government agencies….” (p. 34) The notion that a credible, accurately risk-adjusted score for “empathy” or “trust” can be produced for even a few doctors, never mind all US physicians (with or without bugging the nation’s examining rooms) is absurd.
I surmise that Hoff’s inability to make more realistic recommendations stems from his ambivalence about MC 2.0. In certain parts of the book, he is very critical of “value-based payment” schemes – he calls them “half baked” and “magic bullets.” But in other parts he claims, without evidence, that these schemes have created some benefit and, apparently for that reason, are “here to stay.” When he wrote the last chapter, he must have resolved his ambivalence, at least temporarily, in favor of the conclusion that MC 2.0 is doing some good and, in part for that reason, will never go away even if it is damaging the doctor-patient relationship.
The problem must be named
I am under no illusion that exterminating the forces that are weakening the doctor-patient relationship will be easy. The managed care juggernaut has acquired enormous financial and political power over the last half-century. The managed care diagnosis (overuse caused by FFS payment) and solution (exposing providers to financial risk and micromanaging them) is now a well-established religion. But if we are ever going to defang the forces that are diminishing doctor and patient autonomy and weakening the doctor-patient relationship, we must name them and clearly describe their origins. Hoff’s favorite labels for the corrupting forces – “value-based payment,” “retail thinking,” and “corporate care” – are informative but, by themselves, are not informative enough. They do not tell us who unleashed those forces, upon what rationale, and with what evidence.
All of us who care about the future of the doctor-patient relationship must be more specific in our diagnosis of the crisis: The forces that threaten that relationship were unleashed by managed care theology – its evidence-free diagnosis and its evidence-free solutions. Those solutions are the cure that is worse than the disease. There are solutions to the modest amount of overuse that so excites managed care proponents. But managed care, be it the pre- or post-backlash version, is not one of them. Applying managed care to the overuse problem is like using a chainsaw to cut butter – it is vast overkill.
We must also clearly describe the toxic side effects caused by managed care. Tim Hoff has described one of them – the degradation of trust between doctors and patients. I thank him very much for doing that.
Book: Hoff, Timothy J, Next In Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health Oxford University Press, 2018
 S 1804, the so-called single-payer bill Senator Sanders introduced in 2017, contains a section that authorizes the Department of Health and Human Services to extend every “reform activity” authorized by the Affordable Care Act and MACRA to the non-elderly. These “reform activities” include, of course, all the major elements of the iteration of managed care that emerged after the HMO backlash, including ACOs, medical homes, bundled payments, penalties for hospitals with “excess readmissions,” and the Merit-based Incentive Payment System, none of which are visible to patients. The Trump administration has taken no steps to repeal any of these “activities,” and has explicitly and enthusiastically endorsed the concept of “value-based medicine” and ACOs in particular.
 The evidence that the latest iteration of managed care is failing to cut US health care costs is overwhelming. There is, first of all, the fact that health care spending as a percent of GDP continues to grow at its historic rate. There is, furthermore, a growing body of literature demonstrating that none of the most important elements of Managed Care 2.0 save money. The research on Medicare ACOs, medical homes and bundled payments, which is the only reliable research, demonstrates these “reforms” are breaking even, and that’s only if we don’t count the costs ACOs, “homes,” and hospitals with bundled payment contracts incur in their efforts to cut their Medicare costs. (The exception to the statement that Medicare’s bundled payment program is not saving money is the joint replacement program, but the main reason that program saves money is that hospitals use their market power to lower the price of implants. Like HMOs, ACOs and “homes,” bundled payments were supposed to save Medicare money by reducing the volume of services, not their price.) Two other elements of MC 2.0, pay-for-performance and electronic medical records, are saving no money either.
Kip Sullivan, J.D., is a member of the Policy Advisory Committee of Health Care for All Minnesota