What do we mean by the word “private?” We think of something or someone off by himself or herself, free to do what they please in the best way to accomplish their goals. To many of us, “private” means encumbered and beyond the influence of outside worries and pressures.

Then what exactly is a “private” physician? According to Rakesh Gupta, M.D., it is a physician who makes the best decisions available based on the art of medicine---the physician’sintuition, experience, judgment,and discretion---and the goal of maximizing the possibility of apositive outcome, in a timely manner.

Dr. Gupta recently discussed the meaning of the term “private physician” and its relevance in today’s managed care environment. Responding to aseries of questions, he talked about ways in which pressureput on physicians by managed care has led to the “nearextinction” of the truly private physician. He also speculatedthat recent trends indicate that truly private medicine is experiencing a renaissance.
So doctor, why is “private” versus “not private” medicine something we should be concerned about?

“Simply put, because it affects treatment outcomes and the quality of life for the patient. To illustrate, we have to consider two kinds of medical problems: those that are obvious and known, and those that are chronic.”
Obvious and known problems

“Let’s use the simple illustration of a broken leg. After you determine that the leg is broken, it is


somewhat straightforward what you will do to set it, treat it, and help it to heal. The assumption is that you can get basically the same service from Provider A, Provider B, or Provider C --basically an identical service.”
Chronic Problems

“Many individuals, however, suffer from chronic problems. These problems lead to a disturbance in the quality of the patient’s life. They may have multiple causes that defy easy diagnosis and treatment. That does not mean that they are any less painful than obvious and known problems.”
“Only Out-of-NetworkPhysicians have freedom needed to solve complex diagnostic problems.”

Chronic problems may include: abdominal pain, headaches, fatigue, fever, diarrhea, and sexual dysfunction to name just a few.

“These types of problems present a diagnostic challenge. They require that the physician makes an in depth level of commitment to figure them out. The physician must be freethinking, and have diagnostic leeway to solve these problems.

“These services are often personal in nature, and we refer to them as non-identical services. The outcome is directly influenced by who is providing the service-the physician and other caregivers like nurses and therapists,” Dr. Gupta says.
“In our view a health care plan without Out-Of-Network MD option mayprove to be practically worthless in dire times.”


somewhat straightforward what you will do to set it, treat it, and help it to heal. The assumption is that you can get basically the same service from Provider A, Provider B, or Provider C --basically an identical service.”
Chronic Problems

“Many individuals, however, suffer from chronic problems. These problems lead to a disturbance in the quality of the patient’s life. They may have multiple causes that defy easy diagnosis and treatment. That does not mean that they are any less painful than obvious and known problems.”
“Only Out-of-NetworkPhysicians have freedom needed to solve complex diagnostic problems.”

Chronic problems may include: abdominal pain, headaches, fatigue, fever, diarrhea, and sexual dysfunction to name just a few.

“These types of problems present a diagnostic challenge. They require that the physician makes an in depth level of commitment to figure them out. The physician must be freethinking, and have diagnostic leeway to solve these problems.

“These services are often personal in nature, and we refer to them as non-identical services. The outcome is directly influenced by who is providing the service-the physician and other caregivers like nurses and therapists,” Dr. Gupta says.
“In our view a health care plan without Out-Of-Network MD option mayprove to be practically worthless in dire times.”


      

“We feel that the opportunities for managing care lie in the business aspects of providing care.

“True managing, as we define it, would focus on things like buying groups, volume discounts, and making the system more efficient.
“For many years, managed care controlled costs by simply restricting access to care. This resulted in near extinction of physician independent thinking.”

“Exerting pressure to eliminate the disparity in pricing for hospital services is another example. Take the case of coronary artery angioplasty and stent placement. The facility portion of the cost varies from hospital to hospital. It can vary as much as 2 or 3 times. There is a potential for managed care to make these costs more consistent.

“By concentrating on these types of things, and also working toward administrative efficiencies, managed care can truly manage. And, physicians will be free to practice medicine in the way they feel will best benefit their patients.”
Despite its obvious drawbacks, how did our present system of managed care grow?

“Utilizing various promises and threats, physicians were lured into joining managed care groups. Once they became members, they were expected to play by the rules. If they challenged managed care policy, they were labeled as troublemakers, kicked out of the plan, and in a sense, blackballed for their independent attitude.

“Therefore, over time, fewer and fewer physicians remained private


physicians, and this tended to create frustration and distrust between patient and physician.”
So where are we now?

“We estimate that our system of medicine in this country went from being nearly 100% private to only about 5% private. But then, in 1996, physicians began to say, “enough is enough,” and started leaving managed care plans. They were tired of fighting denials of claims for services they believed their patients needed and deserved. Today, we estimate that 15 to 20% of physicians are private physicians again.”

“One can be assured of private doctor’s services ifyou have Out-Of-Network MD option in your plan.”
So How Do I Tell Who Is A Private Physician Today?

It is more than a question of whether a physician has his or her own office, or works in a multi-specialty group. The easiest way to determine who is a private physician is to look in the phone book. Call the office, and ask what plans they are in. If they are not bound by various plans, they are truly private. Out-of-network doctors could be the only truly private doctors in today’s environment.”

“Out-of-Network MD is a real private MD.”
What does the future hold?

“There are increasing signs of encouragement. A patient’s Bill of Rights has been introduced in Congress. If it becomes law, we will increase private medicine in this country.”

 

Dr. Gupta suggests that you choose a managed care plan that emphasizes
cost saving on identical services, rather that non-identical services.

“Recently, managed care has increasingly letting its members have Out-Of-Network MD options. Now they are trying to control costs by applying real management tools.”

“Realistically, we think that we will end up half way on the line between total managed care, and total independence for the doctor. Perhaps a scenario in which a patient is allowed to go out of network after some sort of arbitration or as an added option in a special health plan.”
How can I get involved?

“You, the patient, have an enormous stake in seeing that private medicine returns in this country. Share your dissatisfaction with your insurance company, your employer, your union officials, your elected officials, and anyone else in a position to influence policy and law.”

“We have lived with managed care in some form or another since the mid ‘80’s. As the pendulum moves back, I’m optimistic that we will finally achieve a balance between controlling costs and preserving the rights of the patients to choose their private doctor.
“We suggest consulting Out-Of-Network MD only iftreatment outcome of In-Plan MD is not satisfactory to patient.”

“Through public awareness, we can encourage a dialogue--between the providers, the insurance companies, the legislators, and the physicians.
 

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